Communication barriers

The first thematic category revealed from the analysis of the focus group

discussions was the communication barrier that strongly influenced the nurses’ delivery of effective pain management. Communication barriers resulted in poor communication due to a lack of a common language in a multicultural setting, not only between the nurse and the patients, but also between the nurses. This communication difficulty was attributed to three factors: firstly, that Arabic was considered a complex language to learn and speak, and therefore, often difficult for expatriate nurses to embrace (Habash & Sadat, 2006). The second aspect was the fact that most of the patients, being

predominantly elderly, did not speak English, which compounded the situation for the non-Arabic-speaking nurses. Finally, these patients may use a different dialect as they come from different regional areas, or where the word from one dialect means a different thing in another dialect. English remains the most widely used language between staff in KSA hospitals. A number of participants from the focus groups noted this communication difficulty with oncology patients, specifically from those expatriate nurses who were non-Arabic speakers. For instance, one of the participants said:

I think the big failure here we are facing as a foreigner or English-speaking nurses is the language. (Diana, FG 4)

It was mentioned in the data that communication between patients and nurses was vital while assessing oncology patients’ pain, as the nurses in the unit play a critical role in ensuring high quality of care through the adequate assessment of their patients. The majority of non-Arabic-speaking nurses reported that they had difficulties with communicating with patients who spoke Arabic language, which then hindered their

ability to be able to effectively manage their patients’ pain. This was clearly explained by a participant who said:

I think the most important problem that we're facing here, when we want to assess our patients’ pain is the communication. Half of us are not Arabic speakers, and all of the patients are Arabic speakers…so I find the language is one of the major barriers to properly assessing the patients’ pain

characteristics. (Hadi, FG 1)

As can be seen from this quote, participants commented that although nurses understood that cancer patients felt pain frequently, nurses were not always able to assess pain effectively because of the language difficulties. Consequently, the patients may not receive the most appropriate treatment for their pain because of the language barrier that hinders the nurses’ ability to determine the intensity of pain. Specifically, as highlighted by the participants, the issue about this communication barrier related to the interpretation of patients’ words regards the nature of pain or its quality. As a

consequence, misunderstandings or wrong perceptions may occur. For instance, it was reported by one of the respondents that:

I think language barrier is the problem….because sometimes; the patient will say things and express his feelings in Arabic words that we do not understand. And sometimes we would wrongly understand the patient description of pain intensity and nature, so, we usually not administrating the right medication or treatment for the patient. (Janki, FG 3).

Another non-Arabic-speaking participant confirmed this issue, which expressed the frustration that was felt as a result:

Yeah, for us, it’s the language barrier. Although we know that our patient still in pain, but because we cannot communicate with the patient and determine the pain on a scale, they mostly still have some degree of pain. (Elisa, FG 3)

The other side to these communication differences is the effect they had on the nurses’ ability to undertake their tasks adequately. It was clear from the data that

expatriate nurses felt reluctant to explain the side effects of medications to their patients, because they were afraid that patients would not be able to understand them or might become angry with them. From this it can be seen that the nurse’s role of explaining issues to the patient was limited. This could then relate to many other aspects of nursing care that they provided. In other words:

We are responsible for explaining to the patient. Sometimes we have a problem to explain to the patient. Like the drug side effects, they cannot understand.

(Prevena, FG1).

Language barrier also affects how Arabic nurses (not Saudi nurses) interpret the Arabic language used by Saudi patients. Participants in the focus group discussions stressed that they faced difficulty in interpreting what the patients said about their pain, partially, because most of the patients talked using either colloquial language (non- formal Arabic language) or a different dialect to their own. For instance, one of the nurses commented that:

Yeah, for us Arabic-speaking nurses, we could not understand all the patients’ language. You know many patients talked in their own regional language. We

understand the formal Arabic not the slang one. Sometimes I cannot get all the words. And this is way I found it difficult to interpret the meaning conveyed by the patient. (Mahmoud, FG 2)

Further, language barriers were not only identified to be a problem for the expatriate nurses. They also became a problem for the Arabic-speaking nurses, who were not necessarily proficient at understanding English. Local nurses were constantly being asked to translate from English into Arabic language to help the non- Arabic nurses communicate with their cancer patient regarding pain management. Focus group discussions conducted with participants from the Arabic-speaking nurses emphasised that they did not always understand what the non-Arabic-speaking nurses were asking them to translate from the English language into Arabic language. This then had a tendency to become a problem of mistranslation. To confound this issue further, the non-Arabic-speaking nurse would probably not be aware that what they had asked to be translated was not necessarily understood by the Arabic-speaking nurse. They would therefore not necessarily realise that a mistranslation had occurred. The other issue is that this adds greatly to the workload for the Arabic-speaking nurse, who has to leave caring for their own patient to assist with translations. This issue of mistranslation is illustrated in the following:

I am an Arabic speaker but not proficient in English. I'm facing a problem which is the language and the communication. My colleagues who cannot speak Arabic ask me to translate instructions to patient or when they need to present

something to a patient, I do my effort to send the proper message, but often, I miss the right translation. (Ali, FG 4)

One of the other problems with the communication barriers is that it affects not only the patients but also their families. Participants in focus group discussions stressed the need to communicate with the patient's family in order to fully provide patient care. This is because, as highlighted in the data, clear communication when educating the patient’s family would help the patient to understand the pain management process. The nurses explained that the family needs to be involved and understand as they are the ones who provide the care and follow the pain medications at home. Providing education to the patient’s family becomes difficult, however, because of the language differences which may lead to misinterpreting of what the nurse is explaining about pain management, as illustrated in the following:

For me, I think it’s a clear communication with the patient and family members. As we all know, for oncology patient, there is always a complaint of pain … Even when they go home … we need to explain to the family to help them understand how their relative feel, they need this piece of information, but we have a language problem that stands in our way. (Anna, FG2)

This has illustrated that generally, the nurse’s ability to effectively manage pain was greatly influenced by the various issues of communication difficulties that occurred between the nurse and the patients, as well as their family members.