Title of study
Purpose
key word ( PICO) P It can be the patient, it can be the population, it can be the problem. I is for the intervention. C is for the comparison, O is for the outcome. this four is the keywords which will be USE to search to search ,
DATA base ( pub mid ) Last 10 years Google Scholar OR Pub Med just like that. You choose any three DATA BASE
Inclusion & excluded criteria You should have inclusion and exclusion criteria. Inclusion and exclusion criteria. So if you have inclusion and exclusion criteria, so this is the guidelines. This is the initial step for you which will be guiding you to take the reduce. So what is this? Inclusion by study will be included the study whichever is done only in Saudi Arabia.Integrated review is based on they have given an approach. The name of approach is White, Moore and Nash approach and he is having this approach is having five steps. You are going to do the review As for the steps which is described by him by the author,
searched the sources from Single M Base Midline Pub Med Cycling for the review included the studies which is focused on nurse patient communication issues, communication barriers, cultural and language issues. You see here. This is the title is Barriers to Nurse Patient communication in Saudi Arabia.I UPPLOAD THE RUBRIC AND ARTICALS I NEED SAME WAY OF THIS ARTICALES , USE INTEGRATIVE REVIEW
Alshammari et al. BMC Nursing
(2019) 18:61
https://doi.org/10.1186/s12912-019-0385-4
RESEARCH ARTICLE
Open Access
Barriers to nurse–patient communication in
Saudi Arabia: an integrative review
Mukhlid Alshammari* , Jed Duff and Michelle Guilhermino
Abstract
Background: Effective nurse–patient communication is important in improving quality of health care. However,
there are several barriers to nurse–patient communication in Saudi Arabia. This is attributed to the increasing
number of non-Saudi expatriate nurses providing health care to patients. In particular, there are differences in
culture, religion and language among non-Saudi nurses and patients. This integrative review aims to identify and
synthesize quantitative and qualitative evidence on the current practice in nurse–patient communication in Saudi
Arabia and its effect on service users’ quality of care, safety and satisfaction.
Methods: An integrative review based on Whittemore and Knafl’s approach (Whittemore and Knafl, J Adv Nurs 52:
546–553, 2005) was used to conduct the review. Peer-reviewed articles containing any of a series of specific key
terms were identified from sources such as CINAHL, EMBASE, Medline, PubMed and PsychINFO. The review
included studies that focused on nurse–patient communication issues, communication barriers, and cultural and
language issues. The search was limited to papers about the Saudi Arabian health system published in English and
Arabic languages between 2000 and 2018. A data extraction form was developed to extract information from
included articles.
Results: Twenty papers were included in the review (Table 1). Ten papers employed quantitative methods, eight
papers used qualitative methods and two used mixed methods. The review revealed two major themes: ‘current
communication practices’ and ‘the effect of communication on patients’. Some of the communication practices rely
on non-verbal methods due to a lack of a common language, which often results in the meaning of the
communication being misinterpreted. Many non-Saudi nurses have limited knowledge about Saudi culture and
experience difficulty in understanding, and in some cases respecting, the cultural and religious practices of patients.
Further, limited nurse–patient communication impacts negatively on the nurse–patient relationship, which can
affect patient safety and lead to poor patient satisfaction.
Conclusions: Current nurse–patient communication practices do not meet the needs of Saudi patients due to
cultural, religious and language differences between nurses and patients. The barriers to effective nurse–patient
communication adversely effects patient safety and patient satisfaction. Further research from the perspective of
the patient and family is needed.
Keywords: Saudi Arabia, Nurse–patient communication, Communication barriers, Quality of nursing care, Patient
satisfaction
* Correspondence: mukhlid.alshammari@uon.edu.au;
mukhlid1983@gmail.com
School of Nursing and Midwifery, University of Newcastle, Callaghan,
Australia
© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Alshammari et al. BMC Nursing
(2019) 18:61
Background
The concept of communication is a complex process of
exchanging information, thoughts and feelings between
individuals using a common system of signs, symbols or
behaviors. This process consists of several components,
including sender, receiver, context, medium, message
and feedback. For communication to occur, a message
(information, thoughts and feelings) is transmitted by
the sender (also called the encoder) through a suitable
medium in a given context to a receiver (also called the
decoder), who then provides feedback [1].
In the health-care setting, several theoretical and conceptual approaches have been employed to improve
health outcomes, including patient-centered communication [2–6]. Patient-centered communication has been
identified as an essential component in delivering quality
health services [4]. High-quality patient-centered communication has been shown to help patients strengthen
their relationship with nurses, handle their emotions,
understand important information regarding their illness, deal with uncertainty, and participate more fully in
decisions regarding their health [2, 4].
