The experiences of foreign doctors in Saudi Arabia: A qualitative study of the challenges and retention motives.

BACKGROUND: The Saudi healthcare system is mainly staffed by foreign doctors who constitute about 73% of the total medical workforce. But, the high rate of turnover among these foreigners had deposited an additional unbearable cost and threatens the stability of the provided healthcare services in the country.
OBJECTIVES: This study was conducted to explore the professional and personal challenges that were experienced by foreign medical doctors while working in one of the major governmental tertiary-care hospitals in Riyadh city. The study also seeks to explore the factors that could influence or motivate their retention.
METHODS: A qualitative study based on semi-structured interviews was conducted on January 2018. A total of 16 foreign doctors were recruited purposefully using a maximum variation sampling strategy. The interviews were recorded, transcribed verbatim, and analyzed using thematic analysis technique.
RESULTS: Three primary themes have been emerged based on the data analysis: (1) Work-related challenges such as; communication and discrimination challenges. (2) Living-related challenges such as; supportive services and restricted movement challenges. (3) Factor motivating retention such as providing good children education, offering flexible traveling regulations, and providing professional development opportunities.
CONCLUSIONS: The findings of this study have indicated that there are more important motivators than money for improving the retention of foreign doctors in the country. Several policy actions have been recommended to maintain their essential role. For example; implementing an ethical code to protect them from receiving deceptive hiring information, developing a specialized pocket dictionary to overcome language barriers, embracing "workforce diversity management" techniques to minimize discrimination at institutional level, and finally it is also recommended to include the foreign doctors' family needs and other living related challenges in any future retention strategies.

Introduction

The healthcare industry in Saudi Arabia is expanding and improving continuously, but this industry is experiencing acute and persistent shortage in the local medical workforce despite the effort that has been made on medical education and training (Althubaiti and Alkhazim, 2014; Bahnassy et al., 2016; Khaliq, 2012). According to the Saudi ministry of health, there are only about 24 thousand Saudi doctors (including Saudi dentists) in the whole country (Ministry of Health, 2016). To solve this serious problem, the country has relied on recruiting and employing doctors from abroad (Albejaidi, 2010). In this paper, the term “Foreign Doctors” who are working and practicing medicine outside their original countries would be referred to as (FDs).

The FDs in Saudi Arabia represent about 73 percent of the total medical workforce (Ministry of Health, 2016). This is compared to only 27.9 and 28 percent in the United States and the United Kingdom respectively (U.S. Census Bureau, 2015; Klingler and Marckmann, 2016). It is obvious that non-Saudi doctors are playing a major role in securing and preserving the Saudi healthcare system. However, the high rates of turnover accompanied by sudden unexplained departures among these foreigners have become a major critical concern that threatens the stability and the delivery of good healthcare services in the country (Almalki et al., 2012; Sayaf, 2015). This high rate of turnover has also deposited an additional unbearable cost on the Saudi healthcare system, including the cost of hiring, training, and engaging of the new foreigners that could otherwise be spent on patient care. Unfortunately, there are no published statistics regarding the cost of medical staff turnover in Saudi Arabia. Although many international studies have declared that there is a significant cost with doctors' turnover that could represent a loss of more than 5 percent of the total hospital operating budget every year (Schloss et al., 2009; Waldman et al., 2010). Therefore, it would be very valuable to understand and evaluate the experiences of these FDs and the difficulties they face while working in Saudi healthcare system.

International studies have shown that FDs are usually experiencing several challenges while working outside their countries. The most common challenges noticed in these studies were cultural differences (Balasubramanian et al., 2016; Henderson et al., 2017; Kamimura et al., 2017; Klingler and Marckmann, 2016), communication and language barriers (Hatzidimitriadou and Psoinos, 2014; Henderson et al., 2017; Klingler and Marckmann, 2016; Reardon et al., 2014), dealing with new health system framework (Henderson et al., 2017; Klingler and Marckmann, 2016; Triscott et al., 2016), and discrimination at work places (Funfe, 2016; Hatzidimitriadou and Psoinos, 2014; Triscott et al., 2016). Klingler and Marckmann (2016) argued that if these challenges are not properly addressed it could affect the physicians' job satisfaction, turnover rates and consequently the retention of this much-needed healthcare personnel. Moreover, these un-resolved challenges could have a negative impact on the quality of the provided healthcare services and patients' safety (Wallace et al., 2009).

Unfortunately, and despite the importance of this topic, the challenges encountered by this highly educated group in Saudi Arabia appear to escape from the attention of researchers so far. Therefore, this interview study was conducted to explore inductively the professional and personal challenges that were experienced by foreign medical doctors in Saudi Arabia. The study also seeks to explore the factors that could influence or motivate their retention. Understanding these challenges and factors would provide an insight for Saudi healthcare leaders and decision-makers to establish an appropriate strategy to support this group to ensure their job satisfaction, retention, and thereby maintaining and securing the stability of Saudi healthcare system and reducing the high cost accompanied by this phenomenon.

