ISSUES IN CLINICAL NURSING doi: 10.1111/j.1365-2702.2005.01525.x

Caring for patients of Islamic denomination: critical care nurses’

experiences in Saudi Arabia

Phil Halligan MSc, BNS, ITU cert. RM, RGN, FRCSI

School of Nursing & Midwifery and Health Sciences, College of Life Sciences, University College Dublin, Ireland

Submitted for publication: 28 July 2005

Accepted for publication: 11 November 2005

Correspondence:

Lecturer at the School of Nursing and

Midwifery and Health Sciences

College of Life Sciences

University College Dublin

Belfield

Dublin 4

Ireland

Telephone: þ353-1-7166420

E-mail: phil.halligan@ucd.ie

HALLIGAN P (2006)HALLIGAN P (2006) Journal of Clinical Nursing 15, 1565–1573

Caring for patients of Islamic denomination: critical care nurses’ experiences in

Saudi Arabia

Aim. To describe the critical care nurses’ experiences in caring for patients of

Muslim denomination in Saudi Arabia.

Background. Caring is known to be the essence of nursing but many health-care

settings have become more culturally diverse. Caring has been examined mainly in

the context of Western cultures. Muslims form one of the largest ethnic minority

communities in Britain but to date, empirical studies relating to caring from an

Islamic perspective is not well documented. Research conducted within the home of

Islam would provide essential truths about the reality of caring for Muslim patients.

Design. Phenomenological descriptive.

Methods. Six critical care nurses were interviewed from a hospital in Saudi Arabia.

The narratives were analysed using Colaizzi’s framework.

Results. The meaning of the nurses’ experiences emerged as three themes: family and

kinship ties, cultural and religious influences and nurse–patient relationship. The

results indicated the importance of the role of the family and religion in providing

care. In the process of caring, the participants felt stressed and frustrated and they all

experienced emotional labour. Communicating with the patients and the families

was a constant battle and this acted as a further stressor in meeting the needs of their

patients.

Conclusions. The concept of the family and the importance and meaning of religion

and culture were central in the provision of caring. The beliefs and practices of

patients who follow Islam, as perceived by expatriate nurses, may have an effect on

the patient’s health care in ways that are not apparent to many health-care pro-

fessionals and policy makers internationally.

Relevance to clinical practice. Readers should be prompted to reflect on their clinical

practice and to understand the impact of religious and cultural differences in their

encounters with patients of Islam denomination. Policy and all actions, decisions

and judgments should be culturally derived.

Keywords: care, critical care, Islam, phenomenology, nurses, nursing

Introduction

Caring has been identified as the essence of the nurses’ role

(Leininger 1986) and as a concept; it has received extensive

attention in the literature (Watson 1979, Roach 1984, Leinin-

ger 1988, Morse et al. 1990). In the past decade caring could be

argued to be more challenging due to the increase in global-

ization and immigration of the patient population. Followers

of Islam form Western Europe’s largest religion minority group

(Sheikh & Gatrad 2001). Saudi Arabia is the ‘home’ of Islam

� 2006 Blackwell Publishing Ltd 1565

but followers of Islam live in all countries of the world and it is

worth noting that Islam can vary from a very strict approach to

a quite liberal one (McKennis 1999). Currently, the world’s

Muslim population is 1.3 billion and in the UK alone, there are

approximately 1.2–1.5 million Muslims (Rassool 2000). Thus,

it is reasonable to assume that, within the next decade, many

nurses, regardless of their location, will care for a Muslim

patient, but how can we be sure that these patients will receive

culturally appropriate services?

Caring is described in many ways and, within the litera-

ture, the concept of caring is often abstract, complex and

poorly defined. Caring has artistic and scientific aspects (Yam

& Rossiter 2000); it is what nurses claim to do every day.

Although some authors view caring as unique to nursing

(Leininger 1985), similarities between lay and professional

caring have been identified (Kitson 1987). One perspective is

the ‘taxonomies of caring’, as proposed by Watson (1979),

Leininger (1981) and Roach (1984), which identifies the

behaviours and factors that constitute caring. Another

perspective is based on the insights of participants in the

clinical practice area, particularly, the meaning of caring for

patients and caregivers (Benner 1984, Forrest 1989, Clarke &

Wheeler 1992).

Caring, within the critical care environment, could be

viewed as different from caring in other nursing environ-

ments. Bucknall and Thomas (1996) argue that there is a

sustained exposure to life threatening crises and higher levels

of stress related to decision-making. Although the role of the

critical care nurse encompasses technical, physical and

psychological aspects of caring; within the literature, the

most cited studies on critical care concern three areas:

communication (Dyer 1995, Caine 1991, Elliot & Wright

1999, Hupcey 1999, Jafar & Muayyad 2005); technology

(Cooper 1993, Locsin 1995, Walters 1995) and the needs of

family members (Molter 1979, Leske 1986, Kupferschmid

et al. 1991, Johnson et al. 1995, Lee et al. 2000). Although

the needs of the family have been studied extensively,

literature highlighting the needs of ethnic minority families

in critical care could not be located.

