Adult Arab Muslim Patients Perceptions of Cardiovascular Nursing Care by Expatriate NonMuslim Nurses P = Adult Arab Muslim patients

undergoing cardiovascular nursing care I = Care provided by expatriate non-Muslim nurses who have Arab Muslim culture seminar = = = independent variable C= Care provided by expatriate non-Muslim nurses who have no Arab Muslim culture seminar O= Increase patient satisfaction rate = = = dependent variable
__ variables of interest young adults (ages 1835 years), middle-aged adults (ages 3655 years), and older adults (aged older than 55 years) Demographic variables: age, gender, nationality, educational level Care provided by non-Muslim nurses with Arab Muslim culture seminar increase the satisfaction rate in adult Arab Muslim patients undergoing cardiovascular nursing care.

IV = care provided by expatriate non-Muslim nurses (with Arab Muslim culture seminar and without) DV = adult Arab Muslim patient satisfaction rate Does the care provided by expatriate non-Muslim nurses with Arab Muslim culture seminar and those without significantly differ on the adult Arab Muslim patient satisfaction rate? Care provided by expatriate non-Muslim nurses with Arab Muslim culture seminar and those without significantly differ on the adult Arab Muslim patient satisfaction rate.

Islamic beliefs and practices influencing health care: Family Influence Arabic Language Religiosity Gender Segregation

Adaptation Providing a culturally congruent care was no easy task for expatriate non-Muslim nurses for it involved long-term adaptation to the culture of the new work environment. Results from the study conducted by Van Rooyen, Telford-Smith, &Strmpher (2010) revealed that South African nurses described their professional and personal experiences in working and living in Saudi Arabia for the first three months indicated that they had to endure various difficult experiences

while adapting to and coping in a new cultural, religious, physical, emotional and professional environment (p. 9). Further, in the study concluded by Tamim, Hejaili, Jamal, al Shamsi, & Al Sayyari (2010, p. 9) that successful adaptation seems to depend on the expatriate nurses ability and willingness to embrace and engage in Saudi culture and their preparedness to change and develop personally and to view the challenges as opportunities for growth. It was also emphasized by Van Bommel (2011) on the utilization of cultural perspectives, past experiences and occupational strategies in dealing with health and illness interactions among 63 expatriate non-Muslim nurses working in the cardiac care unit in Saudi Arabia. A portion of the literature review that was included in the discussion follows (Van Bommel, 2011, p. 43, 92-94).

establish if there is a difference in the adult Arab Muslim patients perceptions of cardiovascular nursing care based on the satisfaction rate for expatriate non-Muslim nurses with Arab Muslim culture seminar and those without in terms of Islamic beliefs affecting health care, such as family influence, Arabic language, religiosity, and gender segregation. Specifically, it will attempt: 1. To illustrate the demographic profile of the adult Arab Muslim patients in terms of age, gender, nationality, and educational level. 2. To determine the adult Arab Muslim patients experiences while receiving nursing care. 3. To assess the adult Arab Muslim patients satisfaction of nursing care in cardiovascular wards. 4. To establish if there is a relationship between adult Arab Muslim patients satisfaction of nursing care in the cardiovascular wards with expatriate non-Muslim nurses who have Arab Muslim culture seminar.

As reviewed by Loftin C, Hartin V, Branson M, and Reyes H. (2013, p. 4), Cultural Competence Assessment (CCA) developed by Schim et al. (2003), which was designed to assess the cultural competence of health care providers, including nurses, will be the basis for this instrument. Originally, the instrument tested the domains of cultural diversity, cultural awareness, cultural sensitivity, and cultural competence behaviors with 26 items utilizing a 5-point Likert-type scale ranging from strongly agree to strongly disagree and no opinion (Doorenbos AZ, Schim SM, Benkert R, & Borse NN, 2005; 54(5):324-331). It was noted in the study by Balcazar, FE., Suarez-Balcazar, Y., Taylor-Ritzler, T., and Keys, CB. (2010, p. 221) that the subscale for cultural diversity asks the respondents to identify various groups that they have encountered within the past 12 months and record this on a single-item index. Cultural awareness and cultural sensitivity subscales and cultural competence behaviors are measured using a 5-point Likert scale. The CCA as an existing instrument will be considered for the collection of data. The CCA will be as assessed to determine if the items embodied in the instrument were appropriate to the concept of assessing custom care self-efficacy among expatriate non-Muslim staff nurses caring for Muslim patients in the selected Jeddah tertiary-care hospital. A written permission to adapt the items contained in the CCA was acquired for free from Lippincott Williams and Wilkins/Wolters Kluwer Health under License number 3233720036077. The Cultural Competence Assessment Tool was used upon the expressed permission of the authors (S. M. Schim personal communication, 21 October 2013).