Materials and methods

Study design

As to our knowledge, there were no previous studies that have systematically addressed the experiences of FDs while working in Saudi Arabia. Thus, an explorative qualitative study design was chosen to establish a basic concept (Al-Busaidi, 2008). This exploratory study was guided by a phenomenological approach, a type of qualitative research that is appropriate for investigating the perceptions and the lived experiences of the participants (Creswell, 2013; Reiners, 2012).

Participants, sittings, and sampling procedures

The study participants consisted of foreign doctors who did not have the Saudi citizenship and who worked in one of the major governmental tertiary-care hospitals in the capital city of Saudi Arabia (Riyadh). This city was chosen because most of the FDs (around 64%) were located (Ministry of Health, 2016). However, the name of the hospital was not mentioned as requested by the participants.

The participants were recruited purposefully through the use of a maximum variation sampling technique to ensure capturing a wide spectrum of experienced challenges and to improve the credibility of the study (Creswell, 2013; De Carvalho, 2008). A sample plan was constructed based on the participants' nationalities and specialties (see Table 1). The nationalities in the sample plan were selected to cover a wide range of participants linguistic and cultural backgrounds. While the medical specialties were chosen for its importance and for the specific communicative requirements needed in these areas (Klingler and Marckmann, 2016). However, during the recruitment process, the sample plan was altered and changed in many ways. First, the doctors from the psychiatry department were excluded because of accessibility problems. Second, foreign doctors who raised and received medical education in Saudi Arabia were also excluded, for their familiarity with the Saudi healthcare system.

Table 1

Sample plan.

	Surgery	Internal medicine	Psychiatry	Obstetrics & Gynecology	Anesthesia
Western	≥1	≥1	≥1	≥1	≥1
Non-western	≥1	≥1	≥1	≥1	≥1
Arabs	≥1	≥1	≥1	≥1	≥1

Instrumentation

Interviews were found to be the most appropriate instrument for this research. However, before starting the interviews, the participants had completed an anonymous demographic survey to gather information about their age, gender, nationality, native spoken language, religion, marital and family status. In addition to their years of experience inside and outside the country.

For the purpose of conducting the interviews, an “interview guide” was developed by the principal investigator (AZ) (see Table 2). The interview guide was made of semi-structured, open-ended questions to allow an in-depth understanding of the participants' experiences and to allow a flexible topic guide (Dicicco-Bloom and Crabtree, 2006). However, many potential probes were utilized during the interviews to encourage clarification and elaboration of the data. These potential probes were developed based on the findings from the existing literature in the international contexts. The interview guide was discussed with the research supervisor (AA) and field-tested by revising the questions after each interview to check their relevance to the study purpose.

Table 2

Interview guide/questions with potential probes.

Questions	List of probes
Q1: Based on your experience can you tell me what are the barriers and challenges you have experienced while working in Saudi hospitals as a foreign doctor?	• Challenges with healthcare system and regulatory framework. • Challenges in clinical practice (e.g. new form of treatment and diseases) • Challenges in professional development • Challenges in communication with other healthcare professionals, patients, and relatives. • Challenges with Cultural diversity in work place. • Discrimination and racism based on race, gender, or nationality. • Ethical challenges.
Q2: What are the barriers and challenges you have experienced while living in Saudi Arabia as a foreigner?	• Challenges with cultural lifestyle. • Safety challenges (e.g. terrorism) • Financial challenges. • Challenges with Living conditions (e.g. transportation and housing). • Emotional challenges (the presence of formal and informal support networks).
Q3: What are the factors that could affect your decision to stay or leave the country?	• Reasons behind choosing Saudi Arabia as a work destination. • The future plans.
Q4: In your opinion, what are the strategies and/or interventions that would assist foreign doctors while working in KSA?	• Advices for other new foreign doctors. • Further suggestions.

Data collection

A total of 16 interviews were performed on January 2018 by AZ (female master student in health administration with no prior connection to the participants). The sample size was determined based on “thematic saturation”. So, the sampling process has continued until no further data were found and until no more new themes or codes were emerged from the interviews (Javadi and Zarea, 2016). At that point, the interviews were concluded and that was reached at 16 interviews. This small number of participants is suitable for the nature of qualitative research (Creswell, 2013).

The participants were identified and contacted during their work time at their departments and invited to participate in the research. The interviews were performed at sites chosen by the participants themselves to ensure reliability of the data. Only the study participant and the interviewer were present during the interviews to allow free discussions. Ten interviews took place at physician offices and at public spaces through face to face meetings, while the remaining six interviews were performed through the telephone. The interviews language was English and the length of the interviews range between 30 to 50 min. Additional notes were taken during and after each interview to help in later interpretations of the data. All interviews were audio-recorded and transcribed verbatim by a professional transcriptionist and reviewed to ensure accuracy.

