|Year : 2015 | Volume
| Issue : 3 | Page : 166-172
Role of language and communication in providing quality healthcare by expatriate nurses in Saudi Arabia
Department of Nursing, Majma'ah University, Riyadh, Saudi Arabia
|Date of Web Publication||2-Jul-2015|
55 Station Landing, Medford, MA 02155
The Kingdom of Saudi Arabia (KSA) has experienced rapid growth in its healthcare system, leading to an influx of many foreign professional nurses in the healthcare workforce. This increasing trend of foreign professional nurses into the KSA healthcare system has serious implications such as cultural, language and communication barriers that in turn have the potential to compromise the ability to ensure quality of care to Saudi patients. KSA is a conservative Islamic country that is guided by strict adherence to a religious belief that if foreign nurses are not sensitive to or understand their Saudi patients, it may interfere with their ability to communicate effectively. This paper examines the language and communication barriers within the KSA healthcare systems and how such barriers have the potential to compromise the quality of care. The paper concludes with strategies and recommendations related to addressing language and communication barriers within the KSA healthcare system.
Keywords: Communication, cultural, expatriate nurses, language, medication errors, Saudi Arabia, Saudi patients
|How to cite this article:|
Albougami A. Role of language and communication in providing quality healthcare by expatriate nurses in Saudi Arabia. J Health Spec 2015;3:166-72
|How to cite this URL:|
Albougami A. Role of language and communication in providing quality healthcare by expatriate nurses in Saudi Arabia. J Health Spec [serial online] 2015 [cited 2018 May 26];3:166-72. Available from: http://www.thejhs.org/text.asp?2015/3/3/166/159898
| Introduction|| |
The Kingdom of Saudi Arabia (KSA) has experienced recent explosive growth in its healthcare system, leading to many foreign workers entering its healthcare workforce.  Because KSA is a conservative Islamic country and has other unique cultural and language traits, the large involvement of foreign workers in its healthcare system has its implications for cultural, language and communication barriers. This paper focuses on language and communication barriers in healthcare systems that can lead to compromised quality of care and proposes recommendations on how to address removing healthcare communication barriers.
| Cultural and Healthcare System Overview of Saudi Arabia|| |
Saudi Arabia, one of the largest countries in the Middle East,  has enormous oil reserves, and the resulting wealth has ushered in an era of socio economic transition. Naturally, the benefits to health and lifestyle in the general population of KSA have been remarkable.
On the other hand, this transition has brought with it new adverse health behaviours. For example, increasing availability of food, such as meat by 313% and oil/fat by 200% between 1974 and 1995, has resulted in a per capita increased consumption of energy from 1,807 to 3,128 kcal/day in the same time span,  while the recommended daily intake in KSA is 2,100 kcal.  According to Euromonitor International, soft drink consumption and restaurant dining have increased in KSA,  and the rate of sedentary lifestyle of Saudi nationals across varying age groups has been estimated to be from 43.3% to 99.5%.  Therefore, obesity is increasing in both adults and children in the Kingdom,  along with a simultaneous increase in type 2 diabetes, hypertension and hypercholesterolemia. 
The Saudi Ministry of Health (MoH) is a government department whose responsibility is to develop a network of primary healthcare centers and ensure that the Saudi population has adequate access to care.  An essential development has been a comprehensive referral system throughout a broad base of general and specialist hospitals.  The Saudi government has channeled considerable financial resources into the improvement of healthcare and social services.  Their objective is to provide free healthcare for Saudi nationals and expatriates employed in the public sector.
The MoH provides 60% of the healthcare services in the Kingdom, while the other governmental agencies and the private sector together provide the remaining 40%,  reflecting significant private sector healthcare development, well-established referral network connecting hospitals, clinics, dispensaries and pharmacies.  The growth rate in the native Saudi population has necessitated strategic planning to accommodate physical and human resources for healthcare. Currently, KSA's healthcare resources include 331 hospitals with 47,018 beds and 2,838 primary healthcare centers,  staffed at a rate of 19.0 physicians, 2.10 dentists, 3.40 pharmacists and 35.0 nursing and midwifery personnel per 10,000 of the population.  According to the Saudi 2012 Statistical Yearbook, "there has been a marked increase in the proportion of Saudis within the nursing workforce during that time the time period 2008 to 2012, up from 44.5% to 55.3% respectively." 
| Effect of Culture and Religion on Healthcare Quality|| |
Saudi nationals do not practice any religion other than Islam, and the prevailing socioeconomic development takes place within the dictates of Islamic religious beliefs.  The Holy Quran (the Islam holy book) and Sunna (prophetic tradition as interpreted by Prophet Mohammed - peace be upon him - PBUH) are the leading codes for the Islamic religion. There are other factors at work in the culture such as economic status, level of education and environmental factors,  but essentially, Islamic practice connected to spirit, behaviour, food, language as well as social traditions is the greatest influence.
