THE SAUDI ARABIAN health care system is experiencing

PREDICTORS OF SUCCESS FOR SAUDI ARABIAN STUDENTS ENROLLED IN AN ACCELERATED BACCALAUREATE DEGREE PROGRAM IN NURSING IN THE UNITED STATES RITA M. CARTY, PHD, RN, FAAN,* MARGARET M. MOSS, PHD, RN,y WAEL AL-ZAYYER, PHD, RN,z YANIKA KOWITLAWAKUL, MSN, RN, PHD(C), AND LESLEY ARIETTI, BAO In the mid 1980s, a professional nursing education program was initiated between the Kingdom of Saudi Arabia and the United States. Based on a perceived and documented need, a collaborative education and research program was established with George Mason University in Fairfax, Virginia, to begin building a community of new scholars to assist in the advancement of professional nursing in the Kingdom of Saudi Arabia. Four cohorts of Saudi citizens from three institutions (King Faisal Specialist Hospital and Research Center, Saudi Arabia National Guard Hospital, and Ministry of Aviation and Defense Hospital), who held a degree in science or a related field, were enrolled in an accelerated baccalaureate program leading to a bachelor of science in nursing degree. This project was funded by Saudi Arabian sources. A descriptive research study was conducted to identify predictors of success in the program. Results indicated a rate of program completion that was higher than expected. Some of the first graduates went on for a doctor of philosophy degree, but not all enrolled completed the program. Many countries around the world are seeking ways to upgrade and increase the supply of qualified nurses within their own borders. This study identified those factors that were predictors of success for Saudi Arabian students who completed a baccalaureate degree in nursing program in the United States. (Index words: Saudi Arabia; International; Education; Success; Predictors; Baccalaureate; Language; Culture; Sex) J Prof Nurs 23:301 8, 2007. A 2007 Elsevier Inc. All rights reserved. *Professor and Dean Emeritus, George Mason University College of Nursing and Health Science, Fairfax, VA. Instructor, George Mason University College of Nursing and Health Science, Fairfax, VA. Assistant Chief of Nursing Affairs, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia. Doctoral Student, George Mason University College of Nursing and Health Science, Fairfax, VA. International Executive Coordinator, George Mason University College of Nursing and Health Science, Fairfax, VA. Address correspondence to Dr. Carty: 11413 Hollow Tree Lane, Rockville, MD 20852. E-mail: rcarty@gmu.edu 8755-7223/$ - see front matter THE SAUDI ARABIAN health care system is experiencing a shortage of Saudi Arabian nurses, with most positions being filled by American, Filipina, and Egyptian nurses. According to Al-zayyer (2003), Saudi Arabia has had a history of consistently low enrollments in university nursing programs. Some of the same reasons that have influenced low enrollments in the United States and other countries have impacted nursing as a career choice in Saudi Arabia. These include a poor image of nursing, low pay, poor working conditions, and long working hours. These factors have created a perceived and documented need for the preparation of Saudi citizens to become nurses to assist in the development of professional nursing in the Kingdom of Saudi Arabia. Journal of Professional Nursing, Vol 23, No 5 (September October), 2007: pp 301 308 301 A 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.profnurs.2007.06.001

302 CARTY ET AL Purpose of the Study The purpose of this study was to identify predictors of success for Saudi Arabian students enrolled in an accelerated baccalaureate program leading to a bachelor of science in nursing (BSN) degree. For the purpose of this study, success was considered as completion of all program requirements, placing the student in good standing and eligible for graduation. Significance of the Study Leh, Robb, and Albin (2004) proposed a new perspective in international health relationships that focuses on the development of partnerships and collaboration among institutions to participate in the sharing of plans, resources, results, and credits. This new perspective takes into consideration the process of power, interest, knowledge, and leadership in addressing health as an international issue. The exchange of health care knowledge and resources needs to be incorporated into international education and practice in nursing to build a community of new practitioners, scholars, and researchers. In 1995, the Saudi United States University Project was initiated by a collaboration between the King Faisal Specialist Hospital and Research Center in the Kingdom of Saudi Arabia and several US universities. The George Mason University College of Nursing and Health Science (GMU-CNHS) was the participating nursing institution in this project tasked to prepare highly qualified and competent Saudi Arabian bedside nurses to become nurse leaders, educators, and researchers (Carty et al., 1998). The program started in May 1995: 12 male Saudi Arabian students were selected to attend an accelerated BSN