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Strategies to Empower Diploma Nurses in Eastern Health Cluster-Saudi Arabia

Adel Harb*, Mariam Alkhalaf, Janette Silva, Abdullah Ngala, Aminah Blancaflor, Mohammed Al Bazroun

Health Academy and Director, Professional Development – Eastern Healthcare Cluster (EHC),Visiting Professor Assistant at King Saud bin Abdulaziz University for Health Sciences (KSAU-HS)

Abstract: In 1954, the Ministry of Health (MOH) established nursing as a profession in Saudi Arabia. Almost three quarters of the nursing workforce in Ministry of Health hospitals are diploma nurses who need to be retained by providing opportunities for both professional development and career progression. This research aims to identify empowerment strategies that may be beneficial in maximising the potential of diploma nurses in this population. Methodology: The study used a qualitative and quantitative design with a grounded theory approach to explore diploma nurses’ views and interpretations of their role and performance. It was conducted in three Health Network facilities within the Eastern Health Cluster (EHC) over a nine months period from June 2022 until the end of December 2022. A purposive sampling technique was used. A total of 15 diploma nurses and 3 Nurse Directors representing three health networks were enrolled in the project, on a voluntary basis. A research questionnaire and focus group interviews were used for data collection after obtaining ethical approval from King Fahad Specialist Hospital Institutional Review Board. Analysis: A descriptive analysis was undertaken to highlight the demographic characteristics. Data was then completed by comparing data entered on the questionnaire in order to provide a better understanding about diploma nurses views and how to enhance their performance. Data were conceptualized through initial coding using a method of constant comparison (conceptual or open coding). Coded data was then compared against other data to create categories before finally emerging into core categories (thematic or axial coding) to support the purpose of the study in enhancing performance. Results: The results were presented as a model that showed three main strategies to empower diploma nurses. They were: perception of diploma nurses’ performance, area for improvement, and education enhancement. Recommendations: Appreciation and recognition are important factors that will empower diploma nurses. Additionally, providing part time bridging programs through universities and opportunities for enrollment in transformation programs (Makken Programs) may also empower diploma nurses by enhancing their level of education. Limitations: small sample size, not including primary healthcare diploma nurses in this research, lack of triangulation methodology - individual interviews besides the focus group and questionnaire could enhance the validity and strength of the study. Furthermore, as the study was conducted in EHC it may not be generalizable. Conclusion: Further studies are needed to identify empowerment strategies and measure their effectiveness in this population.

Keywords: strategies, empower, diploma nurses, eastern health cluster, Saudi Arabia

Received November 28, 2022; Revised January 07, 2023; Accepted January 16, 2023

Citation: Adel Harb, Mariam Alkhalaf, Janette Silva, Abdullah Ngala, Aminah Blancaflor, Mohammed Al Bazroun, Strategies to Empower Diploma Nurses in Eastern Health Cluster-Saudi Arabia. American Journal of Nursing Research, 11 (1). 54-63. January 2023. doi:10.12691/ajnr-11-1-5

1. Introduction

The healthcare system in Saudi Arabia is rapidly evolving, as services develop to meet the 2030 vision in providing a comprehensive, effective and integrated health system. The national transformation program presents many challenges to the nursing profession. The Ministry of Health (MOH) established nursing as a profession in 1954 [1], nurses now constitute the largest percentage of healthcare providers in the Kingdom where they account for 50% of clinicians and provide 80% of healthcare services [2,3]. Reform within the Saudi nursing profession is critical to the success of the transformation [4] given that nurses form the backbone of the health care delivery system.

In Saudi Arabia, diploma nurses constitute three quarters of the nursing workforce in Ministry of Health hospitals [5,6]. As a diploma nurse, they complete either 2.5 or 3.5 years undergraduate training program. On entry to clinical practice as a diploma nurse a mandatory competency assessment program must be completed before they can provide direct patient care. Despite this, it has been suggested that, as they are not educated to baccalaureate level, there is a lack of education and training among them which may be a barrier in providing a high-quality of care to complex patients [7]. Saudi Arabia still relies heavily on expatriate nurses [8]. The national transformation program identifies a requirement for intensive learning and training to take place with the aim of reducing the reliance on expatriate nurses and also ensuring that future local leaders are ready to lead. However, there are limited opportunities for career advancement amongst diploma nurses as national accreditation standards mandate that all head nurses have a BSN degree [9]. Although some nurses are attending programs, bridging from a nursing diploma to a bachelor’s degree spaces are limited and there is an urgent need to expand program capacity [4]. The lack of opportunities perceived within the nursing profession [10], may be a demotivating factor which causes reduced productivity in the workplace.