Nurse–patient communication plays an important role
in improving not only patient’s relationship with the
nurse, but also the patient’s own perception of the treatment process and outcome. Moreover, having effective
communication skills is essential for health-care providers’ practice and their ability to understand the clinical symptoms and psychological and emotional needs of
their patients. Patient-centered communication enables
the building of therapeutic relationships, which helps
health-care providers apply intelligent, sensitive and collaborative approaches to communicate with patients
about their services [2, 5, 7–10].
Despite the potentially significant benefits of patientcentered communication, there have been communication barriers identified across a number of different
practice settings worldwide [11–14]. For instance, limited knowledge and understanding of the culture and
language of a health system on the part of a patient has
been shown to limit the communication process between patient and clinician [13–16]. These barriers are
influenced by several factors including cultural and language diversity [12]. These communication barriers can
affect health outcomes, quality of health care, patient
safety and patient satisfaction.
Nurse-patient communication is a challenge in the
Saudi Arabia health system because many of the nurses
are expatriates and don’t speak Arabic. This issue is not
unique to Saudi Arabia, due to increasing levels of immigration into developed countries such as United States
of America and Australia, there is increasing cultural
and linguistic diversity between nurses and their patients
[12, 14]. In fact, a recent systematic review [13]
Page 2 of 10
suggested that such communication barriers are common to many countries and they adversely affect the
overall quality of health services.
There has been growing interest in research on nurse–
patient communication in Saudi Arabia, including quantitative and qualitative studies [17–21], but despite the
growing evidence base no study has focused on the communication experiences of patients. Furthermore, no
study has examined if the patient’s communication experience impacts satisfaction with their nursing care.
Aim
This integrative review aims to identify and synthesize
quantitative and qualitative evidence on the communication practices among nurses and patients in Saudi Arabia and their effect on patient satisfaction, quality of care
and safety.
Methods
An integrative review was chosen to merge diverse
methods, and synthesize findings from both qualitative
and quantitative studies [22]. The integrative review
used Knafl and Whittemore’s methodology [23]. This
approach involved a five-stage process: (1) identify the
purpose of the review, (2) search the relevant literature,
(3) evaluate and extract data, (4) analyze or synthesize
the data, and (5) present findings [23]. The quality of the
included papers in this review were evaluated using the
Mixed Methods Appraisal Tool (MMAT) [24].
Inclusion criteria and search strategy
The review included papers written in Arabic and English and focused on Saudi Arabian healthcare. Studies
were included if they focused on nurse–patient communication, including communication barriers such as language and cultural issues and their effects on patients.
CINAHL, EMBASE, PubMed, Medline and PsychINFO databases as well as Google Scholar were
searched for articles published between 2000 and 2018.
These databases and the time limit were chosen to ensure a comprehensive search and a sufficient breadth
and depth in the retrieved literature. A two-stage search
approach was utilized to facilitate the search process. An
initial search was conducted in Medline and EMBASE.
Subsequently, the identified key words and search items
were modified and used to search across CINAHL,
PUBMED and PsychINFO. The search items that facilitated the search process were barrier* or facilitat* or
limit* or challeng* or difficult* or obstacle* or problem
or issue AND communicat* or language or cultur* AND
nurs* AND Saudi* AND quality or satisf* or effectiv* or
impact.
Alshammari et al. BMC Nursing
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Data extraction and synthesis
The integrative review contained several stages in the selection of papers. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow
chart (Fig. 1) represents the process. First, the titles and
abstracts of all the papers identified from the scientific
databases were screened against the inclusion criteria.
Second, the abstracts of all the included titles were
reviewed to identify those that required full text review.
The final stage of the selection process involved screening the full text articles to agree on those to include in
the final synthesis. Two reviewers independently managed the selection process.
A pre-defined data extraction form was developed to
guide the process of data extraction. The tool was developed and structured according to the systematic review
reporting guidelines [25]. The data extraction form was
structured into sub-sections, which included description
of study (author, year of publication and title of paper),
methods (study design, methods, sampling and sample
size) and findings.
Critical appraisal
The quality of the papers was assessed using the Mixed
Methods Appraisal Tool (MMAT). This tool has been
Fig. 1 PRISMA chart of article selection
Page 3 of 10
validated and widely used to asses quality of papers with
different methods [24]. MMAT has three categories of
quality score, including low (a score below 25%),
medium (a score of 50%) and high (a score of 75% and
above). All of the included studies were checked on the
basis of data relevance as well as methodological rigor.