Most theorists, except for Leininger, fail to consider the

influence of culture on caring. Caring exists in all cultures;

however, to be effective, caring must be applicable and

culturally relevant (Leininger 1988). Since 1985, research has

demonstrated the inherent relationship between culture and

care. For example, when Leininger (1985) lived among the

indigenous Gadsup people of New Guinea, she observed that

marked differences existed in the caring and health practices of

Western and non-Western cultures. Similarly, the findings of

Luna’s (1989) study of Lebanese-Muslim immigrants in the US

indicate that the important factors in the delivery of care

include gender role practices within the family and religious

activities. In Britain, the findings of a study by Cortis (2000), of

the ex-patient experience of ‘being cared for’ by nurses in a

hospital setting that involved interviews of 38 Pakistani

immigrants in northern England, revealed a lack of congruence

between the patient’s expectations and the experience of caring

received from nurses. Cortis’s findings are similar to those of

Shannon and Brayshaw’s (1995) survey of 25 Australian nurses

in Melbourne regarding the nurses’ knowledge of the culture

and specific health-care practices of their Vietnamese patients.

Shannon and Brayshaw concluded that the majority of the

nurses lacked awareness regarding the beliefs and practices of

the Vietnamese patients. These findings suggest that, as

Leininger (1995) warned, people will avoid seeking healthcare

if they feel that they are treated in an insensitive manner or that

their beliefs and values are ignored. Thus, to provide appro-

priate care, nurses need to be aware of their own values.

To date, empirical studies relating to caring from an

Islamic perspective are not well documented in the nursing

literature. Hussein (2000) argues that, within the context of

health care and nursing practice, there is widespread misun-

derstanding of Islamic concepts and practices. Evidence from

the literature indicates that the concept of caring has been

examined extensively in the context of the Western cultures,

involving immigrants who may have been acculturated into

the culture in which they reside. Research conducted within

the home of Islam involving participants, with extensive

experience in nursing, who were presented daily with

experiences, would provide essential truths about the reality

of caring for patients of Islamic denomination.

Aim

The aim of the study was to explicate the essence of the

experience of caring by accurately describing nurses’ ‘lived

experience’ that is, their ‘life-world’ to assist nurses and other

healthcare professionals in caring for individuals who follow

Islam.

Methodology

Husserlian phenomenology was deemed the most appropriate

design, as the inquiry focused on the participants’ experiences

of caring, rather than on the nature of caring as perceived by

them. A qualitative research design was used, as advocated by

various researchers, due to the lack of prior information on

this subject (Morse & Field 1998, Polit & Hungler 1999) and

because this approach allows the experience of caring to be

discovered inductively within the cultural context (Morse &

Field 1998).

P Halligan

1566 � 2006 Blackwell Publishing Ltd, Journal of Clinical Nursing, 15, 1565–1573

Participants

This study was conducted in a large hospital in the Eastern

province of Saudi Arabia. The selection of the participants

involved a non-probability purposive sampling design. The

participants, who met the criteria as outlined in Table 1, were

drawn from a large population of expatriate critical care

nurses.

To acquire rich data, the participants sought, represented a

range of nationalities, ages and years of critical care experi-

ence across a large critical care unit. Four participants were

selected from the surgical intensive care and two from the

medical intensive care unit; two were Australian and one each

from Canada, Ireland, UK and India. All of the participants

were females as all the male nurses were Muslim. All

participants had been qualified as a nurse for over 10 years

and their ages ranged from 30 to 52 years. Their critical care

experience in Saudi Arabia ranged from one to nine years and

four of the participants had experienced caring in other

critical care units in Saudi Arabia.

Data collection

As no ethics committee was in operation at the time of the

study, permission to conduct the study was obtained in

writing from the nursing and administrative authorities and

informed consent was obtained from all of the participants.

Interviews were tape-recorded with the permission of the

participants and agreement for further support from a

professional counsellor was confirmed as many sensitive

issues could emerge during the course of the interviews. To

ensure that confidentiality and anonymity were maintained,

all demographic factors related to the participant’s identity

were deliberately omitted and the participants were assigned

pseudonyms.

In keeping with the tenets of descriptive phenomenology,

prior to each interview, a process called ‘bracketing’ was

conducted. Bracketing suspends certain components of

experiences and places them outside the brackets, allowing

you to focus on the phenomenon within the brackets

(Geering 2004). As I had extensive experience of caring for

patients throughout the Middle East, I began by writing

down personal and theoretical assumptions regarding my

experiences. Periodically, these notes were reviewed to ensure

that the objectivity of the participants’ meanings of their

experience was maintained as much as possible.