There is a high turnover rate within the Saudi nursing workforce, many leave the profession due to their perception of unfavourable working conditions, low pay and social status [2,11]. The image of nursing must be improved if it is to be seen as an attractive profession within the kingdom [10,12]. Additionally, there is an inadequate supply of new nurses to replenish the workforce. Historically, nursing programs have had poor enrolment rates due to the bad reputation of the nursing profession [13,14]. More recently, nursing shortages have been attributed to an inadequate number of training slots to qualify as nurses [4]. If diploma nurses are not retained by providing opportunities for both professional development and career progression, the deficit of Saudi nurses will grow, requiring a reduction in the workforce or more foreign hires [4].

There is a requirement to enhance the performance of diploma nurses in ministry of health facilities in the Eastern Health Cluster (EHC) in Saudi Arabia if the current workforce is to be retained and be capable of providing the gold standard of care required to meet the 2030 vision of excellence in health care delivery.

This research project therefore aims to identify empowerment strategies that may be beneficial in maximising the potential of diploma nurses in this population

2. Literature Review

The importance of Quality nursing care is emphasized in Saudi Arabia where excellence in health care delivery is identified as a primary goal towards achieving transformation in the healthcare system.

The current number of diploma nurses and high turnover rate within the Saudi nursing workforce means that empowerment strategies may have a critical role to play in enhancing staff performance if excellence in patient care delivery is to be assured.

The concept of empowerment was first described by Kanter [15,16]. Kanter’s empowerment theory suggests that a leader’s competency is mainly influenced by an organization’s behavior in the form of providing formal and informal power. He identifies that it is the importance of formal power in providing recognition and freedom to make choices which keeps the work environment operating at an optimal level. According to his theory, empowerment is promoted in work environments where employees are provided with access to information, resources, support, and the opportunity to learn and develop, which in turn influences job satisfaction [17]. Kanter’s theory has been widely applied to organizational settings in nursing where it has been found that access to resources can empower employees to accomplish their work in more meaningful ways [18,19,20].

Bradbury-Jones et al., provide a different theoretical perspective where power is "executed rather than held" and empowerment for nurses is linked to knowledge [21]. This is in contrast to others who identify that power-sharing, respect for oneself and others, and helping individuals recognize their talents, abilities, and personal power are all part of the process of empowerment [22].

However, Rappaport asserts that it is easier to identify the absence of empowerment, compared to actually defining the concept [23]. Empowerment has been seen from a variety of angles, including structural, psychological, and group viewpoints, which has made it difficult to reliably define and quantify this sophisticated idea. Researchers might use the phrase empowerment when, for instance, they really mean structural empowerment as it applies to people inside healthcare organizations due to the various definitions, forms, and levels of empowerment in the literature. This view is extended on by other theorists who identify that this lack of specificity can also lead to research that just contributes to the body of information about empowerment in general rather than advancing specific understanding about empowerment [24].

Numerous studies identify the importance of empowerment in the healthcare sector where it has been found to have a significant impact on the work environment [25,26,27]. As the core of inter-professional collaboration, empowerment is also linked to higher levels of unit effectiveness, organizational trust, job satisfaction, and positive colleague relations [28].

Multiple interviews with nurses were conducted in one study in Iran [29], which used a grounded theory method to analyze the participants' experiences, their perceptions and the strategies affecting empowerment. The study identified three factors that the participants deemed necessary for personal empowerment: "having authority," "professional self-confidence," and "application of professional knowledge and abilities." It asserts that a powerful nurse is one who is knowledgeable and adept at applying that knowledge and that the power of a nurse depends on knowledge and skills as well as self-confidence in applying that knowledge in the provision of care for customers." It found that the best way for nurses to strengthen their professional authority is through banding together to create unity within nursing organizations. Through this, norms and regulations for the nursing profession can be created which are crucial conditions to assist nurses in their professional development and necessary requirements to establish professional authority. The results of the study identify that empowerment is a dynamic process resulting from mutual interaction between personal and collective traits of nurses as well as the culture and structure of the organization. Power dynamics within the health care system were found to obstruct nurses from demonstrating that they possess the essential elements of empowerment. The study recommended implementing a model to empower the nursing profession which involves restructuring of the nursing system, including its services, education and research subsystems. This should improve the public's perception of nurses and the nursing profession and will strengthen the nurses' sense of professional identity and self-assurance. If this is implemented it will undoubtedly provide nurses with more power to develop and use their professional skills.

