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Providing Professional Development and Emotional Support for the
Remote and Offshore Medic in Saudi Arabia:
A literature review of the benefits for medics and
companies providing healthcare in remote and offshore clinics
Robert Geoffrey Calderwood
Diploma in Remote and Offshore Medicine
Module C01: Health & Wellbeing of the Remote Worker
The Royal College of Surgeons of Edinburgh
(2nd December 2018)
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Abstract
There are more than 150 oil platforms operating in the Arabian Gulf legally obliged to provide onsite
medical cover and an unknown but sizeable number of onshore remote area operations requiring
onsite health care services for their workforce. The remote area medic must be able to appropriately
manage high-frequency, low-acuity illnesses, be skilled in managing low-frequency, high acuity life
threatening conditions, be competent in managing multi-casualty incidents and manage their own
mental health. Infrequent skill use or refresher training leads to skills being lost resulting in a loss of
the medic’s confidence and ability to provide a high quality service. In many clinics the socially isolated
medic is required to be self-reliant and self-taught with limited top-side educational, social or
emotional support being made available. This study examines the benefits of providing this support
to medics when working offshore or in remote areas in Saudi Arabia.
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Providing Professional Development and Emotional Support for the Remote and Offshore Medic in
Saudi Arabia: A literature review of the benefits for medics and companies providing healthcare in
remote and offshore clinics.
Ensuring quality urban healthcare provision is provided across Saudi Arabia is the responsibility of the
Government which focuses on Governmental institutions. In the private sector, remote area
healthcare is self-regulatory. As a consequence of self-regulation and relatively little Government
oversight, the quality of educational and emotional support for remote area medics varies widely
across the sector.
A remote medic should be healthy. The 1978 Alma Ata declaration, reaffirmed by the World Health
Organisation (2006) defines health as "a state of complete physical, mental and social well-being and
not merely the absence of disease or infirmity". Mental health is defined as "a state of well-being in
which the individual realizes his or her own abilities, can cope with the normal stresses of life, can
work productively and fruitfully, and is able to make a contribution to his or her community." (WHO
2001). The isolation of the remote area medic and limited top-side support provided in many clinics
in Saudi Arabia does not provide an opportunity to appropriately address a state of metal health
wellbeing in the medic.
Private health care in Saudi Arabia is staffed by up to 95% expatriate nurses, (Almalki 2011), commonly
from the Philippines or India. Health care provision in remote area clinics is almost exclusively
administered by expatriate nurses provided by private health companies. In a minimally regulated
sector, nurses recruited for remote area work will have a minimum of three years post-registration
hospital experience however the specialty they have worked in is not always considered. Prior to
deployment new recruits are given minimal training in the role expected of them and will be working
in a remote area clinic within seven to ten days of arrival to the Kingdom. Subsequent contact with
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the medic and their employer is minimal and access to continuing medical education is lacking leading
to ill prepared medics with minimal continuing support.
Ciottone (2006) and Ryan et al (2002), describe additional stressors on the remote medic including
“Communicative isolation, … marriage/relationship stability (and) regular communication with
dependents” being of special concern when an employee is deployed for long periods of up to a year
without leave. The standard initial contract for an Indian or Filipino medic in Saudi Arabia before a
vacation is permitted is twenty-four months exacerbating the innate stressors of working in remote
locations.
Stellman (2012) indicates that poor preparation, inappropriate professional education and poor
support all lead to occupational stress and cause both psychological and physical illness. In remote
area health care, preparation should include hiring appropriately qualified staff, preparing them for
remote work and supporting them both socially and mentally whilst on site. This is not the current
business model employed by private health care companies in Saudi Arabia.
Akker et al (2014) define a remote medic as “an advanced clinical practitioner in paramedicine with
an expanded scope of practice … and is resourceful, adaptable, and comfortable working
independently”. Providing the remote medic with appropriate pre-deployment education, onsite
opportunities for professional education and improving social support are all lacking for the majority
of remote medics in Saudi Arabia.