This strict adherence to a religious belief may from time to time pose difficulty for medical practitioners because Muslims believe that health, sickness and death are dictates of Allah (God).  Furthermore, some members of the Saudi population do not see sickness as a result of poor health-practices; instead, it is perceived as a way to atone for one's sins.  This belief may mean that individuals do not take an active role in maintaining a healthy lifestyle.
In addition, Lawrence and Rozmus  emphasized an important Muslim cultural aspect for nurses caring for Muslim patients, and that is the patient's concern for modesty, especially females, during examinations and procedures. Furthermore, religion dictates that women patients cannot be alone with a male physician without the husband or a close relative and a female nurse being present. Moreover, Yosef states in reference to his research that Arab people perceive "treating Arab clients without addressing Arab culture is an indication of culturally insensitive care." 
Rassool  examined the issues specific to Islamic beliefs that were relevant to healthcare professionals who may be treating people of the Islamic culture. Rassool  posited that a fundamental deficit of knowledge regarding the spiritual beliefs of Islamic people resulted in a culture-blind approach to patient care. To provide context, Rassool  then offered an overview of the tenets of Islamic spiritual beliefs, so that non-Muslim healthcare professionals may understand how Muslim patients' perspective on health and faith were intertwined. Furthermore, Rassool  suggested that implementing an Islamic-specific model of healthcare would strongly benefit the non-Muslim healthcare professional and enable them to achieve an all-encompassing, or holistic, level of care for Muslim patients.
| Language and Communication Barriers Between Nurses and Patients|| |
In a qualitative study of 50 expatriate nurses from South Africa working in Saudi Arabia, the nurses reported hindrances in certain aspects of verbal and non-verbal communication with Saudi patients.  A particular difficulty for the nurses was related to non-verbal communication and object cues as a result of Saudi women covering their head, face, and body.  Another barrier to the nursing process was that for Saudis, the use of touch is unwelcome, and the nurses noted stress behind being denied certain aspects of non-verbal communication, particularly touch, spatial limits, eye contact, and intimacy.  For challenges such as these, cultural awareness educational programs have been recommended.
Clear communication between the patient and caregivers is paramount for ensuring the highest quality of health practices. In a study by Cioffi,  23 registered nurses and certified midwives working in Sydney, Australia were interviewed; 10 of whom were from a variety of non-Anglo-centric backgrounds such as Asia, South America, the Philippines, Sri Lanka, Europe and indigenous Australia. The study found that interpreters and bilingual health workers were effectively used to facilitate communication with culturally and linguistically diverse (CLD) patients, and some nurses showed empathy, respect and willingness to make an effort in the communication process, while others showed an ethno-centric orientation.  The chief recommendations were that the medical authority should prioritize health workers having access to appropriate linguistic services, and the provision of support for nurses by multi-lingual healthcare workers.  It was felt that assisting nurses to develop their awareness of cultural diversity would build acceptance, appreciation, and commitment to the care of CLD patients and their families.
It is not only the act of communication, but the parties with which the nurse in the Saudi Arabia workforce communicates that is shaped by the Saudi culture. Expatriate nurses should be made aware of a dominant Arab practice, that Saudi patients will have a family member or "sitter" with them during most of their duration of stay in a clinical setting.  As a consequence, communication, not only with the patient, but with family, friends, and the sitter will be a necessary and an integral part of delivering healthcare. 