Another study conducted in Canada found that staff-nurse empowerment affected satisfaction and commitment in two different ways [30]. Firstly, it identified that satisfaction and commitment are directly impacted by views of empowerment. Secondly, that commitment and satisfaction are indirectly affected by their views of fairness, sense of respect, and confidence in management. The results of this study emphasize that it is critical to develop settings that enable nurses to have access to the resources they need to do their jobs. This study is the first to show how organizational fairness, respect, and confidence in management will play roles in the link between empowerment and job satisfaction. The degree to which employees believed they had access to workplace empowerment mechanisms, as well as their level of job satisfaction and commitment, were all substantially correlated with their perceptions of organizational fairness, respect for management, and trust. These findings imply that developing environments that enable nurses to practice in accordance with professional standards and that promote healthy working relationships in an environment of trust and respect can significantly contribute to attracting and keeping a sustainable nursing workforce.

Moreover, access to resources was the most significant empowerment structure for staff nurses in both urban teaching hospitals and rural community hospitals, according to another study [31]. There was a significant correlation between magnet hospital characteristics and resource access. This aligned with the assertion that magnet hospitals must have adequate manpower to enable professional nursing care of the highest caliber. It is conceivable to have the time to provide the level of care that nurses demand of themselves when there are adequate personnel. When this is not achievable, nurses frequently feel misled by management and frustrated.

In a further study conducted in Jordan, [24] the results have significant global effects for nurses. For the best patient care, nursing satisfaction, patient wellbeing, low burnout, and achieving organizational goals, structural empowerment must be used in the workplace. Nurse leaders can offer nurses educational opportunities and training programs on empowerment and how to use it in the workplace. The assessment of nurses' knowledge and skill in relation to structural empowerment, as well as the resources and information available, ought to be the main emphasis of programs. In order to encourage nurses and improve their performance on the job, administrators should offer them opportunities for learning and growth as well as a strong recognition system.

There is a large amount of literature which provides theoretical perspectives about empowerment and identifies the importance and benefits of empowering nurses in order to promote positive working environments and health care outcomes. The transformation of the healthcare system to meet the 2030 vision in Saudi Arabia emphasizes the importance of delivering a standard of excellence in health care. This places a heavy burden of responsibility on diploma nurses who are primarily responsible for the delivery of nursing care. There is a lack of research conducted in Saudi Arabia, or which focusses on diploma nurses, to suggest how they can be empowered in the current health care environment This study therefore seeks to generate information on how to enhance nursing performance in this nurse population which is empirically under researched.

3. Research Methodology

The study used a qualitative and quantitative study design with a grounded theory approach to explore diploma nurses’ views and interpretations of their role and performance relating to clinical practice. This type of design was chosen as it is particularly well suited for investigating social processes where there is a lack of previous research [32].

4. Research Setting

The study took place in three Health Network facilities within the Eastern Health Cluster (EHC) that provide secondary level care to Saudi Nationals and citizens of the Gulf States, which are situated in the Eastern province of Saudi Arabia.

5. Research Participants

The study was conducted over a nine months period from June 2022 until the end of December 2022. The study used a purposive sampling technique to identify and examine the characteristics of diploma nurses with the aim of enhancing their performance whereby all nurses and midwives working in health network facilities were invited to participate in the study that met the following criteria for eligibility: 2 and a half-year undergraduate diploma nurse training and providing direct patient care. A total of 15 diploma nurses and 3 Nurse Directors representing three health networks were enrolled in the project, on a voluntary basis, as the majority of diploma nurses within EHC are working in these areas.

6. Research Instrument

A research instrument (Table 1) was developed by the EHC Director of Professional Development, in English and Arabic language to guide focus group and questionnaire, it is consisted of 13 semi-structured open-ended questions which aimed to examine views and identify strategies amongst diploma nurses that may be beneficial in enhancing performance.