Problem
In private sector healthcare institutions in Saudi Arabia, a department not producing direct and
measurable income, such as in-house staff education, is allocated a budget that often meets only the
minimum required funding to comply with an agreed contract. Providing emotional support and good
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quality continuing professional education for the remote area or offshore medic is viewed as non-
profit generating. Owners and managers of healthcare companies should be aware of the latent
benefits of maintaining quality care provision through good quality educational and emotional support
for its medics whilst they are deployed in remote areas or on offshore platforms.
Aim
This study is to provide health care companies, contracted to supply health care to remote area
operations in Saudi Arabia, with the evidence that investing in the improvement of education,
continuing education and supporting a medic’s mental wellbeing will ultimately benefit the company.
Background
The majority of nursing staff, from which remote area medics are recruited, are hired with little
experience of remote area conditions or the reduced direct support they will experience in remote
locations in Saudi Arabia compared to their experience at home. The majority are recruited with
minimal understanding of the remote area scope of practice and have applied for their position due
to poor home financial circumstances and as a duty to the family. Their motivation is that Saudi Arabia
offers staff a three to four-fold increase in their earning capacity and an opportunity to gain new skills
not readily available in their home country. (Saudi Arabia OFW 2018). Medics are not provided with
relevant information before arriving in Saudi Arabia and give little consideration to the role expected
of them until they are deployed onsite.
In Saudi Arabia the current guidelines on the hiring of medics for remote area work are governed by
two documents. The first guidelines are provided in a comprehensive 2017 contract signed between
a large pseudo-governmental oil and gas producing company in Saudi Arabia and the health care
provider. The second, a guidelines’ document issued by Johns Hopkins Aramco Healthcare (JHAH
2017) Remote Area Clinics (RAC’s) Unit advising other private companies, ‘buying in’ health care
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provision, of the Minimum Medical Required Standards (MMSR) expected of the sub-contracted
health care provider.
The comprehensive contract details experience and education required before a medic is approved to
work in clinics providing direct healthcare to the company’s employees in remote locations and
specifies that a medic must be at least three years post-registration, have at least two years of
documented emergency room experience and be provided with detailed pre-deployment orientation
and training. The service provision is closely monitored with oversight and authority granted to the
company’s health care provider’s quality assurance personnel.
In comparison, the RAC’s Unit’s MMSR manual is an advisory document with no quality assurance
oversight required of the RAC’s Unit. Oversight is within the purview of the onsite contractor’s health
and safety officers, few of whom have any medical background and whose remit is ostensibly, on-site
construction or operational safety. In reality, health care provision for the majority of remote area
healthcare workers in Saudi Arabia, is a relatively unregulated service.
As a sub-contractor, operating a remote area clinic for private clients is dependent on the budget
allocated and quality expectations of the client. Including a budget for the staff emotional and
educational support is considered a costly extra-contractual service. When contracting quality remote
area care, a private company is often reluctant to pay a premium for these services. Where a cheaper
alternative, not providing such services, is available, cost reduction is the priority consideration. The
cost of providing these services for the medics to maintain skills and mental wellbeing is therefore
incumbent upon the healthcare provider. The responsibility for maintaining and improving quality
healthcare, staff emotional and educational support is within the healthcare companies purview and
the benefits of providing these services should be understood.
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Literature Review
The Royal College of Surgeons of Edinburgh (2018), the Institute of Remote Health Care (2013 and
2017) and the UK’s Health and Safety Executive (2016) provide broad guidelines for the pre-
deployment training of remote and offshore medics. For a minority of remote area medics in Saudi
Arabia, this reflects the only training they may receive whilst the majority are provided with much less
than recommended by the guidelines.
A report by the Australian and New Zealand College of Anaesthetists (Gibbs and Borton, 2006) states
that ‘there should be continued emphasis on maintenance of professional standards’ for medical staff
working in remote locations. In many remote area clinics in Saudi Arabia, the opportunity to maintain
these standards is absent.