program at the GMU-CNHS. Over the past 10 years, the GMU-CNHS accelerated program has successfully graduated 34 Saudi Arabian students, who had baccalaureate degrees in other fields, with BSN degrees. According to the project student records (of the GMU for 2005), 34 of the 37 Saudi Arabian students admitted successfully graduated from the GMU- CNHS. As part of the evaluation of this 10-year program, approval was granted by the GMU Office of Research Subject Protections to identify predictors of success for the students enrolled in this program. All factors considered were data contained in student records or data obtained from student application forms. The main focus of this study was to determine what factors predict the success of Saudi Arabian students who complete a baccalaureate degree in nursing program. Review of the Literature In predicting success, there are many variables, both academic and nonacademic, that may affect a student's success and performance. Such variables include admission criteria, first-year, second-year, and final grade point averages (GPAs), grades in science classes, grades in specific classes in the major course, standardized examination scores, and ethnicity (Waterhouse & Beeman, 2003). Regarding Saudi Arabian students, there is no literature addressing factors that could predict their success in a nursing program. Much of the literature describes barriers to international and minority nursing students' success. Those barriers to success originate from both the socioeconomic and cultural environments in schools of nursing (Evans, 2004). In addition, the barriers may be academically, personally, or environmentally related (Campbell & Davis, 1966; Merrill, 1998). According to Carty et al. (1998), the Saudi Arabian culture is established in tradition and marked by strong family, religious, and social values. The most restrictive Saudi Arabian values involve the interaction between males and females. The relevance of this fact for this study is that students in Saudi Arabia are generally taught by a person of the same sex. This was not the case in the program studied. The faculty were predominantly female, and the students were predominantly male. In addition, married students place a high value on time spent with the family. Thus, attending classes all day, coupled with the need to study at night, is unacceptable because it interferes with family time. The program held little flexibility to accommodate such needs because it was structured in a linear manner such that courses could not be repeated. Thus, if any student failed a course, he or she would be withdrawn from the program. Cultural values give an individual the direction and meaning of life (Campinha-Bacote, 2003). Culture and values influence students' success and their ability to adapt to a different cultural environment. Understanding these concepts helps with the understanding of Saudi Arabian students. Faculty efforts to combine Western technology with the Saudi Arabian culture have not always been successful (Mansour, 1994). A balance needs to be established between Western technology and the students' culture to promote the success of international students, including Saudi Arabian students studying in the United States. In the program studied, many teaching/learning strategies were specifically tailored to meet the learning needs of the Saudi Arabian students. Most students enrolled in the GMU-CNHS program were men. It is likely that some Saudi Arabian men distance themselves from nursing and view nurses as subordinate to physicians. In a culture in which honor is strongly linked to status, nursing may be viewed as a second-rate profession (Carty et al., 1998). Conversely, Mansour (1992) showed that Saudi Arabian parents and students perceive a great need for Saudi Arabian nurses and that nursing is an acceptable career for both men and women. However, the perception of being a nurse might be different for the individual male Saudi Arabian student. According to Sherod (1991), a male nursing student's difficulty with fulfilling role obligations (role strain) is more statistically significant than that of a female nursing student. Male Saudi Arabian nursing students may experience stress and role strain that can interfere with

PREDICTORS OF SUCCESS 303 their success if they are conflicted between their sex and their new occupational role. Haloburdo and Thompson (1998) suggested that the nature and design of an international nursing experience itself may be more important than the duration of that experience in enabling positive learning outcomes. Patterson and Morin (2002) found that although male student nurses experience discomfort with their maternal child clinical rotation, they do ultimately consider it to be a positive experience overall. According to Sanner, Wilson, and Samson (2002), students who develop and have strong study skills during the educational experience are more likely to be successful and to graduate. According to the examination of sex-based barriers for male students in nursing education programs