Table 1. Research Questionnaire

7. Data Collection /Pilot

The quality of the questionnaire was evaluated by a panel of expert nurse practitioners who assessed construct validity to ensure that it met its objectives in exploring diploma nurses’ views and interpretations of their role and performance. A pilot study was tested on five study participants to confirm reliability through the clarity of questions amongst Saudi nurse practitioners [33]. No variables were identified which it was felt may impact on the study [34]. Nonetheless as the pilot size was small, the possibility cannot be excluded that certain problems may not have been detected.

A total of two focus group sessions were conducted amongst health network facility nursing staff to explore knowledge in relation to diploma nurse performance. Each session was conducted over a maximum of 90 minutes. One session was conducted for diploma nurses, a total of 12 participated from a total 15 who were invited; a response rate of 80%. A separate session was held for 3 Nurse Directors, one from each health network, who all attended. The focus group discussions were taped to ensure accurate recording of the discussion and the questionnaire was distributed with a demographic questionnaire by the researcher to participants of both sessions for triangulation of data to increase the credibility and validity of research findings [35].

8. Ethical Considerations

Approval for the study was obtained from King Fahad Specialist Hospital Institutional Review Board, Dammam. The study was conducted based on the informed consents of participants which provided a full disclosure of information to participants which included the identity of the researcher; the purpose and nature of the study; the right to refuse to participate without loss or penalty; the right to withdraw at any time without fear of reprisal; the possible benefits and the potential risks of the study; and measures to be taken to protect privacy and ensure confidentiality [36].

9. Data Analysis / Findings

The study was conducted based on the theoretical assumption that diploma nurses’ performance can be enhanced using empowerment strategies. A descriptive analysis was first undertaken to highlight the demographic characteristics of the 12 diploma nurse participants relating to age, gender, position, years of experience, unit and hospital. The demographic data sheet was received completed in all categories with a 100% response rate, shown in Table 2 below.

Table 2. Demographic data

Figure 1. Age

The majority of diploma nurses were between 30-40 years of age (84%).

Figure 2. Gender

The majority of the participants were female (92%).

Figure 3. Positions

The majority of diploma nurses were employed as staff nurses (91.6%).

Figure 4. Years of Experience

The majority of diploma nurses had between 5-15 years of experience (84%).

Figure 5. Working Unit

The diploma nurses worked in a variety of departments, 3 nurses (25%) worked in critical care areas compared to 6 nurses that were working in medical or surgical wards (50%).

Figure 6. Health Network

The nurses worked in three different health networks. The majority of nurses worked in Dammam Health Network (DHN) 5 (42%) compared to Jubail Health Network (JHN) or Qatif Health Network where 3 nurses were working in each (25%) health network. Unfortunately, it was not clear where one participant was working as Ministry of Health, rather than the name of the health network, had been entered as a response.

10. Qualitative Analysis

Debriefing sessions were held after both focus group interviews to reflect on the focus group process and the significance of the data. One research member transcribed, reviewed and analyzed the contents of the tape for the first focus group session with the diploma nurses. Data triangulation was then completed by comparing data entered on the questionnaire in order to provide a better understanding about diploma nurses views and how to enhance their performance [37]. This process was repeated by a different researcher for the second focus group session with the nursing directors.

The interview data was coded, linked and grouped into categories and concepts to provide a comprehensive theory to identify how the diploma nurses’ performance can be enhanced. Coding and categorization of data was completed aligned with qualitative research principles [38]. Data were conceptualized through initial coding using a method of constant comparison (conceptual or open coding), coded data was then compared against other data to create categories before finally emerging into core categories (thematic or axial coding) to support the purpose of the study in enhancing performance.

The three levels of data coding used to complete the thematic analysis are shown below in Table 3.

Table 3. Data coding levels

The qualitative analysis revealed three main themes which emerged from the focus group data: perception of diploma nurses performance, area for improvement/recommendations, and education enhancement.

11. Perception of Diploma Nurses Performance

The Majority of the participants in the focus group did not see any difference between the performance of diploma nurses and the nurses holding baccalaureate degrees in terms of providing nursing care to the patients, performing nursing procedures or the level of commitment and accountability. They asserted a degree is only a certificate which does not replace experience or necessarily ensure safe practice. Most of the diploma nurses identified that the confidence that they gained through experience enabled them to manage any patients, even critical ones requiring complex care.