Opie et al’s 2010 study (cited in Langan-Fox 2011), found remote area nurses “experience significantly
higher psychological distress and emotional exhaustion compared with other professions”. Following
deployment the medic is going to experience loneliness, boredom, depression and cultural shock,
(Whittaker-Howe et al, 2017). Depression and anxiety are more likely to be exacerbated in medics not
given emotional support nor opportunities to maintain professional standards through continuing
professional education. Depression compounded by anxiety has an adverse effect on immediate recall
and amount of knowledge acquisition, (Kizilbash 2002). The adverse effect of being unable to
undertake continuing professional education and maintain the appropriate skills’ levels taught in their
pre-deployment training has the potential to reduce the level of quality care provision and affect the
reputation of the health care company providing the service.
Riordan (2013) states that “embracing and driving change … pursuing growth and learning
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and building a positive team approach … boosts employee satisfaction” and employees “are seven
times more likely to engage fully in their work.” Whilst opportunities to provide these are available in
urban communities, remote area health care workers are unlikely to have ready access to such
opportunities, particularly in an under-regulated sector, such as Saudi Arabia. It requires a desire to
embrace and drive change by investing in programmes providing remote medics with opportunities
to engage socially with their families and friends and with educational opportunities. Observable and
immediate financial return for the health care provider outweighs any desire to invest in such
programmes.
Results of a study conducted by Chen et al., (2009) concur with previous studies and indicate that
“occupational stress from offshore oil work might produce a negative impact on the mental health of
employees”. To mitigate the effect there is a need to decrease or remove the reason for that stress.
The UK’s National Institute for Health and Care Excellence (NICE 2009) notes that investing in the
promotion of employee wellbeing is beneficial to business . It also notes that there is little researched
evidence on the cost benefit. Doherty’s 2002 study, (cited in NICE 2009) states that business costs
associated with ill health include lost or reduced productivity, Wright and Cropanzo (2000), state that
job performance is related to job satisfaction and Cropanzo and Wright (1999), state that performance
can be predicted by the workforce’s wellbeing.
Graveling (2008) reports that those being at greatest risk are employees that lack support and are
working in a threatening environment, both applicable to the environment remote area medical
workers find themselves deployed to in Saudi Arabia.
By providing emotional support and continuing professional development opportunities to remote
medics, job satisfaction improves (Ducharme and Martin, 2000), the maintenance of appropriate skills
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is maintained and enhanced (Bashhok and Parboosingh,1998), the likelihood of depression, anxiety,
social isolation and boredom will be reduced (Melchior et al 2007), mental wellbeing and professional
development will be maintained (Danna and Griffin 1999, van der Kilnk et al 2006) and quality patient
care enhanced. By adopting a business model for remote health care workers in Saudi Arabia that
incorporates mental health wellbeing through appropriate pre-deployment and continuing
professional development, staff attrition is reduced leading to a lower turnover of staff (Cavanagh and
Coffin 1992) and a resultant reduction in time and costs associated with the recruitment and training
of new staff.
The importance of supporting the remote worker’s mental health is beginning to be recognized.
International SOS (2018) advertise as one of its services, ‘Emotional Support’, being the first
international company to provide a remote workforce with a dedicated programme and online
support concerned with mental wellbeing. In 2016, Robert Gordon University (Murray, I., 2016)
launched a module to be incorporated in to a medic’s pre and post-deployment education entitled
‘Mental Health Wellbeing’. The National Association of Emergency Medical Technicians (NAEMT 2018)
in the US has launched a novel course, ‘Psychological Trauma in EMS Patients’, (PTEP), incorporating
a module and skills stations entitled “Helping Our Own”, focusing on mental wellbeing of the
paramedic. As the presentations and training associated with the modules require additional pre-
deployment time, time that private companies consider non-income generating, uptake of both
modules in Saudi Arabia is negligible.
The advent of the world-wide web (www) and voice over internet protocol (VOIP) communication
provides remote area workers the opportunity to maintain contact with dependents and access to
both face-to-face top-side support and a platform to engage in continuing professional development
that builds on a strong preparatory education focusing on the scope of practice expected of the medic.