With these challenges to culturally competent care, it is not surprising that Saudi patients are not always very satisfied with the care they receive. Mansour and Al-Osimy  interviewed 300 Saudi patients regarding their satisfaction with the quality of healthcare at three primary care centers in Riyadh, Saudi Arabia. The results revealed a high degree of dissatisfaction in one of these centers in the item related to "nurse's way of treating you," which may have been due to the presence of non-Arabic speaking nurses in the center. These findings provide evidence and explanations regarding the gaps in communication with respect to the culture in the KSA healthcare system. These gaps are important because they have the potential to affect the quality of care.
| Quality of Healthcare and Communication Barriers|| |
Language barrier and miscommunication
Research shows that there exists a wide gap in communication between the patient and nursing staff due to multiple factors such as language barriers and lack of cultural awareness. Although non-Arabic-speaking nurses sometimes learn a few words of Arabic, this is not adequate to communicate effectively in another language.  "Knowing a smattering of a foreign language only allows one to make a fluent fool of oneself if the implicit meanings behind highly subtle linguistic symbols are not understood."  As a result, interpreters are needed to facilitate communication between English-speaking staff and Arabic-speaking patients. In addition, selecting an interpreter of the patient's gender is likely to result in a more comfortable and efficient interpretation process in consideration of religion and culture. 
Challenges to the quality of healthcare in Saudi Arabia are revealed in the results of a patient satisfaction survey conducted at King Khalid University Hospital (KKUH) in Riyadh, during the period from October 1995 to March 1996, which focused on various aspects of services rendered to inpatients.  The sample consisted of randomly selected 450 inpatients with probability proportion to the size of the wards, and data were collected by personal interviews.  The overall mean satisfaction percentage was 77% and the highest mean satisfaction was for items on nursing skillfulness and the lowest score was for communication.  With respect to communication, the lowest level of satisfaction was with nurses' attention to patients' cleanliness, and for listening to and conversing with patients. 
Indeed, this dichotomy between high patient satisfaction in terms of skillfulness and low satisfaction in terms of communication begs the question: Given a lack of language ability, how can the nurse do any patient activity or procedure correctly without communicating effectively?  Furthermore, a longer interaction with patients in a two-way communication is required for these skills to be manifested. This is difficult for nurses in KKUH for whom language is a barrier. The vehicle for improving the success of technical care in Saudi Arabia is improving nurse-patient communication. 
Current findings in the scientific literature regarding medication errors in Saudi Arabia imply but do not specifically point to, communication and language problems. Khoja et al., found in their review of 5,299 prescriptions from public and private clinics in Saudi Arabia that 18.7% had errors that ranged from trivial to serious.  In this article, these authors did not speculate as to what caused the errors.  A different study in the pediatric Intensive Care Unit at King Abdulaziz Medical City in Riyadh, Saudi Arabia, which reviewed 2,380 medication orders, found the error rate to be 56 per 100 orders.  These authors suggested that the use of abbreviations in prescriptions and the lack of a computerized physician order entry system were among the factors responsible for this high rate, but do not point to any specific communication barrier.  A study of hospitalized patients at Hera General Hospital in Makkah, Saudi Arabia found that "written communication" was responsible for 34.9% of the 2,627 errors analyzed from records.  Patient medication compliance has also been identified as a source of medication errors in Saudi Arabia,  and this could also be the result of a communication or language barrier.
While many studies of medication errors in Saudi healthcare facilities exist in the scientific literature, most do not analyse the root cause of these errors. It is possible that the root cause for many of these errors is a challenge in communication - between non-Saudi and Saudi healthcare personnel as well as between non-Saudi and Saudi patients. The direct effect of communication and language barriers on the incidence of medication errors in Saudi Arabia has not been comprehensively studied.
The next section will review the five major cultural characteristics of a culture (as put forth by Kendall in 2014 and in previous writings) with respect to communication barriers in the healthcare system of Saudi Arabia.
Five major cultural characteristics of a culture
The major facets of a culture include language, religion, economy, government and traditions.  These items are reviewed here, with reflection on how these cultural characteristics might impact healthcare delivery in Saudi Arabia, with an emphasis on the role of communication.
The most commonly used element to define a culture is the language used by the people. The language is the prima facie element of information sharing in a culture.Most cultures use verbal language as the primary means of communication, either by word of mouth or via electronic media. Folklore is also a form of knowledge sharing among generations within a culture where linguistic elements are utilized to communicate across the ages. 
According to facts from the Saudi Arabian Embassy in Washington DC, Saudi Arabia "occupies an area about the size of the east of the Mississippi River in The United States," and according to the 2010 census, has a population of 27 million, including 8.4 million foreign residents.  Similar to the US, regional Arabic dialects exist in Saudi Arabia regions due to its large land mass. Also similar to the US, there is a large expatriate population, which means many people living in Saudi Arabia do not speak the local language, or if they do speak Arabic, they do not speak with the local dialect.