by O'Lynn (2004), nursing education, as a whole, has failed to provide an optimal environment to encourage the attraction and retention of men as students. In addition, Evans (2004) stated that one of the important barriers for international male or female students' success is struggling with language issues. International students, especially those with English as a second language, can have difficulty adjusting to university life in the United States and successfully dealing with the demands of a nursing program (Sanner et al., 2002). Carty et al. (1998) found that effective communication is one of the keys to success for international students in an education program, and this was especially true for the Saudi Arabian students. Based on a review of the literature, demographic and nondemographic variables (e.g., marital status, family setting and location, health care experience, degree background, admission criteria, and English testing scores) alike are key factors that might predict the success of Saudi Arabian students in a nursing program. As mentioned, the literature shows that international and minority nursing students face multiple barriers to success. Few literature sources specifically identified barriers to or predictors of success for Saudi Arabian nursing students. Research Question What demographic and nondemographic factors were predictors of success for Saudi Arabian students enrolled in an accelerated program leading to a BSN degree in the United States? Methodology This was a descriptive study with a convenience sample and included all male and female Saudi Arabian students who completed an accelerated baccalaureate nursing program under a funded project between 1995 and 2005 (Table 1). Thirty-seven students were enrolled in the project, but 3 were unable to complete it and thus were not included in the data: 1 student left for academic reasons, whereas the other 2 students left for personal reasons. They therefore did not meet the criteria for the study and were not included. There were four cohorts of Table 1. Descriptive Data on the Participants Cohort Minimum Maximum M SD First cohort (n = 11, all-male cohort) Graduate GPA 3.32 4.00 3.6255 0.22536 Age (years) 22 28 24.36 2.111 Admission GPA 3.01 4.33 3.2973 0.36808 ELI or TOEFL 10 28 20.64 5.870 No. of children 0 2 0.18 0.603 Second cohort (n = 9, all-male cohort) Graduate GPA 2.96 3.77 3.4256 0.25150 Age (years) 24 33 27.22 3.032 Admission GPA 2.14 3.24 2.8200 0.38665 ELI or TOEFL 22 40 28.44 5.270 No. of children 0 4 1.67 1.500 Third cohort Male (n =2) Graduate GPA 2.94 3.64 3.2900 0.49497 Age (years) 27 33 30.00 4.243 Admission GPA 2.66 3.08 2.8700 0.29698 ELI or TOEFL 24 25 24.50 0.707 No. of children 0 3 1.50 2.121 Female (n =6) Graduate GPA 2.96 3.60 3.2833 0.24598 Age (years) 24 38 30.67 5.715 Admission GPA 2.20 3.78 2.8833 0.58804 ELI or TOEFL 16 41 26.50 9.482 No. of children 0 3 0.67 1.211 Fourth cohort Male (n =5) Graduate GPA 2.81 3.32 3.2060 0.22233 Age (years) 23 25 24.00 0.707 Admission GPA 2.35 3.15 2.6940 0.36970 ELI or TOEFL 25 29 26.60 2.191 No. of children 0 1 0.20 0.447 Female (n =1) Graduate GPA 3.35 3.35 3.3500 Age (years) 25 25 25.00 Admission GPA 2.08 2.08 2.0800 ELI or TOEFL 36 36 36.00 No. of children 0 0 0.00 students, for a total of 34 participants, 27 male and 7 female students, as follows: first cohort: 11 male students and 0 female student; second cohort: 9 male students and 0 female student; third cohort: 2 male students and 6 female students; and fourth cohort: 5 male students and 1 female student. The factors studied were as follows: 1. admission GPA: the GPA of the students from their first degree program in Saudi Arabia before their admission to the accelerated program; 2. university background: the academic qualification earned by the students in Saudi Arabia before their admission to the accelerated program;

304 CARTY ET AL Table 2. Correlations Among the Five Continuous Variables for All Students Graduate GPA Age Admission GPA ELI or TOEFL No. of children Graduate GPA Pearson's correlation 1 0.190 0.627 * 0.018 0.047 Significance (two tailed).283.000.920.790 Age Pearson's correlation 0.190 1 0.271 0.371 ** 0.628 * Significance (two tailed).283.122.031.000 Admission GPA Pearson's correlation 0.627 * 0.271 1 0.294 0.055 Significance (two tailed).000.122.092.759 ELI or TOEFL Pearson's correlation 0.018 0.371 ** 0.294 1 0.425 * Significance (two tailed).920.031.092.012 No. of children Pearson's correlation 0.047 0.628 * 0.055 0.425 ** 1 Significance (two tailed).790.000.759.012 *Correlation is significant at the.01 level (two tailed). **Correlation is significant at the.05 level (two tailed). 