Results
Study characteristics
A total of 150 records were reviewed from CINAHL,
EMBASE, PubMed, Medline, PsychINFO and Google
Scholar, of which 26 duplicates were deleted. From this,
124 titles and abstracts were assessed against the inclusion criteria, with 79 excluded. A full text review of the
remaining 45 documents was undertaken. Twenty five
manuscripts were later excluded, 10 because of the
population, seven were excluded because it did not focus
on nurse-patient communication issues and its effect on
health outcomes; and eight were excluded because the
study setting did not include Saudi Arabia healthcare
context. Overall, data was extracted from 20 full text articles and included in the final synthesis (Fig. 1). Of the
20 papers included, eight used qualitative methods, 10
used quantitative methods and two used mixed methods
(Table 1). Further, 15 of the included studies targeted
Cross-sectional
survey
Descriptive
Semi-structured,
face-to-face
interviews
Descriptive survey
Descriptive survey
Phenomenological Qualitative
design
Not reported
ZA Mani and MA Ibrahim [20]
A Shubayra [27]
M Silbermann, RM Fink, S-J Min, MP
Mancuso, J Brant, R Hajjar, N Al-Alfi,
L Baider, I Turker and K ElShamy [21]
WA Suliman, E Welmann, T Omer and
L Thomas [28]
G Abudari, H Hazeim and G Ginete [29]
AH Al-Doghaither [30]
Cross-sectional
survey
Explorative design Qualitative
Cross-sectional
survey
Phenomenological Qualitative
design
Explanatory
sequential design
Descriptive
Semi-structured
interviews
BM Hammoudi, S Ismaile and O
Abu Yahya [33]
A Khalaf, A Westergren, Ö Ekblom, HM
Al-Hazzaa and V Berggren [34]
AG Mohamed [35]
J Mebrouk [36]
H Alabdulaziz, C Moss and B Copnell [17]
DN Alosaimi and MM Ahmad [18]
20 nurses
234 nurses
5 nurses
343 nurses
In-patient at tertiary
referred hospital
Paediatrics at
secondary health
level hospitals
In-patient at tertiary
referred hospital
Five hospitals at
different health levels
In-patient at
secondary health
level hospital
High
High
High
Medium
High
Medium
High
Medium
High
Limited verbal communication and limited knowledge of religion
and culture exist among expatriate nurses.
There are differences in language, religion and culture among
nurses and patients.
Saudi nurses have enough knowledge regarding language, religion
and cultural whereas expatriate lack knowledge. Expatriate nurses
usually use non-verbal communication.
According to nurses, patients can be dissatisfied due to many
reasons including communication.
There are differences in language, religion and culture among
nurses providing health services.
Nurses’ languages and cultural diversity influence medication
administration as well as reporting errors.
Nurses from different cultures have different perceptions about the
safety environment.
Communication barriers threat patient safety (medication error).
Different levels of satisfaction are perceived by patients related to
nurses competency level or interpersonal skills
Non-Muslim nurses are facing several challenges in taking care of
Muslim cancer patients.
There are communication barriers that influence nurse–patient
relationships.
There are numerous communication difficulties in palliative care.
Language barriers impeded effective nursing education to
patients.
There are communication difficulties between nurses and patients
in end-of-life care.
Patients are satisfied with health services regardless of language
barrier.
(2019) 18:61
Qualitative
Mixed
methods
Quantitative
15 nurses
In-patient at four
tertiary referred
hospitals
In-patient at tertiary
referred hospital
319 nurses
In-patient at
university hospital
Cross-sectional
Mixed
survey
method
Case study design
367 nurses
High
Oncology department High
at tertiary referred
hospital
Three national guard
health affairs facilities
AF Almutairi, G Gardner and
A McCarthy [32]
Quantitative
High
Oncology department High
at three tertiary
referred hospitals
Peritoneal dialysis at
tertiary referred
hospital
65 healthSecondary level and
care providers Private hospital
450 patients
10 nurses
393 patients
Medium
Quality of Key findings related to review
the paper
ICU at tertiary referred High
hospital
In-patient at tertiary
referred hospital
Settings
H Aljadhey, MA Mahmoud, MA Hassali, A
Exploratory design Qualitative
Alrasheedy, A Alahmad, F Saleem, A Sheikh,
M Murray and DW Bates [31]
Quantitative
Quantitative
776 healthcare
providers
9 nurses
Qualitative
Quantitative
77 nurses
116 patients
Quantitative
Quantitative
Cross-sectional
survey
MD Al-Mendalawi [26]
Methodology Participants
Study design
Author/year
Table 1 Characteristics of the included studies
Alshammari et al. BMC Nursing
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Descriptive,
exploratory study
design
Cross-sectional
design
Phenomenological Qualitative
design
Phenomenological Qualitative
descriptive
E Sidumo, VJ Ehlers and S Hattingh [38]
H Al Fozan [39]
P Halligan [19]
M Van Bommel [40]
Quantitative
Quantitative
Quantitative
Cross-sectional
design
MA Atallah, AM Hamdan-Mansour, MM
Al-Sayed and AE Aboshaiqah [37]
63 nurses
6 nurses
302 patients
and family
caregivers
50 nurses
100 patients
Methodology Participants
Study design
Author/year
Table 1 Characteristics of the included studies (Continued)
Medium
Medium
Medium
CCU at tertiary
referred hospital
High
There are language, cultural and religious diversity among
expatriate nurses and patients in ICU.