Religion is another defining characteristic of a culture though again it should be noted that within one culture, there may exist different religions. This factor may vary depending on other characteristics of a society, such as their form of government or law. In the United States, there are many religions, mostly due to the fact that religious freedom is a tenet of the U.S. Constitution, which itself is a defining element of the American culture.
In a country like Saudi Arabia, however, religion and politics are tightly interwoven and represent a challenge in uniting a more diverse expatriate population with the native one in a common understanding of the culture within the country. For an expatriate nurse, this can pose a significant challenge, not only to overcome cultural prejudices, but also to embrace the native cultural paradigm in order to provide the native Saudi patients with the best treatment approach, given the patient's background and beliefs. 
In a theocracy like Saudi Arabia, primary considerations in how decisions are influenced by the governance structure relate directly to the Islamic belief systems. Through theonomous laws, countries like KSA are guided in the construct of their constitution, the conduct of their foreign policy and the approach to their domestic policy as well. Beliefs that are so deeply held cannot be ignored, and are not regarded distinct from the political structure. Indeed, the power to rule is seen to come from the divine, and those that rule in power are believed to be divinely inspired. Quinn  noted that knowing about the religion and structure in a country revealed how people thought, what they believed in, and how they felt regarding healthcare and the healthcare profession; it is inescapable in a theocracy to separate the idea of faith and statehood.
In addition, in a theocracy, the decisions made at the national level trickle down into community issues, and the word from the divinely inspired leaders do not get polluted depending on the level of authority. The message for the theocratic system is the same through different levels of authority because the laws are inspired by divine belief structures. 
Without a culturally sensitive expatriate nurse who is aware of the theonomous laws and beliefs and how they influence people, treating the indigenous population will be challenging and likely to result in dissatisfaction for both the nurse and the patient. For the expatriate nurse, the factor of governance may not be the most significant element on their medical perspective; however, the laws and regulations can influence the medical realm of Saudi Arabia within which the nurse works. Understanding the political structure of the country is an important briefing element for the expatriate nurse in Saudi Arabia. 
In essence, the factors of language, governance and religion drive the model of the country's economy. How a country conducts business and commerce speaks of the mindset its people. In Saudi Arabia, social services such as healthcare are funded by the government,  and the government is funded by the royal family, as Saudi Arabia is a monarchy. Therefore, the healthcare economy of Saudi Arabia, more so than many other countries, is entwined inextricably with its religion and its governance.
Traditions are likely one of the strongest facets of a culture. Each of these elements discussed is not independent of each other; they are interrelated and have effects upon other areas. Traditions arise from language via knowledge sharing, religion, government, commerce, and many other intricacies within a culture, which in turn define that culture. 
In Saudi Arabia, challenges exist in defining the difference between "traditions," which are cultural facets, and actual religious constructs dictated by the religious practices in Saudi Arabia. Traditions are considered to be much more flexible than religious practice in Saudi Arabia. It must be recognized that even Islamic expatriates may bring different traditions from their native countries; these could create friction with Saudi Arabian traditions as well as possibly religious expressions.
| General Recommendations for Nursing Practices|| |
Taking into consideration the language, religion, governance, economy, and traditions in Saudi Arabia, the following recommendations can be made for improving communication in the practice of nursing in Saudi Arabia.
Increase culturally competent care
It must be ensured by Saudi Arabian healthcare organizations (HCOs) that the patients are well-received by healthcare personnel, and cared for in an efficacious, considerate and courteous manner. This care should respect cultural issues and practices, and be delivered in a language easily understood by patients.
Implementation of human resources strategies is recommended to recruit, sustain and uphold a diverse healthcare workforce, and instill leadership at all organizational levels by the HCOs. The demographic attributes of the local population should be considered.
It must be ensured that staff members from every level and discipline are continuously being provided knowledge and instructions in HCOs on how to observe language and culture to create a patient-friendly environment.
Increase the availability of language access services
Language aid services must be made available to staff and patients by the HCOs, such as interpreters and multilingual staff. These services should be available at all times, and patients with a low command of English or Arabic should not have to pay extra.