All of the participants were interviewed individually using

an open-ended, unstructured approach that allowed the

participants to be in charge of the situation. Participants

were invited to ‘tell me about their experiences of caring in

Saudi Arabia?’ In addition, notes relating to participant

responses, what I thought was happening and any significant

non-verbal communication was recorded immediately after

the interview. This process allowed me to be situated in the

life-world of my study (Munhall 2001) and reflect on what

might be going on and their associated meanings. All

interviews were then transcribed verbatim.

Data analysis

The data were subjected to the phenomenological process of

analysis developed by Colaizzi (1978). Colaizzi’s framework

was chosen as it allowed analysis to occur simultaneously

with data collection (Omery 1983), the stages are flexible and

non-linear (Holloway & Wheeler 1996) and, finally, it

allowed participants to validate their transcripts

thereby enhancing the rigour of the study. After reading

and re-reading the transcripts of the interview, the interview

responses were categorized. This process allowed the

identification of significant statements and, subsequently,

the meanings of the critical care nurse’s experience to emerge.

Following this step, the personal notes were compared with

the interview data, the meanings were organized into theme

clusters and referred back to the original transcripts for

validation; any discrepancies were also noted. Then, the

results were integrated into exhaustive descriptions of the

phenomena of caring and the process concluded when all

participants validated the findings.

Findings

Three main themes emerged from the data: family and

kinship ties, cultural and religious influences and nurse–

patient relationships. Due to the large amount of data arising

from the study, the main themes and a selection of the sub

Table 1 Sampling criteria

Inclusion

Non-Muslim male and female senior staff nurses in critical care unit

Willing to take part in the study and to sign the consent form

Has an in-depth knowledge of the phenomenon under inquiry

Able to articulate their experience fluently in the English language

Has at least one year’s experience of caring in a critical care unit

in Saudi Arabia

Exclusion

Expected to leave Saudi Arabia or to take vacation during the

interview period

Has been a patient in a critical care unit in Saudi Arabia; it was felt

that their might be a risk of participants recounting their

experience of being a patient rather than caring for a patient

Issues in clinical nursing Critical care nurses’ experiences in Saudi Arabia

� 2006 Blackwell Publishing Ltd, Journal of Clinical Nursing, 15, 1565–1573 1567

themes are presented. A complete illustration of the themes

and sub themes is shown in Table 2.

Family and kinship ties

Family involvement was described as pivotal to the experi-

ence of caring and as a significant contributor to the

emotional, social and psychological well-being of the patient.

The families were viewed as the principal decision-makers, as

they often ‘dictated the care’, including the extent of the care

to be given. Frequently, the physician discussed major ethical

decisions with the family, without the patient’s involvement,

which created a stressful situation for many of the nurses.

One nurse described how she felt:

Doctors tend to give the families a…lot of authority over deci-

sions…and sometimes they do not have the medical knowledge to go

with it. Consequently, some patients are put through a lot of.pro-

cedures and pain as they keep doing a lot of interventions for a long

time that you wouldn’t normally find in the Western world…it is very

frustrating…

Visiting was described as a very social occasion with the

patient often having as many as 20 visitors at a time. On

arrival, the family members would, regardless of the patient’s

clinical status, ‘greet, hug and kiss each other’ and bring the

‘coffee and cake out and put ‘carpet’ on the floor’ and the

nurses were frequently invited to join in. Visitors ‘frequently

visited all the other patients’ in the unit and stayed for

protracted periods. In addition, the constant presence of

visitors was perceived as a ‘nuisance’; one nurse felt that she

had to ‘justify her actions to the family, as well as to the

patient’. The critical care nurses also described the presence

of a relative as being a hindrance to the patient’s participating

in care.

Religious and cultural influences

The role of religion was viewed as all encompassing. The

influence of Islam was evident in all of the narratives and

appeared to be intertwined in every aspect of patient care. All

of the participants recounted that ‘everything you do is

centred on religion and it is their main way of life’. One

participant noted, the fact that Muslims are called to pray five

times daily is ‘…not very conducive…to sleep and rest. They

are getting up [out of bed] because their call to prayer is more

important.’ In contrast, another nurse described how she

attempted to meet the spiritual needs of her patients by

allowing them to pray and by positioning them in the

direction of Mecca:

…to say their prayers and…help with the washing hands, and face

before prayer. Some of the patients bring in sand…to dip their hand.

It is a way of purification before saying their prayers. They usually

ask us for the direction that they should pray…Some of the patients

ask us to wake them up early for the morning prayers. They are

people of deep faith.

The attitudes of the patients were viewed as strongly aligned

to their religion and this was identified as a source of stress

because it created a feeling of ‘powerlessness’ in the nurses.