The questionnaire is composed of forty nine (49) questions. There will be non-scaled questions, such as the participants diversity and experience; community of service; self reported cultural competence assessment; age; self identification race/ethnic; educational level; prior diversity training; type of prior training; and current role. The scaled questions will measure the participants cultural awareness and sensitivity; cultural competence behavior; and social desirability with alternative replies of Strongly Agree, Agree, Disagree, Strongly Disagree and No Opinion. This will be utilized to determine the expatriate non-Muslim nurses perceptions of providing culturally congruent care to Muslim patients, as well as to determine the expatriate non-Muslim nurses perceptions of their level of providing culturally congruent care to Muslim patients, particularly on cultural awareness and sensitivity, cultural competence behavior, and social desirability.

Respondent Focus Groups Focus groups-a form of in-depth group interviewing- are conducted early in the questionnaire development cycle and can be used in a variety of ways to assess the question-answering process. Such groups may gather information about a topic before questionnaire construction begins (for example, to learn how people structure their thoughts about a topic, their understanding of general concepts or specific terminology, or their opinions about the sensitivity or difficulty of the questions). Focus groups help identify variations in language, terminology, or interpretation of questions and response options. Self-administered questionnaires can be pretested in a focus group, to learn about the appearance and formatting of the questionnaire. In addition, knowledge of content problems is gained. One of the main advantages of focus groups is the opportunity to observe a great deal of interaction on a topic in a limited period of time. They also produce information and insights that may be less accessible without the give and take found in a group. Because of their interactive nature, however, focus groups do not permit a good test of the "normal" interviewing process. Researchers also do not have as much control over the process as with other pretesting methods. (For example, one or two people in the group may dominate the discussion and restrict input from other focus group members.)

Family Influence Expatriate non-Muslim nurses need to recognize the central importance of the family in taking care of patients of Islamic denomination (Luna, 2002) and that the inclusion of the patients family in the planning of care is essential to the delivery of culturally competent care (Leininger, 1981). In the Kingdom of Saudi Arabia, the family is the traditional foundation of society that extends beyond the immediate relatives and all the members of the tribe (Cuddihy, 1999). Followers of Islam are obliged to visit a person and to enquire about their health (Johnson, 2001). Visiting the patient became a social occasion to greet, hug, kiss, eat, drink and talk. Constant presence of visitors was considered a hindrance to patients participation in care. Families were viewed as the principal decision-makers regarding care and to what extent care will be provided. Arabic Language Communication is integral to the process of caring and 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. Therapeutic nurse patient relationship has a communication barrier. Nurses were not fluent in Arabic language, while patients prefer to converse in their own language. Communication becomes non-verbal and often time misinterpreted. Caring also becomes a frustration when there are cultural restrictions, such when the patient needs air, but were covered with face veil. The nurses described how they had to be very sensitive to the patients culture, as touching the patients in times of distress was often neither welcomed nor appreciated. The nurses emphasized their constant battle to be understood, which was a finding that paralleled to that of Lunas (1989) study which indicated that patients appreciated the nurses making an effort to communicate in Arabic. In the study by Tamim, Hejaili, Jamal, al Shamsi, & Al Sayyari (2010, p. 6-8) findings suggest that most Saudi patients have a family member or watcher with them. Communication needs to be conveyed to the patient, members of the family, friends and watcher in a manner that they can understand. Arabic language became a hindrance when nurses do not know nor has little usage of the language. From verbal communication, the nurse shifts to non-verbal communication, but also found it inappropriate or unnecessary. Saudi women are covered from head to toe making eye contact, touch, space, distance and intimacy, as hindering their interaction with patients. Although these non-verbal cues are considered therapeutic, in the kingdom it is prohibited. Van Bommel (2011) highlighted the experiences of 63 expatriate non-Muslim nurses working in the cardiac care unit in Saudi Arabia utilizing cultural perspectives, past experiences and occupational strategies in dealing with health and illness interactions. A segment of the literature review that was included in the discussion follows (Van Bommel, 2011, p. 89-92). Language challenges were identified by expatriate non-Muslim nurses as an obstruction in caring for Muslim patients that rendered them inability to explain procedures to the patients, misunderstanding of patients basic requests, inability to explain visiting hours as well as difficulty in explaining changes in the patients conditions to visitors. Simple instructions before scheduled interventions or surgery, discharge planning and health education might have been neglected because of the language barrier. Some participants