Patients must be offered services for language support by HCOs for communicating in both written and spoken language of their choice.
Healthcare organizations must ensure that the level and quality of language support offered to patients by interpreters are high, and the interpreters remain proficient. Language support should not be provided by friends and family (except upon patient's request).
Patient-related material issued by the HCO must be easy to comprehend, and printed signage should be in the language of choice for the local subpopulation in the HCO's service area.
Increase organizational support for cultural competence
Healthcare organizations should establish, execute and encourage a written, well-considered plan that documents objectives, planned operational changes and administrative systems with responsibility/oversight to monitor services that respect culture and language.
Healthcare organizations should carry out continuous self-assessment of activities concerning diverse groups, and should promote the incorporation of linguistic and cultural practices based on evaluations provided by internal audits. Programmes for performance enhancement should be put in place, and patient satisfaction levels with communication measured by staff.
Healthcare organizations must make sure that patient demographic information such as race and language are collected and kept in health records. These data should be accessible to the information management systems of the institution and constantly updated.
Healthcare organizations should keep a profile of the local community with respect to epidemiological, cultural and demographic factors, and refer to this profile when planning and executing services to ensure that they respond to local traits regarding linguistics and culture.
Healthcare organizations should foster sharing and collaborative associations with local communities, and employ various informal and formal activities to increase community involvement toward strategic planning.
Healthcare organizations should make sure that the process of conflict resolution and grievance is sensitive, both culturally and linguistically, and that it is able to recognize, avoid and solve conflicts concerning cultural issues and complaints raised by patients.
Healthcare organizations are being charged with continuously publishing data aimed at public audience with the purpose of reporting the results of strategies for diversity. These reports can reveal the success of programmes, as well as inform communities about the availability of such information through public notices.
| Implications for Nursing Practice|| |
The considerations listed above must be considered when managing the delivery of nursing care to Saudi patients in KSA. Most importantly, in Saudi Arabia, there is an emphasis on the family's contribution to decisions and joint decision-making. Religion and culture play a significant role in the determination of Muslim patients' healthcare and understanding of the process and this is especially true in KSA, where adherence to Islamic practices is strong. Certain aspects of community and family care-taking have essential importance to the Saudi family, and these must be taken into account in nursing. Of note, the direct involvement in care and the constant presence and consistent support extended toward the patient by his or her family are hallmarks of Saudi culture.
Furthermore, it is important to reflect certain cultural patterns through the policies and conduct of the hospitals that cover activities such as visiting, maintenance of modesty, specific care for each gender, proper communication process and the spiritual needs of the person.  In addition to this, the role of a translator is essential in areas where language differences are common, thus providing culturally competent care for the Saudi population. There are also certain differences in the cultural and psychological attitudes of Muslim patients as well as nurses. Processes that reflect accommodation of religious preferences in the supervision of the clinic would be very helpful for the nurses to identify the existence of cultural barriers, stereotypes and ethnocentric orientation.
Finally, there should be frequent assessment of the nursing management as to whether they have adequate and proper knowledge and skills to tackle different ethical situations, and to provide equal care to the patient and their family, regardless of their background. Education of expatriate nursing professionals in Saudi Arabia will also reduce their emotional stress and lead to the provision of clear communication with patients and families and culturally sensitive healthcare.
| References|| |
Madani KA, Al-Amoudi NS, Kumosani TA. The state of nutrition in Saudi Arabia. Nutr Health 2000;14:17-31.
Al-Kanhal MA, Al-Mohizea IS, Al-Othaimeen AI, Khan MA. Nutritional evaluation of some legume-based dishes consumed in Saudi Arabia. Int J Food Sci Nutr 1998;49:193-7.
Euromonitor International. (n.d.). Global Market Research and Analysis for Industries, Countries, and Consumers. Available from: http://www.euromonitor.com/
. [Last retrieved on 2014 Sep 28].
Al-Hazzaa HM. Prevalence of physical inactivity in Saudi Arabia: A brief review. East Mediterr Health J 2004;10:663-70.
Abalkhail B. Overweight and obesity among Saudi Arabian children and adolescents between 1994 and 2000. East Mediterr Health J 2002;8:470-9.
El-Hazmi MA, Warsy AS. Prevalence of overweight and obesity in diabetic and non-diabetic Saudis. East Mediterr Health J 2000;6:276-82.