Patients misinterpret some of the expatriate nurses’ non-verbal
communication.
Patients are satisfied with Saudi nurses who have same language,
culture and religion.
Limited knowledge about cultural and religious practices exists
among expatriate nurses.
Different levels of patient satisfaction occur depending on either
nurses’ competency or interpersonal skills.
Quality of Key findings related to review
the paper
ICU at tertiary referred Medium
hospital
In-patient of national
guard health affairs
facility
Obstetric unit at
secondary level
hospital
In-patient at tertiary
referred hospital
Settings
Alshammari et al. BMC Nursing
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Alshammari et al. BMC Nursing
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Page 6 of 10
nurses’ perspectives of the communication and five focused on patients’ perspectives of communication. A
quality assessment of the included papers found that
most (12 out of 20) were asssessed as high quality, while
the remaining papers (eight out of 20) were assessed as
medium quality.
Identified themes
The major themes were grouped into two themes:
‘current communication practices’ and ‘the effect of
communication on patients’ (Table 2). The sub-themes
identified from the ‘current communication practices’
theme were language, religion and cultural diversity;
communication practices; and communication barriers.
The sub-themes identified from the ‘effect of communication on patients’ theme were quality of care and patient satisfaction.
Current communication practices
In Saudi Arabia, the nursing workforce across almost all
health facilities is dominated by non-Saudi nurses, primarily from the Philippines and India, supplemented by
nurses from the USA, UK, Australia and various European countries [40]. The increasing number of nonSaudi or expatriate nurses has created several challenges
in the delivery of health care. In particular, the challenges are ascribed to several factors, mostly linked to
cultural, language and religion differences. The current
communication practices present a barrier to patientcentered interaction between nurses and patients [19,
29]. These challenges are described below.
Language, religion and cultural diversity
Seven of the included papers explained that there are
differences in language, religion and culture among
nurses providing health services to patients in Saudi
Arabia [17–20, 34, 38, 40] with the language, religion
and culture of non-Saudi nurses differing from their
Saudi patients. Unlike the expatriate nurses, almost all
patients in Saudi Arabia speak Arabic and share the
same cultural values, norms and religion [40].
Khalaf, A et al. (2014) stated that the religious-cultural
norms and values of Saudi patients appear as entirely
new to many non-Saudi nurses [34]. Some cultural or
religious practices, such as gender segregation or females
covering their hair or faces, do not appear to be rational
to many nurses. In addition, some religious-cultural
practices, which lead female patients to have a preference for female practitioners when seeking health care,
are sometimes seen as irrational by non-Saudi nurses.
Consequently, multiple studies have found that nonSaudi nurses experience difficulty in understanding, and
in some cases respecting, the cultural and religious practices of patients [20, 38]. This was attributed to the fact
that most of these expatriate nurses have limited knowledge about the practices of their patients. In particular,
the nurses have limited knowledge about the cultural
and religious practices of patients [18, 38]. For instance,
a previous study showed that more than half of all expatriate nurses lack knowledge of Saudi culture [38].
Practically, this makes it difficult for the nurses to
understand the communication dynamics of patients in
the process of seeking health care.
The differences in language, culture and religion are
significant factors that can directly influence the communication experience of the patient. These factors cannot be overlooked in the delivery of health care [17, 19,
38]. For example, cultural and traditional practices including the use of herbal medicine, preference for
breastfeeding and practice of burying the placenta are
believed to improve health and prevent illness of both
baby and mother. Along with strong family bonds, these
factors have historically played a significant role in delivery of Saudi Arabian health care. In addition, religious
beliefs and practices such as fasting and praying are perceived as relevant factors in the recovery of patients [36,
40]; however, some non-Saudi nurses have demonstrated
difficulty in understanding these religious-cultural practices that contribute significantly in the delivery of
health care.
Nor is this a new phenomenon. Differences in language between nurses and patients have historically created problems in the health systems of Saudi Arabia,
particularly in some routines of nurses. Two studies
identified that language diversity causes significant challenges in caring for patients with life-threatening conditions; in particular, when discussing patient wishes in
terms of their care and during sessions of health education [20, 29]. Other studies identified that nurses experienced difficulty in understanding patients, particularly
Table 2 Emerging themes and sub-themes
Theme
Sub-theme
Number of papers
Current communication practices
Language, religion and cultural diversity
7
Effect of communication on patients
Communication practices
4
Communication barriers
6
Quality of care and patient safety
5
Patient satisfaction
5
Alshammari et al. BMC Nursing
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when seeking information during health-care delivery,
such as taking the history of the patient [18, 19]. Several
studies have suggested that the phenomenon not only
poses significant challenge to the nurses but also to the
patients and their families [17, 20, 34]. In particular,
some nurses avoid conversations with patients or their
families due to language differences.