Some of the participants observed that, no matter how ‘good

you look after them, whatever happens, its Allah’s will if they

live or die’.

…[Because of their] deep faith…whatever you tell them, they say

‘everything is according to the will of God’. Whether it is good or

bad, they accept it with only one sentence ‘Ilhamdullilah [thanks be

to God].

The care of patients who were diagnosed as ‘brain dead’ was

described as being a very stressful time for the nursing staff.

The evidence from the participants indicates that life for a

patient of Islamic faith continues to the last beat of the heart,

even in situations where the patient has been pronounced

brain dead. According to one nurse:

It’s like you can tell that the brainwaves are flat, we have done all

the tests, and the patient is clinically brain dead…We have

to…continue until Allah decides when it is right [time] for him to

end this life.

…it’s stressful, it is stressful…you have to continue life saving

measures until Allah decides or the patient actually dies.

Caring was also described as being gender specific. Older,

male patients disliked female nurses taking care of them and

similarly, female patients did not want male nurses, or male

caretakers, in the room. Such factors created a problem in the

critical care unit because:

…when the patients are really heavy it’s…difficult to lift the patient

with another female nurse. We have male hospital attendants; it is

just easier to call him and get the work done…

Table 2 Findings of the study

Themes Family and

kinship ties

Cultural and

religious influences

Nurse–patient

relationship

Subthemes Involvement Language Communication

Autonomy Religion Emotional labour

Visiting Death and dying Collegiality

Support Diet Universality

Gender preferences

P Halligan

1568 � 2006 Blackwell Publishing Ltd, Journal of Clinical Nursing, 15, 1565–1573

Nurse–patient relationship

Difficulty in communicating was considered as a major

barrier in developing a good rapport; this was viewed as

difficult for both the patient and the nursing staff. As

recounted by one nurse:

It is difficult to build a good rapport with the patients…to build close,

friendlier relationships with the patient…the patients do like to talk

and tell about the families, about their problems at home but when

they tell us in long sentences we usually don’t understand.

Patients were described as eager to converse in their language,

even though they knew that the nurses did not understand

them. Nurses attempted to reciprocate by smiling and

listening to the patient and the family. However, it was

frequently ‘…left up to the nurse to interpret how the patient

was feeling, mainly by just seeing the clinical status of the

patient or by just asking specific questions’. One participant

described this situation as ‘a constant battle every day to be

understood’ and she felt that the patient was equally

frustrated:

…she could not be understood by us and we could not understand

her. She used to get into these panic attacks and she used to literally

stop breathing on the ventilator…

Communication was primarily non-verbal and caring was

viewed as ‘being more difficult due to the language

barrier’. Tension was often created between the patient,

the family and the nurse, as the nurses were not fluent in

the Arabic language. Therefore, the patients and the

families often attempted to get the attention of the staff

by using a number of gestures, such as, ‘clicking of the

fingers’, which was considered as aggressive. As one nurse

noted:

Even speaking English there is a lot of miscommunication; verbal and

non-verbal and that causes aggression and mistrust. How can you

‘trust’ someone who you can’t even communicate with?

Communication was also made more difficult by the Saudi

culture. For example, females are required to cover their faces

if they are in view of a male, and often the patients are:

…on 100% oxygen or [mechanically] ventilated, we don’t like to

cover their face fully…we have to tell the visitors that…they have to

stand either behind the curtain as we cannot really cover their faces

On occasion, in the process of caring, the nurses felt

compelled to conceal or to suppress their own feelings, as

this enabled them to function in a detached manner. In

addition, their feeling of frustration and irritation with the

doctors and the family members was compounded when the

nurse wanted to perform better ‘care’ in certain situations.

For example, as one participant stated:

…one boy, who had 80% third degree burns, and you can imagine

the agony he was in. His parents never allowed him to be medicated

to alleviate the extreme suffering he was in…and the doctors went

along with it…you get angry with the doctors in some ways…so

badly burned, you couldn’t walk up there and cuddle him.

Most of the participants’ frustration was described in terms

of the situation where a critically ill or dying patient was

made a full resuscitation code (cardiopulmonary resuscitation

and advanced cardiac life support) by the physician and the

family agreed to it but the nurse felt it was futile. In the words

of one participant:

…you can get a lot of conflict between the patient’s’ family and the

nurses, although the nurses tend not to show it. They do become

frustrated about this because instead of giving pain relief and keeping

them comfortable, they are not allowed…

Most of the emotional labour experienced by the nurses was

strongly aligned to the aspects of care that are deeply rooted

in the patient’s religion and culture. At times, this made the

nurses feel ‘powerless’, but they tried to disguise how they

felt. Comforting patients ‘when they feel sad‘ or ‘really upset’

was not viewed as part of the nurses’ role; touching patients

was not valued and therefore, restricted to tasks only. The

nurses described how they had to be very sensitive to the

patient’s culture, as touching the patients in times of distress

was often neither welcomed nor appreciated.