Almalki M, Fitzgerald G, Clark M. Health care system in Saudi Arabia: An overview. East Mediterr Health J 2011;17:784-93.
Aldossary A, While A, Barriball L. Health care and nursing in Saudi Arabia. Int Nurs Rev 2008;55:125-8.
Al-Yousuf M, Akerele TM, Al-Mazrou YY. Organization of the Saudi health system. East Mediterr Health J 2002;8:645-53.
Abu-Zinadah S. Nursing situation in Saudi Arabia.
Riyadh: KSA, Saudi Nursing Board, Saudi Commission for Health Specialties; 2006.
Littlewood J, Yousuf S. Primary health care in Saudi Arabia: Applying global aspects of health for all, locally. J Adv Nurs 2000;32:675-81.
Al-Shahri MZ. Culturally sensitive caring for Saudi patients. J Transcult Nurs 2002;13:133-8.
Lawrence P, Rozmus C. Culturally sensitive care of the Muslim patient. J Transcult Nurs 2001;12:228-33.
Yosef AR. Health beliefs, practice, and priorities for health care of Arab Muslims in the United States. J Transcult Nurs 2008;19:284-91.
Rassool GH. The crescent and Islam: Healing, nursing and the spiritual dimension. Some considerations towards an understanding of the Islamic perspectives on caring. J Adv Nurs 2000;32:1476-84.
Van Rooyen D, Telford-Smith CD, Strümpher J. Nursing in Saudi Arabia: Reflections on the experiences of South African nurses. Health SA Gesondheid 2010;15:19.
Cioffi RN. Communicating with culturally and linguistically diverse patients in an acute care setting: Nurses′ experiences. Int J Nurs Stud 2003;40:299-306.
Gallagher EB, Searle CM. Health services and the political culture of Saudi Arabia. Soc Sci Med 1985;21:251-62.
Mansour AA, Al-Osimy MH. A study of satisfaction among primary health care patients in Saudi Arabia. J Community Health 1993;18:163-73.
Ross E, Deverell A. Psychosocial Approaches to Health, Illness and Disability: A Reader for Health Care Professionals. Pretoria: BPR Publishers; 2004.
Al-Doghaither AH. Inpatients satisfaction with nursing services King Khalid University Hospital, Riyadh, Saudi Arabia. J Family Community Med 2000;7:37-45.
Khoja T, Neyaz Y, Qureshi NA, Magzoub MA, Haycox A, Walley T. Medication errors in primary care in Riyadh City, Saudi Arabia. East Mediterr Health J 2011;17:156-9.
Al-Jeraisy MI, Alanazi MQ, Abolfotouh MA. Medication prescribing errors in a pediatric inpatient tertiary care setting in Saudi Arabia. BMC Res Notes 2011;4:294.
Dibbi HM, Al-Abrashy HF, Hussain WA, Fatani MI, Karima TM. Causes and outcome of medication errors in hospitalized patients. Saudi Med J 2006;27:1489-92.
Qureshi NA, Neyaz Y, Khoja T, Magzoub MA, Haycox A, Walley T. Physicians′ medication prescribing in primary care. In Riyadh City, Saudi Arabia. Literature review, part 3: Prescribing errors. East Mediterr Health J 2011;17:140-8.
Kendall D. Sociology in Our Times. United States:Wadsworth: Cengage Learning; 2014.
Friedland R, Mohr J, (eds). Matters of Culture: Cultural Sociology in Practice. Cambridge, England, New York: Cambridge University Press; 2004.
Al-Ahmadi H. Factors affecting performance of hospital nurses in Riyadh Region, Saudi Arabia. Int J Health Care Qual Assur 2009;22:40-54.
Quinn DM. How religion, language and ethnicity impact perioperative nursing care. Nurs Clin North Am 2006;41:231-48, vi.
Perl L. Theocracy: Political Systems of the World. New York: Marshall Cavendish Benchmark; 2007.
Carty RM, Moss MM, Al-Zayyer W, Kowitlawakul Y, Arietti L. Predictors of success for Saudi Arabian students enrolled in an accelerated baccalaureate degree program in nursing in the United States. J Prof Nurs 2007;23:301-8.
Halligan P. Caring for patients of Islamic denomination: Critical care nurses′ experiences in Saudi Arabia. J Clin Nurs 2006;15:1565-73.