Leadership Experiences of Nurse Managers in a Saudi Ministry of Health Hospital: A Focused Ethnographic Study

One of the key priorities of Saudi Vision 2030 is to ensure that all Saudi citizens have access to high-quality healthcare, but this goal is constrained by international and domestic nursing staff shortages. Nursing directors have recommended introducing a professional career path focused on developing nurses' leadership skills. Despite recognition of nurse managers' key role in recruiting, retaining, and engaging nurses, few studies have explored how Saudi managers acquire and deploy leadership skills. This study explores how nurse managers view and experience workplace leadership.

This ethnographic study examined nurse managers' perceptions and experiences of leadership development in a Saudi hospital affiliated with the Ministry of Health. Qualitative data were collected during periodic visits over eight months, including workplace and continuing medical education observations, document examinations, and informal and semistructured interviews with 21 nurse managers. A framework analysis approach was used to interpret and summarize the data.

The data were organized into four major themes: imbalanced power dynamics, no shared vision, workplace rituals and behaviors, and the need for learning. The findings indicated a power imbalance, consistent with international studies. The hospital had hierarchical and transactional management structures and a culturally pervasive leadership approach framed by wasta ("middleman" or "go-between" in Arabic). Such nepotism, normalized in Saudi business practice, is officially recognized and condemned as corrupt by state legislators. The Saudi government is rigorously combating this practice through strict regulations and enforcement. A climate encouraging adherence with the directorate's guidelines led managers to comply, even though they employed strategies to subvert some of its authority.

Wasta was used to enhance performance, obtain rewards, secure favorable work assignments, gain meritless promotions, and allocate staff arbitrarily. Paradoxically, while managers criticized the capricious use of wasta, they also employed it to secure what they believed they deserved, sometimes at the expense of their colleagues' careers.