Communication barriers
Six studies have shown that there are numerous interpersonal therapeutic communication barriers existing
between nurses and patients as well as family caregivers
[17–21, 27]. These barriers occur at different levels, including nurses to patients as well as at the interprofessional level [21, 34]. The inter-professional communication barriers are the barriers occurring at the
health provider level, mostly between nurses from Saudi
Arabia and non-Saudi expatriate nurses. The communication barriers occurring at different levels of the health
system are ascribed to several factors, again mostly
linked the differences in language, culture and religion
[17, 18, 20, 26, 29, 34].
Consequently, the limited Arabic language, culture
and religion knowledge have negatively impacted on the
delivery of health care, particularly by limiting the communication processes between non-Saudi expatriate
nurses and patients [17, 18, 20]. In particular, the language difficulties limit nurses’ ability to effectively communicate with patients [17, 18, 20]. Similarly, the
communication barriers occurring at inter-professional
level affect health services planning [31].
As well as the in-service training programs noted above,
the health authorities have employed several strategies to
overcome these challenges, particularly at the health facility level. As described by Almutairi, AF et al. (2013), these
strategies include the use of interpreters or family member
to translate conversations [32]. Although these strategies
can be useful, they are not always as effective as needed.
For example, both translators and family members have
been shown to deliver an incomplete or unclear rendering
of the conversation to the patient, which could adversely
influence health-care practice [32].
It has been argued that the provision of interpreters in all
hospitals in Saudi Arabia would be a good step towards improving communication [32]. However, many of these
translators would need training in personal and professional
interpretive skills, particularly in the area of medication administration [41]. Although most current interpreters are
competent in the English language, their skills are limited
to the understanding of medical terms and jargon.
Page 7 of 10
currently employed by nurses in health facilities across
Saudi Arabia that are perceived to be effective in interpersonal therapeutic communication [18, 19, 29, 36].
Existing evidence suggest that most nurses employ nonverbal communication practices in their communication
with patients. Predominantly, this takes the form of gestures and signs, and sometimes therapeutic touch as well
as smiling [29, 36]. In some instances, these non-verbal
communication practices help patients understand the
process of health-care delivery. In particular, recent evidence suggests that the non-verbal communication appears to reassure patients and their families about the
medication processes, which provides them with a degree of relief [29].
However, despite the increasing use of non-verbal
communication practices, two studies have highlighted
that such communication is frequently misinterpreted by
patients [19, 36]. Two examples are the clicking of fingers to attract the patient’s attention, and the use of direct eye contact with patients. To Saudi patients, the
clicking of fingers to attract attention can be understood
as offensive [19], while direct eye contact by female
nurses to male patients could be understood as a rude
behavior [36].
In addition to the non-verbal communication, some
nurses communicate verbally to facilitate patientcentered interaction [18]. The verbal interactions are
usually limited and delivered through few Arabic/Islamic
terms. A recent study suggested that words such as “Bismillah” or “Alhamdillah” – which translate as “in the
name of Allah” and mean to start with the blessing of
God – are mostly used prior, during and after medication processes, largely to make the patient feel more
comfortable [18].
The Ministry of Health in Saudi Arabia has responded
to these issues by instituting cultural training and orientation programs for nurses. This training is delivered as
an in-service program with the primary aim of exposing
nurses to religious-cultural practices in the delivery of
health care in Saudi Arabia [40]. However, despite this
development, two studies have suggested that these
courses appear to have limited impact and lack the ability to meet the needs of such nurses [32, 40]. In particular, this training and orientation program has a short
duration and scope, and it has been noted that in order
to address such communication gaps, improvements
would be required in the content, structure, duration
and intensity of the program [32].
Effect of communication on patients
Quality of care and patient safety
Communication practices
Four studies identified communication practices as a key
theme. They identified several communication practices
Five studies suggested that a comprehensive understanding of the culture, religion and language of a geographical setting play significant role in improving the quality
Alshammari et al. BMC Nursing
(2019) 18:61
of care and safety of the population [27, 28, 31–33]. In
particular, nurses who have some knowledge and understanding of Saudi religious-cultural practices are perceived to be more competent in delivering care
compared to those with limited competency [31]. For instance, some expatriate nurses continue to struggle with
communication and subsequently feel frustrated, particularly in understanding aspects of the patient’s culture
and religion [19]. One study proposes that a deep understanding of some elements of the religious-cultural attributes – such as Muslim lifestyle, hygienic practices,
ways of dressing, and gender segregation by nurses – is
necessary to improve the quality of care and safety of patients [40].
Four studies highlighted that communication barriers
caused by the differences in religious-cultural practices have
implications for the safety of the patients [27, 31–33]. These
challenges are experienced in areas such as medication
safety and the emotional, psychological, physical and spiritual domains of patients and family members. In some instances, the challenges affect not only patients but also the
nurses delivering care to patients.