Discussion

Overall the expatriate nurses felt that caring for patients of

Islamic denomination presented them with professional and

personal challenges, as they struggled with the stress,

frustration and tensions of practicing within a different

culture. The issue of family involvement permeated through-

out all the narratives. In this study, the involvement of the

family in the care of their relatives, including the regular

visiting of family members, created stress for many of the

participants. However, the nurse needs to recognize the

central importance of the family in taking care of patients of

Islamic denomination (Luna 2002) and that the inclusion of

the patient’s family in the planning of care is essential to the

delivery of culturally competent care (Leininger 1981). In

Saudi Arabia, the family is the traditional foundation of

society; it extends beyond the immediate relatives to include

all the members of the tribe (Cuddihy 1999). The reality that

the Muslim family as ‘the cornerstone in caring’ is also found

in Omeri’s (1997) study of care meanings, expressions and

Issues in clinical nursing Critical care nurses’ experiences in Saudi Arabia

� 2006 Blackwell Publishing Ltd, Journal of Clinical Nursing, 15, 1565–1573 1569

practices of Iranian Muslim immigrants in Australia. As

indicated in the present study, family visiting and support

(emotional, social and physical) are important ways of ‘being

together’. Followers of Islam are obliged to visit a person and

to enquire about their health (Johnson 2001). The findings of

this study support those of Hupcey’s (1999), in that nurses

viewed families as a distraction to the nursing staff. However,

the nurses retained a position of power, as they continued to

prioritize the physiological needs as the most important

consideration. The priority of physical care is also empha-

sized in Jafar and Muayyad’s (2005) study of the communi-

cation of Jordanian critical care nurses with critically ill

patients, which indicated that nurses preferred to care for

sedated or unconscious patients, as they are considered ‘less

demanding’.

Communication is integral to the process of caring and is

an essential part of the care of critically ill patients (Jafar &

Muayyad 2005). The nurses’ lack of knowledge of the Arabic

language was viewed as a major barrier to effective care. The

nurses emphasized their ‘constant battle’ to be understood;

this finding parallels that of Luna’s (1989) study which

indicated that patients appreciated the nurses’ making an

effort to communicate in Arabic. Interpreters are usually

employed in many hospitals in Saudi Arabia and in Western

countries. However, in this setting none were employed as

each employee was required to have English as first or second

language and Arabic language courses were available for all

staff members. The communication pattern that the partic-

ipants described frequently was the bedside greeting intro-

ductions, and this activity reflects the value that Saudi Arabs

place on community allegiance and group harmony (Lustig

1988). Arabs use a number of gestures to get their points

across, for example, the ‘clicking of the fingers’, a widely

accepted practice in the Middle East, is considered to be a

rude and unprofessional gesture in Western societies. Know-

ledge of the patient’s culture may reduce some of the

frustration, as one nurse noted: ‘Once you learn their

practices…it helps you to understand’.

In this study, the influence of religion was found to be all

encompassing in the process of caring for their patients. Islam

was entwined in every facet of the patient’s lives and the

participants viewed it as a source of stress, which created a

feeling of powerlessness’ in the nurses. Religion in the West

does not always penetrate or have so wide an impact so

widely upon the daily lives, functions and attitudes of people

as do followers of Islam in the nation of focus. Followers of

Islam view illness, suffering and dying as a part of life and as

a test from Allah (Rassool 2000). Illness is viewed as

atonement for sins; death is part of the journey to meet

Allah (Athar 1993, cited in Rassool 2004). Therefore, in

caring for Muslim patients, it is essential that healthcare

professionals are knowledgeable about Islam and are able to

integrate it into their patients care plans.

Death is a universal phenomenon. In all media, the

international debate on how individuals should end their

lives is apparent. Nurses were distressed by the length of time

that the patients were continued on treatment. Comparison

with Western patients, patients diagnosed as ‘brain dead’

were viewed as having prolonged interventions. The term

‘brain dead’ refers to an irreversible, complete loss brain

function while the heart continues to beat (Potter & Perry

1993). Islam view of death is guided by two beliefs: Allah

appoints the time of death and there is life after death

(McKennis 1999). Dying, according to Islamic teachings, is

part of a covenant and the end of life is up to Allah (Rassool

2004). However, contrary to the findings in this study,

Muslim physicians are not encouraged to prolong the

suffering of someone in a vegetative state and mechanical

supports are not to be used to maintain a patient in a

vegetative state (Athar 1998, cited in Rassool 2004).