Providing a good quality evidence based pre-deployment educational curriculum and introducing a
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requirement to provide access to the web in remote area clinics would be a first step in providing
verifiable quality remote area care in Saudi Arabia.
Recommendations
Research indicates that appropriate pre-deployment experience and an introductory educational
curriculum, focusing on the scope and expectations of the worksite, alleviates the uncertainty a medic
experiences when deployed, thus reducing anxiety. Mental wellbeing is improved by contact with
colleagues, family and friends through VOIP communication platforms enabled by the internet and
appropriately focused continuing professional development onsite and during offsite rotations. It is
therefore recommended that these interventions are implemented by the health care providers to
improve the overall service provided to the contracting companies.
Limitations
A meta-analysis conducted by Graveling (2009) concludes that their study into interventions in the
workplace that promote mental wellbeing was “hindered by the imprecision of terms” and the
“plethora of outcome measures utilised”.
This study’s research has been neither as broad in its parameters nor as in depth as Graveling (2009)
and Baxter (2009). The limited search capabilities resulting from the plethora of terms used to describe
wellbeing have however provided evidence that the mental health and wellbeing of remote area
medics is a novel topic in a field of research that focuses on more traditional areas of employment.
The evidence provided here is intended to be a starting point with recommendations having been
extrapolated from the search results.
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Conclusion
The provision of mental health and educational support requires further study to provide information
specifically relating to the wellbeing of the remote medic.
Greater accountability of the private companies providing remote area medical services and
appropriate monitoring of health care provision by companies contracting such care is required to be
able to improve the working conditions of remote area medics in Saudi Arabia.
By providing verifiable pre-deployment education tailored to the scope of practice expected by
contract, providing access to the internet whilst onsite, ensuring realistic continuing education is
available both onsite and during periods back at ‘base’ are measures that will improve the mental
wellbeing of the medic. The latent benefit is to ensure a progressive health care provider remains in
the forefront of care provision to the remote area workforce in Saudi Arabia.
(2435 words excluding the abstract)
(2582 words including the abstract)
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References
Acker, JJ., Johnson TJ., Lazarsfeld-Jensen, A. (2014). Industrial paramedics, out on site but not out of
mind. Journal of Rural and Remote Health. 18.
Baxter, S., Goyder, L., Herrmann, K., Pickvance, S,. Chilcott, J. (2009). Mental well-being through
productive and healthy working conditions (Promoting well-being at work). Sheffield. School of
Health and Related Research. University of Sheffield.
Bashhok, PG., Parboosingh, J. (1998). Recertification and the maintenance of competence. BMJ. 316:
545-8
Cavanagh, SJ., Coffin, DA. (1992). Staff Turnover Among Hospital Nurses. Journal of Advanced
Nursing. 17(11). 1369-1376
Chen, W.Q., Wong, T.W., Yu, T.S. (2009). Mental health issues in Chinese offshore oil workers.
Occupational Medicine. 59, 545–549. Available at <https://doi.org/10.1093/occmed/kqp118>
(Accessed 24 November 2018)
Ciottone, G. R. (Ed.). (2006). Disaster Medicine (3rd ed.). Philadelphia: Mosby Elsevier.
Danna, K., Griffin, RW. (1999). Health and Well-Being in the Workplace: A Review and Synthesis of
the Literature. Journal of Management. 25:357-384
Ducharme, LJ., Martin, JK. (2000). Unrewarding Work, Coworker Support, and Job Satisfaction: A
Test of the Buffering Hypothesis. Journal of Work and Occupations. 27: 223-243
Page 13 of 15
Gibbs, N., Borton, C. Editors. (2006). A review of anaesthesia related mortality 2000-2002.
Melbourne. Australian and New Zealand College of Anaesthetists
Graveling, RA., Crawford, JO., Cowie, H., Amati, C., Vohra, S. (2008). A Review of Workplace
Interventions that Promote Mental Wellbeing in the Workplace. Institute of Occupational Medicine,
Edinburgh.