The following insights were expressed by the diploma nurse focus group:

“Experience and good spirit make diploma nurses competent in providing nursing care.”

“No, there is no difference because both do the same work.”

“From my point of view and from what I see, experience and hard work, diploma nurses are stronger and better.”

The Nursing directors shared similar perceptions regarding the performance of diploma nurses whereby they agreed that there was no obvious difference in performance as both diploma and baccalaureate degree nurses complete the same competences and training.

The following insights were expressed by the nurse director focus group:

“When it comes to comparing both, based on the feedback from nursing mangers, some of the 2.5 diploma nurses are much better because they have more experience, and nurses learn by experience”.

“I cannot see any obvious differences especially as they are completing the same competencies.”

“Nursing is like the military, you gain experience with time.”

12. Area for Improvement

One view that was expressed frequently by diploma nurses during the focus group session was that diploma nurses were not fully appreciated or recognized and they emphasized the importance of this in fostering a positive working environment. In addition to ongoing recognition, there was consensus within the group that nursing leadership should acknowledge and appreciate the contribution of nurses with many years of working experience by transferring them to areas with reduced workloads.

Communication was seen as another area for improvement, diploma nurses identified the need for better communication between nurses, physicians and patients in order to facilitate improved teamwork and health care outcomes. They also felt that the quality of their care delivery could be improved if more medical supplies and equipment were available as they believed that the shortage of resources which reflected negatively on their performance.

Diploma nurses were enthusiastic about improving their performance and identified the need for increased job opportunities and professional development programs in order to strengthen their capabilities. Some members of the group felt that there was disparity between themselves and baccalaureate degree nurses in relation to course availability and accessibility as they often did not meet the criteria for course enrollment. They also added that they would benefit more from the courses they were able to attend if they were conducted in Arabic to promote better understanding of the content. However, they also mentioned the need for English language courses as they felt that improved linguistic skills may lead to better engagement within the both the nursing and multidisciplinary team.

The nursing director’s strongly agreed during their focus group session that diploma nurses must be more involved, engaged, and empowered if their performance is to be enhanced. They provided the following insights which were aligned with the views of the diploma nurses:

“They need to be appreciated for what they are doing.”

“We have to give opportunities for them; these are really excellent at their job.”

13. Education Enhancement

Most of the diploma nurses who participated in the focus group were enthusiastic about the possibility of a diploma nurse development program. Several topics were suggested for the program, these included documentation, nurse scheduling, leadership competence, patient assessment and Intravenous therapy. Practical sessions with pre and posttest assessment were also requested.

The diploma nurses expressed positive views about the baccalaureate degree bridging program and there was a willingness to join the program within the group. However, some highlighted that there were challenges in enrolling on the program due to shortages of staff and lack of availability of spaces. Nurses were also concerned about enrolling on the program as it is conducted on a full time basis. The baccalaureate bridging program design was discussed within the group and different opinions were shared about the best schedule timing, duration and teaching methods. Some supported the idea of full time study dedication compared to others that preferred the possibility of being released from work on a part time basis to complete practical training and certification while still continuing their own duties.

The necessity of bridging programs was emphasized in the nursing directors’ focus group session as some EHC facilities in the health network are working towards magnet program accreditation where baccalaureate degrees are a mandatory requirement. They suggested that a practical solution, to promote access for the large number of nurses interested in the bridging program, would be for universities to provide a modular based credit program which nurses could complete while still attending their work responsibilities.

14. Discussion

The ongoing reform of health care services in Saudi Arabia poses many challenges to the nursing profession as it strives to achieve excellence in health care delivery. The onus is on nursing leadership in Ministry of health facilities to maximise the potential of diploma nurses through empowerment strategies, given that they constitute a large percentage of the workforce, if they are to meet the 2030 vision in health care transformation.

The analysis of 12 diploma nurses and 3 nursing directors’ views relating to the diploma nurses performance showed that the capabilities of diploma nurses can be strengthened. Three themes emerged from the focus group discussions which encapsulate their beliefs: ‘perceptions of diploma nurses performance’, ‘areas for improvement’, and educational enhancement.