Analytic approach

The data were analyzed by (AZ) through the use of thematic analysis technique. This technique was chosen because it offers an accessible and flexible method for analyzing the qualitative data and because the results of this technique could be presented in a suitable manner to educate the public and to inform the policymakers (Braun and Clarke, 2006).

The following steps were followed to conduct the analysis; first, the transcripts of the interviews were reviewed several times. The reading and re-reading process gave the researcher the opportunity to familiarize with the data and to have a sense of the whole. Second, initial codes were generated inductively for each interview and then compared with others to identify recurring codes. Finally, the identified codes were organized into significant groups. Each group was given a specific theme or sub-theme (Javadi and Zarea, 2016; Vaismoradi et al., 2013). These themes represent the essence of the challenges experienced by FDs.

To ensure an authentic analysis, the results was supported by illustrative quotes from the participants' own words. Each one of the participants was given an abbreviation (e.g. Doctor 1, Doctor 2, …, and Doctor 16) that was used under each related quote. See Table 3 for detailed sample characteristics for each foreign doctor. Finally, to ensure consistency and validity, the research supervisor (AA) performed a separate analysis and then the coding process were compared and discussed to draw the final conclusions.

Table 3

Detailed sample characteristics for each doctor (n = 16).

	Gender	Age	Nationality	Religion	Specialty	Current position	Experience in KSA (yr.)	Worked outside KAS	Private situation	Family lives in KSA
Doctor 1	M	50–59	Indian	Muslim	Internal Medicine	Consultant	>10	No	Married, children	Yes
Doctor 2	F	30–39	Pakistani	Muslim	Ob/Gyn	Resident	6–10	Yes	Married, children	Yes
Doctor 3	F	50–59	Indian	Muslim	Internal Medicine	Consultant	>10	No	Married,Children	Yes
Doctor 4	M	40–49	Jordanian	Muslim	Internal Medicine	Consultant	6–10	No	Married, children	Yes
Doctor 5	M	40–49	Egyptian	Muslim	Anesthesia	Consultant	6–10	No	Married, children	Yes
Doctor 6	M	50–59	British	Muslim	Internal Medicine	Consultant	3–5	Yes	Married, children	No
Doctor 7	M	40–49	Pakistani	Muslim	Surgery	Consultant	>10	No	Married, children	Yes
Doctor 8	M	50–59	Indian	Muslim	Anesthesia	Consultant	>10	No	Married, children	No
Doctor 9	F	40–49	Pakistani	Muslim	Internal Medicine	Associate professor	6–10	Yes	Married, children	Yes
Doctor 10	M	40–49	Philippines	Non-Muslim	Internal Medicine	Resident	3–5	No	Married, children	Yes
Doctor 11	F	40–49	Pakistani	Muslim	Internal Medicine	Associate Professor	6–10	No	Married, children	Yes
Doctor 12	M	50–59	Yemeni	Muslim	Internal Medicine	Consultant	3–5	No	Married, children	Yes
Doctor 13	M	50–59	Sudanese	Muslim	Surgery	Associate Professor	>10	No	Married, children	Yes
Doctor 14	M	50–59	Irish	Muslim	Ob/Gyn	Associate Professor	3–5	Yes	Married, children	No
Doctor 15	M	40–49	Pakistani	Muslim	Internal Medicine	Consultant	>10	No	Married, children	Yes
Doctor 16	F	50–59	Spanish	Non-Muslim	Ob/Gyn	Consultant	≤3	Yes	Married,No	No

Note. n = number of the participants.

Ethical approval and consent to participate

Ethical approval of this research was granted from the Institutional Review Board (IRB) in the College of Medicine at King Saud University Hospital (KSUH), (26 December 2017, No. E_17_2789). The participation in the study was voluntary and the right to withdraw at any time was well-maintained. Furthermore, the participants were well-acknowledged about the study purpose, goals, methods and how the interview material will be protected. A written informed consent was given to each one of the study participants to explain their rights and to assure their anonymity and confidentiality.

Results

Interviews findings

In total, 16 interviews were analyzed. The demographic characteristics of the sample are described in Table 4. Three primary themes have been emerged based on the interview data analysis as following; (a) Work-related challenges, (b) Living-related challenges, (c) Factors motivating the retention of FDs. A detail description of each one of these themes are given below.

Table 4

Demographic characteristics (n = 16).