However, attempts to hasten the death of the patient or to

withhold nutrition and hydration are prohibited (Pennachio

2005). More research is needed to explore and to clarify the

end of life practices within the Muslim culture.

In all nursing contexts, physical touch and patient modesty

is an integral part of the nurse–patient interaction, regardless

of the cultural context. The nurses’ descriptions verified that

touching the patient was ‘instrumental touch’ or task

orientated, as identified by Watson (1979). A number of

factors seemed to militate against the nurses touching the

patient. As noted in Hall’s (1966) proxemic theory, Arab

societies are ‘contact’ cultures. However, touching tends to be

among the same sex and within families. Although men are

often observed walking hand in hand down the streets, men

and women never touch in public, as touching the opposite

sex is considered offensive. In the present study, this created a

problem for the participants when patients or families were

given bad news, as the nurses were not able to ‘touch’ or

‘comfort’ in the usual way. Modesty is an important issue and

is held in high regard by males and females in the Arab

culture. Disrobing in public, including the hospital, is

considered immodest (Kulwicki et al. 2000). Patients pre-

ferred to have providers of the same sex and husbands often

requested to stay while their wives were being examined

(Pennachio 2005). Commonly, traditional Arab women

expect to see female carers only; trying to meet this need

creates staffing difficulties. Thus, management must actively

recruit mixed genders of carers for patients of various ethnic

groups. However, due to the current shortage of nurses the

possibility of achieving this gender mix seems remote.

P Halligan

1570 � 2006 Blackwell Publishing Ltd, Journal of Clinical Nursing, 15, 1565–1573

Finally, in any context, caring draws on emotional com-

ponents that can incur emotional labour. Within this study,

emotional labour transcended all aspects of the participants’

caring experience. Worldwide, critical care nurses are

confronted with ethical issues of patient care management

and Saudi Arabia is no exception. With the advances in

healthcare technology, a means has been created, whereby;

the patient can be maintained on life support for long

periods. The findings of this study indicated that high levels

of stress and frustration, experienced by staff, were related to

the aspects of care that brought about emotional labour and

to conflicts regarding the standard of care, particularly, the

participants’ perceptions of death and dying. Stress among

the nurses was related to conflicts experienced in balancing

care and the difficulties in managing their own emotions.

Emotional labour, according to Hochschild (1983), is guided

by ‘feeling rules’, which come from social conventions, the

reactions of others or from within the individual. In the

context of this study, the feeling rules may have come from

any of these sources. The concept of emotional labour is vital

in demonstrating the importance of knowing the patient’s

religion and cultural values in order to provide competent

care. Emotional labour, as demonstrated in Staden’s (1998)

research, is as difficult and challenging as physical labour

and, in nursing, is characterized by extreme emotional

demand. It is argued here that the experience of emotional

labour is aligned to aspects of the patient’s and family’s

religious beliefs and cultural traditions. Therefore, emotional

labour is a tenet of practice of caring for Saudi Muslim

patients. More research is required to clarify the extent to

which the concept of emotional labour is evident and how

relevant it is to critical care nursing.

The experiences narrated provide rich sources of data in

caring within a complex domain of inquiry. Nevertheless, the

findings of this study must be considered in relation to its

limitations. All of the six participants were female, therefore

the results may only reflect the female perspective of caring

but the sample provides rich data from a wide experienced

population, across two settings and from participants who

care daily for large population of Muslim patients. Therefore,

to this end, it is hoped that most of the findings of the study

will contribute towards a body of transcultural knowledge

that will assist healthcare professionals worldwide to assist in

caring for Muslim patients.

Implications for nursing practice

There are many implications for nursing arising from this

study that should be considered as nurses’ care for Muslim

patients. Firstly, all actions, decisions and judgments ought to

be family orientated and culturally derived. Religious and

cultural frameworks provide the most comprehensive and

holistic perspective for caring and understanding the patient

population of Muslim denomination. Specific care practices

need to take into account the care constructs of presence,

involvement and support, as these have been identified as

important to the family. In addition, the policies and

philosophies of the hospitals and other institutions needs to

reflect the cultural practices related to visiting, modesty,

gender specific care, communication and spirituality. In

addition, where language is a problem, it is important to

have access to interpreters in order to provide culturally

competent care for Muslims.

Secondly, there are differences in the cultural and psycho-

social forms of expression of the Muslim patients and their

families and those of the nurses. The process of reflection and

clinical supervision could assist nurses in identifying their

own cultural barriers, stereotyping, and ethnocentricity, thus,

ultimately improving care.

Finally, nursing management should continually assess

whether nursing staff have the appropriate knowledge and

skills to handle the particular ethical situations involved in

caring for the patient and his/her family of Muslim denomi-

nation and, with the aim of reducing emotional labour,

provide a mechanism, which would assist the staff in

becoming more competent.