Health and Safety Executive (UK). (2000). Health care and first aid on offshore installations and
pipeline works: Offshore Installations and Pipeline Works (First-Aid) Regulations 1989. Sudbury, HSE
Books.
Institute of Remote Healthcare (IRHC). (2013). Remote Healthcare Guidance Document for Energy
and associated Maritime activities. IRHC Remote Healthcare Workshop. 14th January. Bergen,
Norway. Institute of Remote Healthcare. 5
Institute of Remote Healthcare (IRHC). (2017). Competency and Training for Health Care
Practitioners Working in Remote Environments. Revised January 2017. Consensus Document ed.
Aberdeen: Institute of Remote Health Care.
Johns Hopkins Aramco Healthcare Company. (2017). General Services Contract: Operations for RACs.
Dhahran. JHAH.
Kizilbash, A.H., Vanderploeg, R.D., Curtiss, G. (2002). The effects of depression and anxiety on
memory performance. Archives of Clinical Neuropsychology. 17:1. 57-67
Page 14 of 15
Langan-Fox, J., Cooper, C.L. eds. (2011). Handbook of Stress in the Occupations. Cheltenham, Edward
Elgar Publishing. pp. 18
Melchior, M., Caspi, A., Milne, BJ., Danese, A. (2007). Work stress precipitates depression and
anxiety in young, working women and men. Journal of Psychological Medicine. 37:8 1119-1129
Murray, I. (2016). “Mental Health and Wellbeing.” (Powerpoint slides). Johns Hopkins Aramco
Healthcare, Remote Area Clinics’ Unit, Dhahran. 17 May 2016. Lecture.
NAEMT. (2018). “Helping Our Own.” (Powerpoint slides). Canadian Medical Centre, Dammam. 26
June 2018. Presentation.
NICE. (2009). Mental Wellbeing at Work: Guidance and guidelines. [online]. Available at <
https://www.nice.org.uk/guidance/ph22> (Accessed 29 October 2018).
Remote Area Clinics’ Unit. (2017). Minimum Medical Standards Requirements Manual. Dhahran.
JHAH.
Royal College of Surgeons of Edinburgh (2016), Generic Core Material - Prehospital Emergency Care
Course, Version 3. Edinburgh, Royal College of Surgeons of Edinburgh. Available at:
http://ebooks.fphc-rcsed.org/pdfreader/generic-core-material-prehospital-emergency-care-course.
(Accessed on 24 October 2018 )
Ryan, J., Mahoney, P. F., Greaves, I., & Bowyer, G. (Eds.). (2002). Conflict and catastrophe
medicine: A practical guide (1st ed.). London: Springer-Verlag London Limited.
Page 15 of 15
Saudi Arabia OFW. (2018). Why Do Filipinos Want To Go To Saudi Arabia for Work. [online]. Available
at: <https://saudiarabiaofw.com/why-do-filipinos-want-to-go-to-saudi-arabia/>. (Accessed 23
November 2018).
Statista. (2018) Number of offshore rigs worldwide as of January 2018 by region. [Online]. Available
at: <https://www.statista.com/statistics/279100/number-of-offshore-rigs-worldwide-by-region/>
(Accessed 21 October 2018)
(Stellman, JM., (2012). Encyclopaedia of Occupational Health and Safety. [online]. Available at:
<https://www.ilo.org/safework/info/publications/WCMS_113329/lang--en/index.htm> (Accessed 12
November 2018).
van der Klink, JJ., Blonk, RW., Schene, AH., & van Dijk, FJ. (2001). The benefits of interventions for
work-related stress. American journal of public health, 91(2), 270-6.
Whittaker, S., Brown, G., Williamson, N., Greenberg, N. (2017). The psychological health of remote
area medics in Iraq. Occupational Medicine. 67:9. 666-671.
World Health Organisation, (WHO). (2001). Strengthening mental health promotion. Geneva, World
Health Organization: Fact sheet, No. 220
World Health Organisation, (WHO). (2006). Constitution of the World Health Organisation. [online].
Available at <http://www.who.int/publications/almaata_declaration_en.pdf>. (Accessed 12
November 2018).