Three studies suggested that where nurses have
religious-cultural practices that differ from those of their
patients, safety can be impacted [27, 32]. For example, patients may find it difficult to adhere to the nurse’s instructions, resulting in a clear threat to patient safety [26, 31,
33]. Another threat to patient safety is caused by miscommunication between nurse and patient or between health
professionals. Aljadhey, H et al. (2014) have suggested that
language barriers could account for an increase in medication errors [31]. Similarly, Hammoudi, BM et al. (2017)
found that some non-Saudi nurses are hesitant to report
medication errors or subsequent adverse effects on the patient for fear of disciplinary action [33].
Patient satisfaction
Five studies highlighted that patients exhibit different
levels of perceived satisfaction from different aspects of
health care in Saudi Arabia [26, 30, 35, 37, 39]. Approximately 75% of patients reported being satisfied with the
health care they have previously received; however, while
these patients are generally satisfied with the technical
competence of nurses [30, 37], approximately half of
them are dissatisfied with the interpersonal therapeutic
communication of most expatriate nurses.
In particular, nurses who share the same language, culture and religion as the patient are perceived to communicate professionally and clearly, to respect culture and
religion, and to maintain patient’s privacy. This contributes to building a good relationship between nurse and
patient, resulting in an improved satisfaction with patient care [36, 37, 39]. Although patients recognize that
expatriate nurses are generally technically competent,
Page 8 of 10
patients are less satisfied with interpersonal therapeutic
communication, as they perceive nurses to be ignorant
of their language, culture and religion [37]. This can be
perceived as disrespect, which might contribute to reported levels of violence towards nurses. A previous
study highlighted that communication barriers was one
of the important factors in work-related violence [35].
Discussion
This review aimed to synthesize evidence on nurse–patient communication practices among nurses and patients in Saudi Arabia and their effect on patients’
quality of care, safety and satisfaction. The review included 20 papers in the final synthesis. The review findings suggest that there is a diversity in the language,
religion and culture of nurses providing health-care services in Saudi Arabia. In particular, nurses providing
health care in Saudi Arabia are largely expatriate and
tend to have limited knowledge about Saudi language,
religion and culture. Consequently, expatriate nurses rely
mostly on non-verbal communication strategies to interact with patients. The review findings suggest that the
cultural and language training provided to expatriate
nurses is not fit for purpose. Bozionelos [42] qualitative
study of 206 expatriate nurses in Saudi Arabia found
that nurses are provided with limited face-to-face training due to an overall pressure on nursing services related
to the nursing shortage in Saudi Arabia. The limited
knowledge about the language, religion and culture of
non-Saudi nurses, together with the current communication practices described earlier, have significantly contributed to nurse–patient communication barriers in
Saudi Arabia. The review findings suggest that the interpersonal therapeutic communication barriers occur
among health care professionals as well as between
nurses and patients. In addition, the review findings
highlighted that the communication barriers have significant influence on the outcomes of health-care service
delivery; in particular, communication barriers have
negative effect on the perceived quality of care, patient
safety and patient satisfaction.
It is noteworthy that no study has addressed nurse–patient communication experiences from patient perspectives
in Saudi Arabia. Given the nurse–patient communication
challenges discussed in this paper, future patients with
complex needs may face specific challenges in accessing
health-care services due to the nature of their conditions,
which requires frequent attention from nurses. In particular, patients may require attention in therapeutic communication to make complex and significant medical decisions.
In addition, some patients may need more attention from
nurses in the process of treatment. Consequently, to improve access to treatment for patients, it is important not
only to understand the burden of their conditions but also
Alshammari et al. BMC Nursing
(2019) 18:61
to address the therapeutic communication issues with service providers, particularly nurses.
Based on these review findings and Bozionelos [42]
study, some of the recommendations for clinical and
policy practices should include the provision of adequate
cultural and language training before expatriate nurses
leaving their home country; and the implementation of
mentorship programs to support and guide expatriate
nurses [42]. This can help to improve the communication between nurses and patients in the delivery of
health care services. Second, the current in-service training curriculum for nurses in Saudi Arabia should be expanded, and incorporate a component on language,
cultural and religious practices. This ought to carry
through at least the first year of employment for all
nurses, include a formal evaluation component, and be
reviewed regularly by the Saudi Ministry of Health for
quality and effectiveness.
In addition, the review findings recommend the following in future research. First, because current studies
on nurse–patient communication issues largely use the
perspective of nurses, with limited studies focusing on
patients, particularly those with complex needs, future
research should aim at investigating the perspectives of
patient and family members on nurse-patient communication issues. Second, researchers and clinicians should
aim to use a mixed methods approach to examine the
perspectives of both nurses and patients on communication issues. This can help achieve convergence in data
analysis. Finally, future research should aim at designing
interventional studies to examine the effectiveness of the
nurse-patient communication strategies on patient satisfaction and health outcomes.
Strength and limitations
The strengths of this study include the use of a systematic approach to search data from relevant scientific databases, revealing most available papers on the subject of
nurse–patient communication and associated issues
such as cultural, religious and language challenges, perceived quality of care, patient safety and patient
satisfaction.