Conclusion

The findings of this study highlight very important insights

into the way that nurses experience caring for critically

ill patients of Islamic denomination. The concept of the

family and the importance and meaning of religion and

culture were central in the provision of care. In focusing

attention on the traditions, religion and concerns of their

patients, the interface between care and culture was high-

lighted. While nurses valued the physical components of

caring, the families played a major role in meeting the

patient’s emotional, social and psychological needs. The

beliefs and practices of Islamic patients, as perceived by

expatriate nurses, may have an effect on the patient’s health

care in ways that are not apparent to many health-care

professionals and policy makers internationally. Intercultural

misconceptions and misunderstandings of many healthcare

professionals have potential consequences. Thus, health-care

professionals need to be better equipped to meet the needs of

their patients.

This study provides the readers with the opportunity

to reflect on their clinical practice and to understand

the impact of religious and cultural differences in their

Issues in clinical nursing Critical care nurses’ experiences in Saudi Arabia

� 2006 Blackwell Publishing Ltd, Journal of Clinical Nursing, 15, 1565–1573 1571

encounters with patients. It should enable the health-care

professional to understand, and to respond more effectively

to, the health care of patient who follows Islam throughout

the world. This understanding can be extended to health

services planners, administrators, educators as it allows

greater access to and utilization of culturally competent

health services.

Acknowledgements

I gratefully thank the nurses who participated in the study;

and I am equally appreciative to Conal Hamill for his

constant encouragement, and support throughout this study.

Contributions

Study design: PH; data collection and analysis: PH; manu-

script preparation: PH.

References

Benner P (1984) From Novice to Expert: Excellence and Power in

Clinical Nursing Practice. Addison-Wesley, Menlo Park, CA.

Bucknall T & Thomas S (1996) Critical care nurse satisfaction with

levels of involvement in clinical decisions. Journal of Advanced

Nursing 23(3), 571–577.

Caine R (1991) Incorporating care into caring for families in crisis.

ACCN Clinical Issues in Critical Care Nursing 2, 236–241.

Clarke JB & Wheeler SJ (1992) A phenomenon of caring in nursing

practice. Journal of Advanced Nursing 17, 1283–1290.

Colaizzi P (1978) Psychological research as a phenomenologist views

it. In Phenomenology: A Method for Nursing Research (Omery A

ed). Advances in Nursing Research 5, 49–63.

Cooper M (1993) The intersection of technology and care in the ICU.

Advances in Nursing Science 15, 23–32.

Cortis J (2000) Caring as experienced by minority ethnic patients.

International Nursing Review 47, 53–62.

Cuddihy K (1999) Saudi Customs and Etiquette. King Fahad

National Library Catalogues-in-Publications Data, Riyadh.

Dyer I (1995) Meeting the needs of visitors – practical approach.

Intensive Care Nursing 7, 135–147.

Elliot R & Wright L (1999) Verbal communication: what do critical

care nurses say to their unconscious or sedated patients? Journal of

Advanced Nursing 29, 783–790.

Forrest D (1989). The experience of caring. Journal of Advanced

Nursing 14, 815–823.

Geering R (2004) Bracketing in research: a typology. Qualitative

Health Research 14, 1429–1452.

Hall ET (1966) The hidden dimension. In Arab Cultural Communi-

cation Patterns (Fenghali E ed). International Journal Relations 21,

345–378.

Hochschild AR (1983) The Managed Heart: Commercialisation of

Human Feeling. University of California Press, Berkeley, CA.

Holloway I & Wheeler S (1996) Qualitative Research for Nurses.

Blackwell Science, London.

Hupcey J (1999) Looking out for the patient and ourselves: the

process of family integration into the ICU. Journal of Clinical

Nursing 8, 253–262.

Hussein R (2000) The crescent and Islam: healing, nursing and the

spiritual dimension. Some considerations towards an understand-

ing of the Islamic perspectives on caring. Journal of Advanced

Nursing 32, 1476–1484.

Jafar A & Muayyad A (2005) Communication with critically ill

patients. Journal of Advanced Nursing 50, 356–362.

Johnson S, Craft M, Titler M, Halm M, Kleiber C & Mongomery L

(1995) Perceived changes in adult family members roles and

responsibilities during critical illness. Image: Journal of Nursing

Scholarship 27, 238–243.

Johnson C (2001) An Islamic understanding of health care: what can

it teach us? Accident and Emergency Nursing 9, 38–45.

Kitson A (1987) A comparative analysis of lay-caring and profes-

sional (nursing) caring relationships. International Journal Nursing

Studies 24, 155–165.

Kulwicki A, Miller J & Myers Schim S (2000) Collaborative part-

nership for cultural care: enhancing health services for the Arab

community. Journal of Transcultural Nursing 11, 31–39.