	Frequency	Percentage (%)
Age (years)
30–39	2	12.5
40–49	7	43.75
50–59	7	43.75
Gender
Male	11	68.75
Female	5	31.25
Nationality
British	1	6.25
Irish	1	6.25
Spain	1	6.25
Philippines	1	6.25
Pakistan	5	31.25
India	3	18.75
Egypt	1	6.25
Jordan	1	6.25
Sudan	1	6.25
Yemen	1	6.25
Native spoken language
Arabic	4	25
English	3	18.75
Other	9	56.25
Marital Status
Married	16	100
Single	0	0
Family lives in Saudi Arabia with the participant
Yes	12	75
No	4	25
Number of children
Non	1	6.25
1–3	11	68.75
≥4	4	25
Current position
Consultant	10	62.5
Resident	2	12.5
Associate Professor	4	25
Religion
Muslim	14	87.5
Non-Muslim	2	12.5
Professional specialty
Anesthesia	2	12.5
Internal medicine	9	56.25
Obstetrics & Gynecology	3	18.75
Surgery	2	12.5
Work experience in other countries
Yes	3	18.75
No	13	81.25
Years of experience in KSA
<3	1	6.25
3–5	4	25
6–10	5	31.25
>10	6	37.5
Total	16	100

Note. n = number of the participants.

First theme: work-related challenges

FDs have identified four main work-related challenges while practicing their job in the hospital as following; (1) Communication challenges, (2) Discrimination challenges, (3) Institutional challenges, and (4) End service challenges (see Table 5 for a full overview).

Table 5

First theme: Work-related challenges.

Sub-themes	Clusters
1. Communication challenges	- Language barrier - Cultural barriers (provide care to the opposite sex)
2. Discrimination challenges	- Lack of professional development - Unfair workload distribution - Different vacation rules - Different salary scales
3. Institutional challenges	- Bureaucratic work - Lack of planning and system - Lack of adequate information - Non-welcoming atmosphere
4. End service challenges	- Job insecurities - Unjust retirement benefits

Communication challenges

One of the major challenges that have been identified by the participants while working in their hospital was the difficulty in communication Two major sub-categories have been reported by the participants under this theme including; the language barriers, and the cultural barriers (see the previous Table 5).

First, the language barrier was mainly reported by the participants who did not have an Arabic background. However, most of the participants reported that the language was a challenging issue only at the initial stage of their work (the first 2–3 years of their arrival to KSA):

"The initial phase was difficult [...] I don't know how to interact with my patients properly and I was very slowly got adjusted. But now after twenty years, I become more comfortable." (Doctor 8)

They have also reported that the language barrier was faced only when they are communicating with patients or other non-medical departments such as human resource (HR). This is because most of the medical staff speak English fluently:

"I am working in a hospital where the official language is English practically […] So, I have not got any problem with colleagues. But working with patients was really difficult." (Doctor 8)

"All people in HR are not fluent in English so, they don't know how to communicate […] We have to go and inquire about each and everything." (Doctor 9)

Second, when it comes to the cultural barriers within the hospital such as providing the care to opposite sex, especially female patients, only one participant has reported facing such difficulty (Doctor 10: the non-Muslim male doctor). However, the presence of female nurses during the work time has helped to reduce this problem:

"As a doctor, I was trained and raised to see both male and female patients […] But due to the practice or the religion here there is a barrier when it comes to see a female patient. But I am all right with the presence of many female nurses." (Doctor 10)

Discrimination challenges

Four main sorts of discriminations were reported by the study participants including; lack of professional development opportunities, unfair workload distribution, different vacation rules, and different salary scales (see the previous Table 5). Other kinds of discriminations at personal level was not cited.

First, around ten doctors from the study participants have reported facing restricted opportunities for continuing their education and training just because they are foreigners. This restrictions in the education and training have limited their ability to build on their career and to get better chances for professional development. They have also cited that the promotions were only given after a long journey of struggles and fight:

"There are different policies between Saudis and non-Saudis […] The promotion criteria for them is easy, for us is very hard. For example, Saudi physician becomes consultant in three years' time, where it took me 15 years to become consultant." (Doctor 8)

The second kind of discrimination was the unfair workload distribution among different colleagues based on their nationalities. However, the participants have shown a variety of opinions when it comes to the workload distribution. Only three participants have reported that they experience unfair workload distribution because they were foreigners:

"There are different roles […] Our role is usually doubled than others […] we do more on-calls, we do more clinics, just because we are foreigners" (Doctor 14)

However, the other thirteen participants have cited that the work has been distributed equally within their departments:

"The workload is equally for all doctors with the same level, the doctors who are residents, who are Saudis or non-Saudis, they are taking the same workload […] It is equal." (Doctor 4)

Another discrimination issue was the differences in vacation rules between different nationalities. For example; doctors from specific nationalities (non-Western and Arabs) have shown a struggle with the guarantor rule. Having a guarantor is a hospital rule that require FDs to specify another employee who will be his/her guarantor to ensure that they will return back after their vacation. This rule is not applied on Saudi, Western or other European doctors. One participant has complained that having a guarantor is a time consuming and a sign of lack of trust between the doctors and their institution:

"When I apply for vacation, then I have to bring a guarantor. I think this one should be cancelled from the rules […] It is like they are not trusting you. This is very bad, it takes time […] Sometimes it is very embarrassing."(Doctor 4)

The final issue that have been raised by the participants under the discrimination theme was the presence of different salary scales that was based on the nationalities of the doctors and not on their qualification:

"Once it comes to our work responsibilities we are the same in comparison to Saudi doctors, but when it comes to salary, there is a big difference […] It must be based on the qualification, and not as my friends say, on the passport [smile]." (Doctor 10)

Although the Western and European doctors have the advantages with higher salary scales than others, but they have clarified that this is not the case in their countries:

"However, I have the advantages, but to be honest this salary differences is not acceptable. I worked in UK for twenty years, they appreciate you because you are qualified not because of your race or passport." (Doctor 14)

Institutional challenges

Participants, especially those who come from Western nationalities, have described four challenges with the system of the healthcare organization. These challenges range between difficulties with the bureaucratic work, lack of planning and systematic approach, lack of adequate information, and non-welcoming atmosphere (see the previous Table 5).

First, some of the participants had complained about the institutional bureaucratic work that involves many hierarchal managerial levels which consumes their time and efforts:

"I spent a lot of time with bureaucracy […] For example, just to renew the Saudi commission license I have to go many times and approve my request by many head departments […] this is stressful." (Doctor 16)

Second, several participants have criticized the lack of planning and systematic approach within their institutions:

"I think the problem here is more institutional; you know when I say institutional it means the system approach, where we use rules and plans […] We need to look at how policies are made and also to ensure that people follow those policies." (Doctor 6)

Third, various participants have complained about the lack of adequate information especially at the initial stages of their employment. For example, one participant has reported receiving misleading information during his recruitment process:

” I came here with the knowledge that I was going to be housed, […] that's why I brought my family, but when I arrived they said no […] they were not going to give me a housing […] It was really a tough time.” (Doctor 10)

Finally, the overall organizational culture toward the foreigners was identified as another institutional stressing issue. For example, several participants have experienced a non-welcoming atmosphere within their institution:

"Wherever you go, you face hardship. There is something in the overall environment […] For example, when it comes to entering even the educational areas like entering the library […] You are stopped just because you are a foreigner." (Doctor 3)

End service challenges

The improper hospital treatment for the participants at the end of their service was a major issue that have been raised by many of the study participants. This issue was given a separate theme because usually the final treatment would leave a bad impression about the country regardless of all the goods that have been done. Categories under this theme includes job insecurities and unjust retirement benefits (see the previous Table 5).

First, several participants have complained about job insecurities which resulted from the act of ending the contracts of the FDs by the hospital at any time without giving a prior notice:

"This is very unsecure position […] Even if you are working very well you will never know, if they don't need you they can end your contract straight away […] They cannot terminate the doctors like in between without even giving a prior notice." (Doctor 9)

The other issue under the end service challenges was the unjust retirement benefits. Participants have criticized the amount of money that would be given to them at the end of their service. And stated that the retirement benefits are not linked to their qualification or working years:

"I work very hard even in the weekends, I ignore my family but not my work and at the end of my service they will give me only 50,000 Riyals […] Regardless for my work years and qualification […] Actually, this is the most time that I regret coming here." (Doctor 1)

Second theme: living-related challenges

When going outside the hospital, the participants have experienced several personal challenges while living in Saudi Arabia. These challenges have been categorized into three main sub-themes; (1) Social & cultural challenges, (2) Supportive services challenges, and (3) Restricted movement challenges (see Table 6 for a full overview). Each item would be discussed in greater detail as follows:

Table 6

Second theme: Living-related challenges.

Sub-themes	Clusters
1. Social & cultural challenges	- Adaptation to a new culture - Social isolation
2. Supportive services challenges	- Improper children education - Poor housing quality - Inadequate healthcare services
3. Restricted movement challenges	- Traveling restrictions (Exit/Re-Entry Visa) - Women driving ban - Job transferring restrictions

Social & cultural challenges

Two main categories have been identified under the social & cultural challenges which include; adaptation to a new culture, and social isolation (see the previous Table 6). First, it must be noted that most of the participants in this study were Muslims, as a result, positive experiences and a great adaptation to Saudi cultural lifestyle have been reported:

"Because we are coming from conservative Islamic country […] So we have no actual problem […] and I like this culture that during prayer time they close the shop. Really culturally I did not feel really any problem." (Doctor 15)

However, one participant (Doctor 16: the non-Muslim female doctor) has shown difficulties in adaptation to Saudi cultural lifestyle. Challenges such as male and female segregation, in addition to the restrict female dress codes have been cited by her:

"Not everyone can adapt to this culture here, and the way of living, especially if it's a woman […] It was stressful to be restricted to wear (Abaya) and also the segregation where women need to sit in one place and men on another. I feel that I am little bit constrained." (Doctor 16)

On the other hand, the participants have cited that the community attitude toward the foreigners has been enhanced in the last few years. They also mentioned that they face more acceptance from the new generations:

"Now the things are not like before, a reasonable percentage of Saudis are highly educated and the attitude of the community towards the foreigners now is good, not like before." (Doctor 13)

Second, some of the participants have reported experiencing a kind of social isolation because most of them are living inside isolated compounds or because of the long medical working hours:

"I don't mix with Saudis that much […] Maybe it’s the nature of the medical work that have long working hours." (Doctor 3).