mentioned that they used basic Arabic terminology but were uncertain about the patients levels of understanding. Communication in nursing was found by Aboul-Enein & Ahmed (2006, p. 169) to be necessary in the treatment and care among patients and to avoid facing a problem on miscommunication, trained interpreters will be provided. Religiosity Followers of Islam view illness, suffering and dying as a part of life and a test from Allah (Rassool, 2000). Illness was viewed as atonement for sins and death is part of the journey to meet Allah (Rassool, 2004). The influence of Islam is evident in all aspects of patient care, such as praying five times a day that is not conducive to rest and sleep, but the athan (call for prayer) was more important among patients, thus they often got out of their beds. Stress sat in among nurses when patients told them that the quality of care does not matter for the decision to live or die was up to Allah. Although nurses were expected to take care of the patient for Muslims believed that life continues up to the last beat of the heart. Islam as a religion influenced the Muslim patients traditional religious practices which included prayers five times a day which expatriate non-Muslim nurses found difficult to understand. Wehbe-Alamah (2008) had found in his study those Muslim patients perceptions of healing, religious practices like consumption of zam-zam (holy water) and fasting during Ramadan all posed challenges to the expatriate nurses (p. 85). Gender Segregation The act of caring was also gender specific with male nurses caring for male patients. Disrobing in public, including the hospital, was considered immodest (Kulwicki, Miller, & Myers Schim, 2000). Muslim patients also preferred to have health care providers of the same gender with the presence of the husbands most often asked to be with their wives during physical examination (Pennachio, 2005). General guidelines found by Galanti (2004, p. 219) for the delivery of culturally competent care described that in caring for Muslim patients by non-Muslim nurses in the kingdom stereotyping must be avoided; Muslim patients avoid direct eye contact with people from the opposite sex as a sign of modesty and respect and not due to lack of interest in the planning of care; take into consideration that loss of appetite might not be a sign of illness, but rather of the patients belief system; critical medical conditions and its prediction of survival is always shared with the patients family first before the patient; expect female Muslim patients to be all the time covered from head to toe and be taken cared by a nurse of the same gender; and for non-Muslim nurses to have a culturally congruent attitude has to endure the fact the Muslims have diverse health belief and Muslim patients are expected to have many visitors during the period of their confinement. Protection from the evil eye according to the study conducted by Karout N, Abdelaziz SH, Goda M, Al Tuwaijri S, Al Mostafa N, Ashour R, and Al Radi H (2013, pp. 177) emphasizes the value of pronouncing the name of God at the starting of any procedure to kept from harm such as breastfeeding, assessment of the abdomen, vaginal examination, giving birth, this value is strongly affected by the participants' believes that they will be hurt, or their baby will face a harm, or their breastfeeding will failed.

FAMILY INFLUENCES 1. During your hospital stay, how often did the nurse involve the members of your family in the plan of care? 4 3 2 1 Always Usually Sometimes Never

2. How often do nurses If yes, how often do you get assistance in using the toilet or bathroom? 4 3 2 1 Always Usually Sometimes Never

3. How often do nurses view your family as the principal decision-maker? 4 3 2 1 Always Usually Sometimes Never

ARABIC LANGUAGE 4. Communicates to me nursing care in Arabic language? 4 3 2 1 Always Usually Sometimes Never

5. Limits or avoids eye contact and touch in providing nursing care? 4 3 2 1 Always Usually Sometimes Never

6. Provides interpreters to avoid miscommunication? 4 3 2 1 Always Usually Sometimes Never

RELIGIOSITY 7. Understands the healing practices of praying five times a day, consumption of zam-zam, or fasting during Ramadan? 4 3 2 1 Always Usually Sometimes Never

GENDER SEGREGATION 8. Care is provided by a nurse of the same gender? 4 3 2 1 Always Usually Sometimes Never

9. Does not unnecessarily expose female patients? 4 3 2 1 Always Usually Sometimes Never

PROTECTION AGAINST THE EVIL EYE 10. Emphasizes the value of pronouncing the name of God at the starting of any procedure? 4 3 2 1 Always Usually Sometimes Never

During your hospital stay, how often did the nurse involve the members of your family in the plan of care? How often do nurses view your family as the principal decision-maker? How often do nurses communicate with you about nursing care in Arabic language? How often do nurses limit or avoid eye contact and touch in providing nursing care? How often do nurses provide an interpreter to avoid miscommunication? How often do nurses understand the healing practices of praying five times a day, consumption of zam-zam, or fasting during Ramadan? How often do nurses understand not to disturb you during prayer times? How often do care is provided by nurses of the same gender? How often nurses do not unnecessarily expose you? How often do nurses emphasize the value of pronouncing the name of God at the starting of any procedure?