Kupferschmid B, Briones T, Dawson C & Drongowski C (1991)

Families: a link or liability? AACN Clinical Issues in Critical Care

Nursing 2, 252–257.

Lee I, Chien W & MacKenzie A (2000) Needs of families with a

relative in a critical care unit in Hong Kong. Journal of Clinical

Nursing 9, 46–54.

Leininger M (1981). A phenomenon of caring in nursing practice.

Journal of Advanced Nursing 17, 1283–1290.

Leininger M (1985) Qualitative Research Methods in Nursing. WB

Saunders, Philadelphia.

Leininger M (1986) Care facilitation and resistance factors in the

culture of nursing. Topics in Clinical Nursing 8, 1–12.

Leininger M (1988) The phenomena of caring: Importance, research

questions and theoretical considerations. In Qualitative Research

Methods in Nursing (Leininger M ed). Grune & Stratton Press,

Orlando.

Leininger M (1995). Transcultural care diversity and universality: a

theory of nursing. Nursing and Healthcare 6, 208–212.

Leske J (1986) Needs of relatives of critically ill patients; a follow up.

Heart and Lung 15, 189–193.

Locsin R (1995) Technologies and caring in nursing. Image – the

Journal of Nursing Scholarship 27, 201–203.

Luna L (1989) Transcultural nursing care of Arab-Muslims. Journal

of Transcultural Nursing 1, 22–27.

Luna L (2002). Arab Muslims and culture care. In Transcultural

Nursing: Concepts, Theories, Research and Practice (Leininger M &

McFarland eds), 3rd edn. McGraw Hill, New York, pp. 301–311.

Lustig MW (1988) Cultural and communication patterns of Saudi

Arabians. In International Communication: A Reader (LE Samovar

& Porter RE eds), 5th edn. Wadsworth, Belmont, CA, pp. 101–103.

McKennis A (1999) Caring for the Islamic patient. AORN Journal

69, 1187–1196.

Molter N (1979) Needs of relatives of critically ill patients: a des-

criptive study. Heart and Lung 8, 332–339.

Morse JA, Solberg SM, Neadder WL, Bottorff JL & Johnson JL

(1990) Concepts of caring and caring as a concept. Advances in

Nursing Science 13, 1–14.

P Halligan

1572 � 2006 Blackwell Publishing Ltd, Journal of Clinical Nursing, 15, 1565–1573

Morse JA & Field PA (1998) Nursing Research: The Application of

Qualitative Approaches, 2nd edn. Stanley Thornes Publishers,

United Kingdom.

Munhall P (2001) Nursing Research, A Qualititative Perspective, 3rd

edn. Jones & Bartlett, London.

Omeri A (1997) Cultural care of Iranian immigrants in new South

Wales, Australia: sharing transcultural nursing knowledge. Journal

of Transcultural Nursing 8, 5–16.

Omery A (1983) Phenomenology: a method for nursing research.

Advances in Nursing Science 5, 49–63.

Pennachio D (2005) Cultural Competence: Caring for your Muslim

patients, Medical Economics. http://www.memag.com/menag/

content (access 07/06/2005).

Polit D & Hungler B (1999) Nursing Research: Principles and

Methods. Lippincott, Philadelphia.

Potter P & Perry A (1993) Fundamentals of Nursing, Concepts,

Process and Practice, 3rd edn. Mosby Publishers, St Louis.

Rassool H (2000) The crescent and Islam: healing, nursing and the

spiritual dimension. Some considerations towards an under-

standing of the Islamic perspectives on caring. Journal of Advanced

Nursing 32, 1476–1484.

Rassool H (2004) Commentary: an Islamic perspective. Journal of

Advanced Nursing 46, 281–283.

Roach S (1984) Caring: The human mode of being: Implications for

nursing. University of Toronto Press, Toronto.

Shannon M & Brayshaw D (1995). Are nurses aware of the differing

health care needs of Vietnamese patients? Journal of Advanced

Nursing 22, 456–464.

Sheikh A & Gatrad A (2001) Caring for Muslim Patients. Radcliffe

Medical Press, Oxon.

Staden H (1998) Alertness to the needs of others: a study of the emo-

tional labour of caring. Journal of Advanced Nursing 27, 147–156.

Walters A (1995) A Heideggerian hermeneutic study of the practice

of critical care nurses. Journal of Advanced Nursing 21, 492–497.

Watson J (1979) Nursing on the caring edge: metaphorical vignettes.

Advances in Nursing Science 10, 10–18.

Yam B & Rossiter J (2000) Caring in nursing: perceptions of Hong

Kong nurses. Journal of Clinical Nursing 9, 292–302.

Issues in clinical nursing Critical care nurses’ experiences in Saudi Arabia

� 2006 Blackwell Publishing Ltd, Journal of Clinical Nursing, 15, 1565–1573 1573