In the end, when talking about living in Saudi Arabia, it is very important to notice that the participants have cited that this country is a very safe place to live in and that they are not affected by terrorism in their daily life:

"I don't think any single place in the world is completely quiet […] I still consider this a perfectly safe place to live, I am raising a child here." (Doctor 2)

Challenges with supportive services

FDs have criticized the quality of three supportive services that were provided for them such as improper children education, poor housing quality, and inadequate healthcare services (see the previous Table 6).

First, the lack of good children education with high international standards was identified as a major challenging issue. Many of the study participants have cited that the public universities will not offer seats for the foreigners. While the private universities were either expensive or not up to the standard:

"My child will go after two years to the university level […] there is no seat offered by the government […] However, the private colleges are just new in the last 4-5-6 years […] And they are not up to the standard." (Doctor 7)

Second, the quality of the houses that was provided by the hospital was another challenging issue for the participants. It has been noticed that most of the participants in this study are living outside the hospital compound. While those who lives in the hospital compound have raised many complains about the quality of the houses or the maintenance and other ancillary services:

"It is old, the building, the furniture, even we do most of the maintenance […] And if you compare the price of the building per year we are supposed to live in a better situation." (Doctor 14)

Finally, around two participants have experienced challenges with the healthcare services that are provided by the hospital. They mainly emphasize on the lack of a good insurance plan, in addition to the overcrowded staff clinics:

"Those who are working in private companies, they have insurance, they have a variety of options, many clinics, many hospitals, but we have no chance. Even in our hospital you will not find treatment in a favorable time." (Doctor 13)

Restricted movement challenges

FDs have described three kinds of restrictions in their movement ability while they are living in Saudi Arabia. Such as limitations in their traveling ability (Exit/Re-Entry Visa), women driving ban, and limitations on their ability to transfer from one job to another (see the previous Table 6).

First, the most problem that has been raised by all FDs regardless of their nationalities or background is the restrictions on their traveling abilities by using complex traveling regulations such as the need for Exit/Re-Entry Visa. The Exit/Re-Entry Visa means that if you are a foreigner and you are planning for traveling, then you should apply for this Visa every time you are moving outside or to the country. One of the study participants had cited an example of the difficulties associated with the application process for the Exit/Re-Entry Visa in a personal Emergency situation:

"See my mother dies […] It was very difficult to arrange the Exit/Re-Entry Visa. It was a holiday and everywhere it is closed […] So, at the end, I did not go […] That was the most difficult time for me here." (Doctor 8)

Second, in a country that has a very restricted gender role, the female participants, in particular, have repeatedly raised the issue of the woman driving ban as a big challenging issue for them:

"In OB/Gyn, sometimes we have emergent cases, then I have to depend on the hospital driver because I cannot drive as a woman […] Sometimes the drivers are not responding quickly, and this is an urgent case, one-minute can make difference." (Doctor 16)

(Note: these testimonies have been taken before women were allowed to drive in KSA)

Finally, job transferring restrictions was another issue that was reported by FDs. The participants have cited that they encounter difficulties and restrictions when they try to change their hospital or move from one job to another. They noted that the transfer process is very complicated, as you need to go outside the country to be able to apply to a different hospital, while you cannot transfer internally (from within the country):

"The hospital will not give you transfer, they give you the final exit, and you have to arrange for coming back [...] So, this is really a big problem, and it is a stressing issue for the foreigners." (Doctor 4)

Third theme: factors motivating retention

Many of the participants look to Saudi Arabia just as a stepping point before moving to other countries. This has resulted in an increasing rate of turnover among the foreign medical workforce:

"Working here is only a temporary thing […] people will come here for 4–5 years to get experience and then go." (Doctor 2)

When FDs were asked about the factors that could influence or motivate their retention in the country, their responses were varied. However, the participants have repeatedly cited three factors as a major contributor to their retention (see Table 7). It was noticed that these factors were mentioned previously in the previous themes, but it is re-represented here according to their impact on the retention of FDs as following;

Table 7

Third theme: Factors motivating retention.

Sub-themes
1. The provision of good children education that simulates the international standards.
2. Offering more flexible traveling regulations and removing the Exit/Re-Entry Visa.
3. Providing professional development opportunities.

