Noura A. Abouammoh

3.4 Cultural competence in Saudi Arabia

The final body of literature in this review focused on cultural competence in SA itself. Al-Ahmadi and Martin (2005) carried out a systematic review to investigate the quality of primary health care services in SA, based on access and clinical and interpersonal effectiveness. They included 31 articles, which covered the Western, Central, Eastern, Northern and Southern regions of SA and differed in their methodologies and focus. The authors mainly found cross-sectional surveys and retrospective records review types of studies that examined the quality of primary health care services. They found a significant variation in the quality of primary health care services: for example, good access was reported to vaccination programmes and prenatal care, while access to programmes targeting chronic health conditions was found to be below the target (AL-Ahmadi and Martin, 2005). Five of the studies focused on assessing the quality of interpersonal aspects of care through examining patients’ satisfaction with communication and exchanging information with their physicians. The studies identified poor patient satisfaction in terms of interpersonal care, which was described in terms of language and cultural differences between the majority of IMG primary health care physicians and local patients. However, none of the studies included attempted to attain a qualitative understanding of the issue of language and culture in interpersonal care.

3.4.1 Saudi based literature in regards to cultural competence

There is very little research investigating the status and experiences of international health workers in SA. Despite researchers’ acknowledgement of the critical situation of cross-cultural care provision by expatriate nurses (Aldossary et al., 2008, Mutair et al., 2014, Luna, 1998) and physicians’ (Searle and Gallagher, 1983, Elzubier, 2002) in SA, most publications found were review papers that presented the challenges faced by international health workers, from the authors’ perspective. In addition, these papers acknowledged the importance of cultural competence training in the provision of appropriate health care to local patients and explained the situation, as well as calling for solutions.

Although IMGs dominate the physician workforce in SA, previous research has been directed towards international nurses whose numbers, compared to IMGs, are noticeably decreasing (64% and 50% in 2008 and 2012, respectively, of the total nurses working under the MOH) (MOH, 2012).

One qualitative study was found concerning international nurses’ experiences in caring for Muslim/Saudi patients (Halligan, 2006). The study involved six non-Muslim critical care nurses’ experiences in caring for Muslim patients. The nurses involved were from Australia, UK, Canada, Ireland and India.

Levels of appreciating local Muslim patients’ religious needs, in this study, varied. For example, while some nurses kindly assisted patients in performing their prayers by positioning them in the direction of “Kaba”, others got frustrated when patients needed this kind of assistance, as they believed that the patients were too sick to move (Halligan, 2006).

The nurses in Halligan’s (2006) study used terms such as “frustrating” and “stressful” to describe some of the situations where they had to deal with local patients’ customs and beliefs which were different from their own. For instance, they thought that it was not convenient for them and for the patients to have a large number of visitors surrounding the bed. Additionally, they disliked the fact that visitors stayed for a long time and brought coffee and food for the patients and for themselves to consume during their visit, although the participants were aware that these customs are part of the Saudi culture (Halligan, 2006). The nurses were also frustrated by Saudi doctors following patients’ wishes, a course of action which they believed was often not in the best interests of these patients. For example, the parents of a boy who had 80% third degree burns refused to medicate their son and the doctor followed their wish.

The nurses in the study by Halligan (2006) were irritated by behaviours that are deeply rooted in the religion and culture of local people. They also felt “powerless” in terms of providing health care for local patients. Thus, it was interesting to find that the nurses felt obliged to suppress their opinions and feelings and function in a detached manner, focusing only on the physiological needs of the patients. This behaviour may have had a negative influence on patient safety, as it missed essential factors in delivering quality care, such as relationship, rapport and emotional support, even if patients were satisfied with this kind of care.

The situation was complicated by language discordance, which was acknowledged by the nurses as a significant challenge to communication. The nurses thought that they were in “a constant battle to be understood”. To provide appropriate care they needed to be engaged in lengthy conversations with the patients, which ideally should have involved descriptions and expressions of feelings. The nurses in the study were not able to understand long sentences and depended on facial expressions and gestures to understand feelings. In response to patients’ discourse, they smiled at the patients as a mechanism to maintain trust, yet they believed that no trust can be built with patients if communication is poor.

It should be noted that the nurses in this study may not be representative or typical of expatriate nursing staff in SA. The author implied that the nurses received Arabic language courses and, as noted, the majority came from the Western world, indicating that the study was conducted in a tertiary care hospital.

Younge et al. (1997) published a review paper on communication with cancer patients in SA. They were interested in communication in general; however, as the international health workforce is dominant in SA, they noted that:

“the commitment to continuing care with proper communication that is required for the whole of medicine is likely to be fully realized only when the majority of the workforce are Saudi nationals” (Younge et al., 1997, p.315)

In this statement, “continuing care” related to the high turnover rate among international health workers in SA. In addition, the use of the expression “proper communication” might reflect their belief that culturally competent communication cannot be acquired through training by international staff. A similar observation was noted in Aldossary et al. (2008) who reviewed the development of nursing with the current challenges in SA. They concluded that:

“The challenges for Saudi Arabia are increasing its proportion of indigenous nurses who will be able to deliver culturally appropriate high quality care and to share the Arabic language of their patients. Without this, it may prove difficult to deliver effective health education within nursing work” (Aldossary et al., 2008, p.128)

As health care provision and patient education are duties shared by nurses as well as primary health care physicians, this statement may challenge the effect of cultural competence training. It may also provide a solution which is hard to achieve, given the situation in SA, where the demand for health care exceeds the supply of local GPs.

In 1998, Luna, a nurse who worked in a tertiary care hospital in SA published a review paper suggesting educational programmes for international nurses, based on her own experiences. She stressed the importance of introducing effective trans-cultural educational programmes designed for international nurses, as she recognized the challenges in providing care to Saudi patients who do not share the same belief system. In her paper, she focused on the concept of cultural competence in terms of its significance, applications and challenges, and proposed some strategies to educate international nurses using SA as an example, rather than a unique setting that needed more specific investigation (Luna, 1998).

A review paper was published more recently which aimed to raise awareness among international nurses and to improve their understanding of culturally competent care from the Saudi perspective (Mutair et al., 2014). In this paper, Mutair et al. (2014) provided an information base that allows nurses and all international health care providers to have a general understanding of the Saudi culture. They focused on the nature of the family unit in SA, and confirmed the importance of this unit, as well as calling for a family-centred model of care, as a cultural requirement. The authors’ call for this type of care was based on their observations and analytical thinking, but patients’ comments regarding their actual needs were not discussed or investigated in the paper.

The issue of cultural competence in SA has been overlooked, despite the dominance of IMGs in the healthcare workforce. The Saudi-based research has highlighted the existence of the challenges proposed by cross-cultural care; however, only one study has investigated cross-cultural care among international nurses, with no studies considering the role of IMGs or patients’ needs in this regard.