3. degree background: science or humanities degree; 4. health care experience: any kind of health care experience the students had in Saudi Arabia before their admission to the accelerated program; 5. English Language Institute (ELI) and Test of English as a Foreign Language (TOEFL) score: students' English proficiency as measured by the TOEFL examination or as verified by the ELI at the GMU; 6. marital status: students were either married or single; 7. number of children: actual number of children, either with the students in the United States or at home in Saudi Arabia; 8. family in the United States: any family member living in the United States; 9. age: age of students upon their admission to the accelerated program; 10. graduate GPA: students' GPA upon completion of the accelerated program; 11. articulation of nursing goals: students' statements of goals for their nursing career; and 12. National Council Licensure Examination: this was considered as an outcome of the program and therefore not included as a predictor of success in the study. Data Analysis SPSS version 11.5 (SPSS, Chicago, IL) was used to analyze the data. A correlational technique was used to study the relationship between the dependent variable (the graduating GPA as defined in Item 10 a key indicator of success regarding completion of the program) and the independent variables (age, admission GPA, graduating GPA, ELI/TOEFL score, and number of children). A comparison of mean values was used to determine the differences on categorical variables (university background, degree background, marital status, family in the United States, health care experience, and having articulated goals). Pearson's correlations were used to determine the level of significance among the identified variables. Figure 1. Mean graduating GPA score in each cohort. Figure 2. Mean admission GPA and graduating GPA scores in each cohort.

PREDICTORS OF SUCCESS 305 Figure 3. Mean graduating GPA scores of the students by sex. Figure 5. Mean graduating GPA scores of the students by sex and degree background. Among the four cohorts, male students in the first cohort had the highest maximum graduating GPA (4.00) and the highest maximum admission GPA (4.33). Male students in the fourth cohort had the lowest maximum graduating GPA (3.32) and the lowest maximum admission GPA (2.81). There was only one female student in the fourth cohort, so the data were not comparable within the female group. Table 2 shows that the admission GPA is significantly and positively related (r = 0.627, P b.001) to the graduating GPA. It indicates that higher admission GPA scores are related to higher graduating GPA scores. There is no relationship between graduating GPA and ELI or TOEFL score, age, or number of children. Figures 1 and 2 indicate that the students in the first cohort had the highest graduating mean GPA score (3.6255). The fourth cohort students had the lowest graduating mean GPA score (3.23). Similarly, the first cohort students had the highest admission mean GPA score (3.2973). The fourth cohort students had the lowest admission mean GPA score (2.5917). Figure 3 indicates that all male students had a higher graduating mean GPA score (3.4563) as compared with all female students (3.2929). Figure 4 indicates that students who have a BS degree background had a higher graduating mean GPA score (3.4421) as compared with students who have a bachelor of arts (BA) degree background (3.31). Figure 5 indicates that male students who have a BS degree background had a higher graduating mean GPA score (3.4838) as compared with male students who have a BA degree background (3.2367). Female students who have a BS degree background had a lower graduating mean GPA score (3.420) as compared with female students who have a BA degree background (3.242). Male students who have a BS degree background had a higher graduating mean GPA score (3.4838) as compared with female students who have a BS degree background (3.2420). Male students who have a BA degree background had a lower graduating mean GPA score (3.2367) as compared with female students who have a BA degree background (3.4200). Figure 6 indicates that married students had a higher graduating mean GPA score (3.4600) as compared with single students (3.3995). As shown in Figure 7, married male students had a higher graduating GPA score (3.4718) as compared with single male students (3.4456). In addition, married female students had a higher graduating mean GPA score (3.3950) as compared with single female students (3.2520). However, single male students had a higher graduating mean score (3.4456) as compared with single female students (3.2520), and married male students had a higher graduating mean GPA score (3.4718) as compared with married female students (3.3950). Figure 8 indicates that the students who have family living in the United States had a higher graduating mean GPA score (3.4525) as compared with the students who do not have family living in the United States (3.4064). As shown in Figure 9, male students who have family living in the United States had a lower graduating mean GPA score (3.4489) as compared with male students who do not have family living in the United States (3.4600), but female students who have family living in the United States had a higher graduating mean GPA score (3.4633) Figure 4. Mean graduating GPA scores of the students by degree background. Figure 6. Mean graduating GPA scores of the students by marital status.