Second, the review used a data extraction form to extract all relevant information that met the inclusion criteria. The data extraction form was developed using
relevant methodological standards and criteria. Similarly,
the review was not limited to any particular sphere of
health care, and so could identify all relevant papers, irrespective of any particular health condition being
examined.
The study also has several limitations. First, the study
was necessarily limited to a selection of specific search
items, and so could have missed some relevant papers.
Further, the study was limited to papers focusing on
Page 9 of 10
Saudi Arabian health care, and so cannot be generalized
to other settings. However, the use of a systematic approach [23] – including data searching, data extraction
and collaboration with experts in the field – attempted
to reduce the impact of the limitations.
Conclusion
The study concludes that language, culture and religion
differences exist between patients and nurses in Saudi
Arabia, primarily due to the preponderance of expatriate
nurses in working in the Saudi Arabian health-care system. These differences create barriers to clear and effective communication and produce a negative impact on
health outcomes for patients in Saudi Arabia. Moreover,
the findings of this review indicate a need to improve
communication between patients and health-care providers in order to provide safety and high-quality practice in Saudi Arabia, which will contribute to higher
quality of care and patient satisfaction. There should be
a focus on research in extensive training programs for
nurses.
Abbreviations
MMAT: Mixed Methods Appraisal Tool; PRISMA: Preferred Reporting Items for
Systematic Review and Meta-analysis
Acknowledgements
The authors want to thank the University of Newcastle Australia. The authors
want also to thank Debbie Booth, University of Newcastle librarian for
supporting the literature search.
Authors’ contributions
The authors conceptualized the study. MA conducted the data extraction. JD
and MG managed the second review of the data extraction. MA, JD and MG
worked closely to draft the manuscript. All of them have read and approved
the final manuscript.
Funding
No funding was required to complete this study.
Availability of data and materials
All data generated or analyzed during this study are included in this
published article (and its supplementary information files).
Ethics approval and consent to participate
Not applicable.
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.
Received: 29 April 2019 Accepted: 15 November 2019
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Integrative Literature
Review Rubric
PURPOSE
The purpose of a literature review is to identify,
define, and clarify a problem, gap in knowledge, or
issue to be addressed by the proposed research
project. In doing so, it should provide an overview of
the state of knowledge on the topic through a
synthesis of previous research. A literature review
should survey appropriate, relevant, and up-to-date
sources. It also should persuade the reader of the
scholarly significance and need for the proposed
research project.
Beginning
Reads as a dump of
information,
potentially taking
the form of an “all
about X” paper.
Fails to connect the
information to
broader scholarly
conversations or to
use the information
to justify the
proposed project.
ORGANIZATION
A well-organized literature will guide the reader
through the scholarly conversation surrounding a
topic, setting up the specific contribution(s) the
proposed research project will make to that
conversation. The literature review should employ a
broad-to-narrow structure, opening with context for
the problem or issue the project will address, then
explaining relevant relations, themes, and trends in
existing literature, and ultimately highlighting the
gap(s) or need(s) that the project will address. When
appropriate (often at the end of the literature review),
the literature review will present the proposed
project’s research question or hypothesis. Paragraphs
or sections should synthesize groups of related
sources according to concept, theory, or methodology,
rather than summarizing sources one at a time. A
well-organized literature review will exhibit
coherence, demonstrated by effective transitions, a
logical flow of information within and among
paragraphs, and balance among its various
components.
Beginning
Exhibits little
strategic or
deliberate
organization. Lacks
overall structure,
and ideas appears
randomly ordered.
Lacks transitions
between and within
paragraphs. May not
use paragraphs, or
the division of
paragraphs may lack
logic.
Developing
Provides some context for
the scholarship included in
the review and begins to
identify a research problem
or gap. Contains some
synthesis of scholarship, but
fails to provide a cohesive
representation of the
scholarly conversations
surrounding the topic of the
proposed project. May
include some information
that lacks relevance to the
proposed project.
Developing
Has some sense of order, but
is confusing or inconsistent.
The order of information
does not effectively set up
proposed research project or
embed it within a broader
scholarly conversation. May
rely on formulaic or
inconsistent organizational
patterns and may not balance
ideas appropriately in the
paper. May have
redundancies or circle
around ideas. May move
from study to study or author
to author.
Competent
Synthesizes
scholarship related to
the proposed research
project. A story is
beginning to develop
that demonstrates the
relationships between
relevant scholarly
conversations and the
proposed project.
Advanced
Clarifies the research
problem, gap, or issue
to be addressed by the
proposed research
project. Strategically
examines relations,
themes, and trends in
the literature in order to
build a case for both the
significance and need
of the research project.