Providing good children education that simulate international standards: the absence of high-quality children education was the number one factor for the participants from non-Western and Arabic nationalities to decide to leave this country:

"My kids are young, but I think when they grew up, I think I have to go back home […] To offer them good education […] The schools here are not too good as in my country. Even the international schools […] The curriculum in our country is stronger." (Doctor 5)

Offering more flexible traveling regulations and removing the Exit/Re-Entry Visa: this factor was a significant issue for the participants especially for those who come from Western nationalities:

"Look the people from the Western countries have already a very good quality of life. So, for us the freedom is very important, to be able to move if we want to […] I don't need to ask permission then to request for this visa, this is the number one stressing issue for me here." (Doctor 16)

Providing professional development and promotional opportunities:

"If I take my deserved position and my promotions, I would not leave this country. I told you before this is a big issue for me. However, if the situation continues like this, I would leave the country, of course, after having the experience." (Doctor 12)

Discussion

Main findings

To our best knowledge, this is the first study conducted about the challenges experienced by FDs while working and living in Saudi Arabia. Some of the identified challenges in this study are similar to the challenges experienced within more developed countries such as U.S and UK. The lack of professional development opportunities and the language barriers are examples of such challenges (Chen et al., 2010; Hatzidimitriadou and Psoinos, 2014; Kamimura et al., 2017; Slowther et al., 2012). While some other challenges were not identified in previous articles and could possibly be specific only to Saudi Arabia such as; restricted traveling regulations and the need for "Exit/Re-Entry Visa" in addition to women driving ban.

It is also very important to notice that some of the described challenges in this study might not be specific only to FDs. For example, the cultural barriers of providing the healthcare to the opposite sex, especially female patients, could be a challenging topic for both Saudi and non-Saudi doctors (Alkabba et al., 2012). However, it is worth to mention that in Islam, it is not prohibited to provide medical care to the opposite sex under certain conditions; such as when no competent female doctor is available (Al-Amoudi, 2017). Furthermore, the lack of planning and systematic approach within the institution and the rush to intervene without proper monitoring or evaluation could be another challenging issue that affect all kind of healthcare workers within the hospital (Aljuaid et al., 2016). In light of this, it is expected that any efforts made to enhance the experiences of FDs in their hospitals might also have a positive impact on other groups of healthcare professionals including the Saudi doctors. Therefore, healthcare leaders and decision-makers should not take those problems lightly. Instead, they must hold the responsibility and search for adequate strategies and solutions to address them. In the following paragraphs, we would conduct a discussion about the possible policy actions and interventions that could be appropriate for overcoming some of the major identified working and living related challenges.

The work-related challenges that face FDs in Saudi Arabia appear to start early from the beginning of their recruitment process. For example, several participants have reported receiving inadequate or misleading information during their employment process. Providing devious information to newly arrived foreigners is unethical behavior (Klingler and Marckmann, 2016; Rothwell et al., 2013). To overcome such challenges and to influence a transparent, and ethical employment process, United States has developed the "Alliance Code for Ethical Recruitment for Foreign-Educated Health Professionals". This ethical code depends on improving the practical standards for those who are directly involved in the recruitment process through providing several certified courses. Furthermore, to ensure an appropriate application of the code, a continuous screening and reporting mechanism would be necessary (Shaffer et al., 2016). However, further research in the area of FDs' recruitment process in Saudi Arabia is needed and recommended.

As stated previously, the identified challenges could have a negative impact on the patients' safety and the quality of healthcare services. For example, some of FDs in the present study have reported initial difficulties in communicating with patients. Several studies have identified the miscommunication between the FDs and their patients as a causing factor for medical errors (Henderson et al., 2017; Triscott et al., 2016). Rothwell et al. (2013) have questioned the efficacy of language courses and recommended offering a specialized mentoring and buddying schemes that could be linked to the FDs during their daily practice. This kind of daily mentoring would not only help in overcoming the language barriers, but it can also lead to better cultural knowledge and performance. However, these mentoring and buddying schemes would require additional human and financial resources. Therefore, we would suggest developing a specialized pocket-dictionary which includes the most common used Arabic words and phrases that is needed to deliver the care to the patients and afford it to all FDs.

Discrimination against FDs at their workplaces was another major challenging issue that has been identified by the study participants. The issue of discrimination against FDs has received significant attention from the international studies (Hatzidimitriadou and Psoinos, 2014; Triscott et al., 2016). Interestingly, the experienced discrimination in this study was mostly identified at institutional level, and mainly from the policies and regulations of the hospital. Those improper hospital policies have encouraged and promoted the discrimination against FDs based on their nationalities. For example, the presence of different vacation policies and several salary scales for each country are clear signs of this type of discrimination. The advantages in such areas were mostly given to the participants from the Western nationalities. On the other hand, the participants from non-Western and Arabic nationalities have identified the absence of equal professional development and promotional opportunities as one of the major discrimination behaviors that would affect their job satisfaction and retention. This result was consistent with previous studies that reveal a significant relationship between the level of job satisfaction and professional development opportunities (Chen et al., 2010; Li et al., 2014). Therefore, to overcome such challenges it is recommended to conduct a comprehensive review of the hospital old policies and regulations and then re-create them by a specialized people in healthcare management to ensure that the organizational environment does not promote any biases or discriminations and that employees are evaluated based on their qualifications, experience, and performance. In this way, the hospital would maintain more satisfied and motivated employees. Another recommendation to overcome the institutional discrimination was given by a study from the German context which advise to utilize more effective "workforce diversity management" techniques such as; embedding the idea of respecting the diversity in the mission statement of the hospital and increasing the leadership awareness about the advantages and the opportunities that diverse workforce could bring (Klingler and Marckmann, 2016). Finally, it is also recommended to conduct a regular FDs job satisfaction surveys to monitor any new trends and to gather feedback information to provide more effective support for FDs at their workplaces.