306 CARTY ET AL Figure 9. Mean graduating GPA scores of the students by sex and presence of family in the United States. Figure 7. Mean graduating GPA scores of the students by sex and marital status. as compared with female students who do not have family living in the United States (3.1650). Male students who do not have family living in the United States had a higher graduating mean score (3.4600) as compared with female students who do not have family living in the United States (3.1650). Figure 10 indicates that, of the 34 participants, students who do not have health care experience had a higher graduating mean GPA score (3.4527) as compared with those who have health care experience (3.3989). As shown in Figure 11, all female students had health care experience; therefore, they cannot be compared within the female group. Among the male students, the mean GPA scores between those who have and those who do not have health care experience are almost the same, although the results do indicate that male students with health care experience scored a little higher (3.4608) than did those without health care experience. The male students scored better than did the female students regardless of health care experience. Figure 12 indicates that all students who articulated goals had a higher graduating mean GPA score (3.4686) as compared with students who did not articulate goals (3.4226). As shown in Figure 13, male students who articulated goals had a higher graduating GPA score (3.5004) as compared with male students who did not articulate goals (3.2025). Female students who articulated goals had a higher graduating GPA score (3.3220) as compared with female students who did not articulate goals (3.2200). Male students who articulated goals had a higher graduating mean GPA score (3.5004) as compared with female students who articulated goals (3.3220). Male students who did not articulate goals had a lower graduating mean GPA score (3.2025) as compared with female students who did not articulate goals (3.2200). Results The results of this study indicate that admission GPA was the most significant predictor of success. A higher admission GPA meant a higher graduating GPA. However, the data further indicate that there was no relationship between GPA, ELI, or TOEFL score, age, and number of children, which were the continuous variables among all students. This finding is somewhat puzzling with regard to the TOEFL or ELI score because experience clearly identified language skills as a challenge for these students' success. Either TOEFL or ELI verification was required for admission, but neither correlated with the graduating GPA. All male students had higher graduating mean GPA scores as compared with all female students. In a predominantly female profession such as nursing, and considering that male students in many cases would have preferred another career, it is surprising that the men had such a high academic achievement. Academic achievement may reflect cultural influence. An expected finding was that those students with a science background would do better than those with a background in the humanities. The project originally required all students to have a science background, but with difficulty recruiting students who matched all Figure 8. Mean graduating GPA scores of the students by presence of family in the United States. Figure 10. Mean graduating GPA scores of the students by health care experience.