Competent
Displays a deliberate
attempt to organize
ideas. Has some
transitions that
shepherd the reader
through the literature
on the topic, but there
may be missing
information, abrupt
turns, and/or out-ofsequence ideas. Has
synthesis that
connects thematically
related studies within
paragraphs or
sections, but some
studies, authors, or
articles may not be
fully integrated.
Advanced
Demonstrates a
deliberate organization
that follows a broad to
narrow structure.
Seamlessly and
efficiently transitions
between ideas.
Paragraphs and sections
synthesize related
bodies of literature as
opposed to
summarizing single
authors or sources.
2
SUPPORT & DEVELOPMENT
Support refers to the way the writer uses
prior scholarship to develop ideas
throughout the literature review and within
its paragraphs and/or sections. A welldeveloped literature review will analyze
and critically evaluate the literature,
utilizing details and examples from sources
to provide evidence for its claims and to
elaborate key points. It should go beyond
superficial evaluations to provide
commentary characterized by depth and
complexity.
Beginning
Support and development
are severely lacking or
absent. Problems with
attribution, citation, and
plagiarism may be
present. If claims about
the literature are present,
they are not accompanied
by adequate evidence and
examples. Observations
about and evaluations of
sources, if present, may
be uncritical, illogical, or
contradictory. Heavily
relies on quotation, and
little to no attempt to
integrate sources into
sentences.
Developing
Support and development are
faulty or inconsistent. Writer
attempts to analyze prior
scholarship but offers
problematic conclusions that
may be vague or simplistic or
rely on sweeping
generalizations. More sources
may be needed. Commentary on
sources may be underdeveloped
or rely heavily on others’
observations. May demonstrate a
reluctance to criticize the
methods, findings, or
conclusions in prior scholarship.
Descriptions of source material
often lack details and examples
or include unnecessary details
and examples. Doesn’t
adequately integrate sources into
sentences, often lacking
transitions that connect the
sources to the surrounding ideas.
Competent
Support and
development are
consistent and logical.
Analysis and evaluation
of the literature are
present and bolstered
by evidence that is
appropriate and, for the
most part, effective.
Occasionally, there
may be too few or too
many details and
examples to support
claims and points.
Commentary reflects
critical thinking but
may sometimes seem
formulaic or warrant
further elaboration or
explanation. Uses
formulaic techniques to
integrate sources into
sentences.
STYLE
This trait generally refers to the choices
that the writer makes for specific
audiences. This may include features like
tone, sentence length and structure,
phrasing, and word choice. The style
should be appropriate for the research area
(e.g., use of 1st or 3rd person) and should
employ a formal and professional tone,
active voice, and precise terminology.
Beginning
Writing has an
inappropriate tone.
Sentences and phrases are
simplistic, unvaried, or
wordy. Writing is stiff,
awkward, and difficult to
follow. Unclear or
incorrect use of
terminology or
vocabulary.
Developing
Writing has an inconsistent or
occasionally inappropriate tone.
Some sentences and phrases are
repetitive, bland, or awkward.
Writing is occasionally difficult
to follow. Some misused
vocabulary or inconsistent
terminology. Word choice may
be ineffective.
Competent
Writing has a
consistent and
appropriate tone.
Sentences and phrases
are typically concise
and effective but may
be somewhat
mechanical. Writing is
easy to follow.
Terminology or
vocabulary is
appropriate and
sensible but may be
predictable.
Advanced
Support and
development
demonstrate complexity
and sophistication of
thought. Carefully
selected details and
examples support the
author’s original
analysis and evaluation
of the literature.
Commentary not only
reflects depth of
insight, but also an
awareness of how much
or how little
explanation the
audience needs to
understand the author’s
points. Uses mostly
summary and
paraphrase over
quotation, and
seamlessly integrates
sources into sentences.
Advanced
Tone contributes to
reader comprehension.
Uses varied sentence
structure and phrases to
convey meaning and to
create interest and
engagement.
Vocabulary is
sophisticated, precise,
and varied.
3
USAGE, MECHANICS, &
FORMATTING
This trait generally addresses issues
dealing with writing convention, citation
style, and formatting. Features may include
grammar, mechanics, usage, citation,
punctuation, formatting, and capitalization.
Beginning
Developing
Competent
Advanced
Contains errors across
most of the areas of
grammar, mechanics,
usage, citation,
punctuation, formatting,
and capitalization.
Problems interfere with
meaning or distract the
reader.
Contains errors across some
areas of grammar, mechanics,
usage, citation, punctuation,
formatting, and capitalization.
Problems may, on occasion,
compromise meaning or distract
the reader.
Few to no errors across
most of the areas of
grammar, mechanics,
usage, citation,
punctuation,
formatting, and
capitalization. The
writing reads smoothly,
and problems do not
compromise meaning.
Demonstrates mastery
of grammar,
mechanics, usage,
citation, punctuation,
formatting, and
capitalization. May use
language and
punctuation to enhance
meaning.
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Turnitin Report
Formatting
Title Page
Citation
Outline