Interestingly, the result of this study reveals that living-related challenges have held the greatest impact on the retention of foreign doctors. Some of everyday activities in open societies are forbidden in Saudi Arabia due to religious reasons or traditions and culture. Challenges such as prohibited mixed gender gatherings, restricted women clothing, and women driving ban were cited by the study participants. The later was a policy related to the norms in Saudi Arabia where local women would mostly hire private drivers and if this was not available a male relative would drive the women to her destination. Moreover, it was noticed that most of the participants were living in compounds or accommodations which is isolated from this restrictive society. The nature of this environment may add additional challenges on FDs while living in Saudi Arabia. However, some of these challenges would no longer be of a policy relevance due to political changes in the country, for example, on June 24th, 2018, women driving ban was ended and the authority started issuing driving license for women.

Furthermore, family issues such as the lack of adequate children education was identified as the number one factor for the participants from non-Western and Arabic nationalities to decide to leave the country. One study from the Australian context found that non-professional social barriers such as limited schooling and housing options could have a great impact not only on the retention of FDs but also on their ability to function effectively within the workplace and society (Terry and Lê, 2013). Therefore, the living related challenges including the foreign doctors' family needs must be considered as an integral part of any retention strategies. On the other hand, the participants from the Western nationalities have identified the complex traveling regulations and the need for “Exit/Re-Entry” Visa as the number one factor for their retention. One of the study participants (Doctor 16: the female Spanish doctor) has indicated that the sense of freedom and the ability to move without restrictions are very important values for the people in the west. However further information about the reasons behind such traveling regulations was needed for devising the relevant policy responses.

Strengths and limitations

Although this study has achieved its purpose, there were some unavoidable limitations to consider. First, the findings of this study cannot be generalized to all FDs who are working and living in Saudi Arabia. This is because of the qualitative nature of this study which involves a small sample size (n = 16), in addition to the geographical restriction to only one city (Riyadh). Furthermore, the study was conducted in an academic well-established hospital, which means that the results cannot be transferred to other less structured hospitals. However, to improve the generalizability and credibility of the data a maximum variation sampling technique was utilized to ensure a heterogeneous sample in term of age, nationalities, and years of experience and thus bringing the generalizability to the maximum level possible within the given limits. Furthermore, to minimize sources of biases in this study, it was ensured that there were no previous connections or benefits between the researchers and the participants or their hospital. However, the participants' voluntary involvement in this study may provoke participation biases, as FDs who choose to participate in this study might have more beliefs on the research topic, while others who might not have encountered any difficulties or are afraid of sharing their extreme negative experiences may choose not to participate in this research. Finally, most of the study participants were Muslims (around 87.5%), therefore a careful attention was given when drawing the final results. Despite these considerations, this research adds a substantial contribution to the expanding body of literature by affording an increased knowledge about the challenges experienced by FDs in Saudi Arabia for the first time. The study also provides a basic ground for Saudi healthcare leaders and decision-makers to establish an appropriate retention and supporting strategies for FDs in this country.

Conclusions

Foreign doctors represent a significant part of the medical workforce in Saudi Arabia. Yet, they are experiencing several working and living related challenges that affect their job satisfaction, turnover rates, retention and most importantly the quality of patient care. This study adds to the existing knowledge of literature by highlighting these challenges for the first time. Several policy actions have been recommended to help in overcoming these challenges such as the need for implementing an ethical code to prevent providing inadequate hiring information, developing a specialized (Arabic-English) pocket dictionary to help FDs overcoming language barriers, and to prevent discrimination at institutional level it was recommended to use more effective “workforce diversity management” strategies. The results of this study have also indicated that there are more important motivators than money for improving the foreign doctors' retention such as providing good children education, more flexible traveling regulations, and good professional development opportunities. Healthcare leaders and decision makers should take a close attention to these results and recommendations to optimize the experiences of FDs in the country and therefore, ensuring the good quality and stability of the Saudi healthcare system and reducing the cost associated with their turnover.

Declarations

Author contribution statement

Amal Zawawi: Conceived and designed the experiments; Performed the experiments; Analyzed and interpreted the data; Contributed reagents, materials, analysis tools or data; Wrote the paper.

Abeer Alrashed: Contributed reagents, materials, analysis tools or data.

Funding statement

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Competing interest statement

The authors declare no conflict of interest.

Additional information

No additional information is available for this paper.