PREDICTORS OF SUCCESS 307 Figure 11. Mean graduating GPA scores of the students by sex and health care experience. admission requirements, this requirement was relaxed. A background in science was a predictor of success for this accelerated program and would be recommended for any future program. Married students with family living in the United States had a higher graduating GPA as compared with single students. This was true for both male and female students. This was not an expected finding. In fact, the project faculty had encouraged students to come to the United States without their family so as to have more time to study. It quickly became evident that married students both wanted and needed their families with them. A strongly held belief of the project faculty was that students who had work experience in a health care setting, regardless of the nature of the experience, would be more successful as compared with students without health care experience. The findings of the study indicate that when considering the total study population, students without health care experience achieved a higher graduating GPA as compared with those with health care experience. However, male students with health care experience scored a bit higher than did male students without health care experience and higher than did the female participants, all of whom had health care experience. Given the intensity and unfamiliarity of the Saudi Arabian students' nursing education experience in the United States, it is possible that any health care experience they may have is so different as to be irrelevant to their US experience as nursing students. Figure 12. Mean graduating GPA scores of the students by having articulated goals. Figure 13. Mean graduating GPA scores of the students by sex and having articulated goals. As a result, a background in health care may, at best, have limited impact on their success. On admission, students were asked to articulate goals for a career in nursing, although, at the time of admission, the goals that students listed were often fairly basic, such as help sick people and work with the doctor. Even so, those students who had at least a basic idea of what a career in nursing entailed achieved higher graduating GPAs as compared with the students who did not articulate goals. Another surprise for the project faculty was that age was not significant with regard to success. It was thought that the younger students would be more successful. This did not prove to be true. Conclusions The most significant predictors of success for Saudi Arabian students in this funded project who were enrolled in an accelerated baccalaureate degree program leading to a BSN degree were admission GPA and a degree in science. Male students were more academically successful as compared with female students, and married students in general were more successful as compared with single students. Students whose families were with them were more successful as compared with students living without their families. ELI score, TOEFL score, age, number of children, and health care experience were not predictors of success. Students who had higher admission GPAs were also the students who were able to articulate career goals in nursing and had higher graduating GPAs. Several of the students have gone on to earn their master's degree. Two have completed their doctor of philosophy in nursing degree, and two others are doctoral nursing candidates. Six have completed a master's degree program, and six more are currently enrolled in a master's degree in nursing program. The remaining students are practicing their profession in Saudi Arabia, with the exception of one student who is in medical school. In light of the severe and deepening global nursing workforce shortage, many countries around the world are seeking ways to upgrade and increase the supply of

308 CARTY ET AL qualified nurses within their own borders. This project offers a collaborative model, which had much success and contributed to the body of knowledge that identifies predictors of success. Although the results cannot be generalized, they do provide insight and guidance in planning future programs. References Al-zayyer, W. (2003). The effectiveness of recruitment and retention strategies and the severity of recruitment and retention barriers of staff nurses in selected tertiary care hospitals in Saudi Arabia. Unpublished doctoral dissertation, George Mason University. Campbell, A. R. & Davis, S. M. (1966). Faculty commitment: Retaining minority nursing students in majority institutions. Journal of Nursing Education, 35, 298 303. Campinha-Bacote, J. (2003). Many faces: Addressing diversity in health care. Retrieved January 31, 2003, from http:// www.nursingworld.org/ojin.topic20/tpc20_2.htm. Carty, R. M., Hale, J. F., Carty, G. M., Williams, J., Rigney, D., Principato, J. J. (1998). Teaching international nursing students: Challenges and strategies. Journal of Professional Nursing, 14, 34 42. Evans, B. C. (2004). Application of the caring curriculum to education of Hispanic/Latino and American Indian nursing students. Journal of Nursing Education, 43, 219 228. Haloburdo, E. P. & Thompson, M. A. (1998). A comparison of international learning experiences for baccalaureate nursing students: Developed and developing countries. Journal of Nursing Education, 37, 13 21. Leh, S. K., Robb, W. J. W., & Albin, B. (2004). The student/ faculty international exchange: Responding to the challenge of developing a global perspective in nursing education. Nursing Education Perspective, 25, 86 90. Mansour, A. (1994). Continuing education in Saudi Arabia: The missed sonata. Journal of Continuing Education in Nursing, 25, 90 92. Mansour, A. A. E. (1992). Nursing in Saudi Arabia as perceived by university students and their parents. Journal of Nursing Education, 31, 45 46. Merrill, E. B. (1998). Culturally diverse students enrolled in nursing: Barriers influencing success. Journal of Cultural Diversity, 5, 58 67. O'Lynn, C. E. (2004). Gender-based barriers for male students in nursing education programs: Prevalence and perceived importance. Journal of Nursing Education, 43, 229 236. Patterson, B. J. & Morin, K. H. (2002). Perceptions of the maternal child clinical rotation: The male student nurse experience. Journal of Nursing Education, 416, 266 272. Sanner, S., Wilson, A. H., & Samson, L. F. (2002). The experiences of international nursing students in a baccalaureate nursing program. Journal of Professional Nursing, 18, 206 213. Sherod, R. A. (1991). Obstetrical role strain for male nursing students. Western Journal of Nursing Research, 13, 494 502. Waterhouse, J. K. & Beeman, P. B. (2003). Predicting NCLEX-RN success: Can it be simplified? Nursing Education Perspective, 24, 35 39.