The diploma nurses and nursing directors shared the same opinion that there is no difference overall between the performances of diploma nurses compared to baccalaureate degree nurses. There is a lack of literature which compares the performance of diploma nurses to baccalaureate degree nurses. However, Adib Hajbaghery & Salsali’s study [29] identified that the “application of professional knowledge and abilities” is needed for personal empowerment. This supports the opinions of both the diploma nurses and directors who emphasized the importance of experience in influencing performance rather than qualifications. As the majority of diploma nurses in the study had between 5-15 years of experience, the extensive development of knowledge and skill acquired through the provision of nursing care during this time may explain why no difference was perceived in performance.

Diploma nurses identified areas for improvement in the workplace that should be addressed from their perspective. Core requirements included the need for appreciation and acknowledgement, the provision of skills, equipment, and resources necessary to work to the best of their ability, and increased job opportunities and access to courses to support professional development. These findings are underpinned by the empowerment theory which identifies the importance of access to information, support, resources, and opportunities to learn and grow if there performance is to be enhanced [15].

Previous studies support the need for healthy work environments where there is a strong recognition system, respect and confidence in management and access to necessary resources and training programs if nurses are to be empowered in the workplace and have increased job satisfaction and commitment to their work [24,30,31]. Staff recognition programs, opportunities for learning and professional growth, and improved access to resources must be provided by senior management in health network facilities in order to further enhance the diploma nurses performance.

Diploma nurses insights received during the focus group session acknowledged the need to develop educational programs to generate new knowledge and reinforce previous learning about specific topics in order to strengthen their performance. The importance of knowledge acquisition in enhancing performance is supported in the literature where it is identified as an empowerment strategy [21,24,29]. Additionally, the need for baccalaureate degree bridging was emphasized as it is a necessity for career advancement. Diploma nurses are willing and eager to learn. The onus is therefore on nursing leadership to ensure availability and access to educational programs which meet the needs of the diploma nurse and they must be supported and sponsored at organizational level to attend bridging programs in the future if they are to enhance their performance and make further contributions to improve nursing practice and health care outcomes.

15. Recommendations and Implications for Nursing Practice

This study has highlighted the reliability of diploma nurses in delivering good nursing care which may at times be better than that of their colleagues with baccalaureate degrees who have less experience. Appreciating and rewarding the contributions of both diploma and degree nurses will be influential in improving patient care delivery, staff satisfaction and staff empowerment. Although registration bodies are more in favor of registering nurses in accordance with their certificates, incorporating and recognizing nurse’s experience will benefit both staff and patients and at the same time aid the retention of highly skilled diploma nurses that constitute the majority of the nursing workforce in the MOH of Saudi Arabia. In order to achieve the aims of the current health care transformation, universities should be permitted to conduct part time bridging programs for diploma nurses that will help in enhancing their education without releasing them for full time studies that might have a negative impact on staff numbers and patient care delivery.

16. Limitations

Although the study adopted a grounded theory approach where data saturation was reached in both the focus group interviews and in response to the questionnaire, primary health care nurses were not included in the research. It is possible that a larger sample size which includes nurses from primary health care may provide different perspectives. Conversely, a larger sample size may limit the responses from some participants who feel pressured to share time with others. Another limitation of the study is the data triangulation. Individual interviews, in addition to the focus group interviews and questionnaire, may enhance the strength of the study and the use of multiple researchers to complete the data triangulation process could limit the possibility of research bias. Finally, the results of the study are limited to EHC diploma nurses and as such they are not generalizable. It is recommended to replicate the research and conduct it as a multi cluster study at national level.

17. Conclusion

Participants identified that the confidence they gained through experience is equal to qualifications. However, capabilities of diploma nurses can be strengthened. Core requirements include the need for appreciation and acknowledgement, the provision of skills, equipment, and resources necessary to work to the best of their ability, and increased job opportunities and access to courses to support professional development. Diploma nurses’ insights received during the focus group session acknowledged the need to develop educational programs to generate new knowledge and reinforce previous learning regarding specific topics in order to strengthen their performance. Involving Diploma nurses in transformation programs through Model of Care (Makken Programs) and planning for bridging programs are recommended strategies. Further studies are needed to identify empowerment strategies and measure their effectiveness in this population.

Acknowledgements

The authors would like to thank the diploma nurses and nursing directors in EHC health network facilities who participated in this study for their support and encouragement. The IRB at King Fahad Specialist Hospital is also appreciated for their approval of this study.

Conflict of Interest Disclosure

There are no conflicts of interest

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