Cultural differences

According to the data analysis, cultural differences also emerged as a major theme in all the five focus groups as having an influence on the nurse’s ability to effectively undertake pain management. Participants in the focus groups highlighted issues related to the religious and cultural differences between patients and nurses

impacted the quality of pain management in the oncology units in KSA. Participating nurses noted differences between their previous experiences in their own culture and patients with what they had experienced in caring for Saudi patients. For example, nurses stated that patients in their country of origin depend on and have faith in the advice from healthcare providers to treat their pain. In contrast, the Saudi patients depend on their religious advice and beliefs, as given to them by religious men. This was clearly described as:

for the knowledge of the people in our country, as we believe in the physicians’ advice, we follow their prescription of the therapy, but for patients which I care for here, they prefer what is traditional… they (Saudi patients) mostly get advice from the religious people, from the sheikh who will describe special remedies for pain and the patients will follow. (Christine, FG 5)

This difference in belief went much further than this, to the extent that nurses reported that the Saudi patients did not comply with their advice about pain management methods. This then added greatly to their workload. As one of the participants said:

…in our country, we don’t have any problem regarding the prescribed method to relieve pain. But here in this country we find difficulty in applying these

methods. Saudi patients have doubts in following the therapy we often spend a lot of time explaining and discussing to persuade them to take the pain killer medications (Vivian, FG 2).

Another commonly discussed element related to religious and cultural influences was the notion that some Saudi patients had a different view of the aetiology of the pain than the medical viewpoint. For instance, the argument that the pain was not caused by

injury or other causes, but rather resulted from an evil eye or a punishment from God. This influenced the nurses’ perception of losing power from a medical philosophy perspective, as they were unable to change the patients’ beliefs or attitudes towards pain management. As one of the participants in group one described:

… their (Saudi patients) beliefes about pain is different. They think that the cause of pain is related to superpower such as an evil eye or something similar. Some patients believe pain comes as a punishment from God. So, we respect what they are saying I mean you can’t argue with this, we cannot change what they think is right … it is very hard. (Hadi, FG 1)

This was also described by other participants who added that because patients believed that the pain was a punishment, they spent most of their time reading from the holy Quran, instead of seeking pain relief:

Maybe they are thinking about ways to defeat the evil eye by reading from the Holy Quran, or they may be feel guilty about something and returning to the Holy book will clear them from sin ….Um, I guess, but this is wrong perception, Allah will not put the cancer on people to punish them and make them suffer

(Muneerah, FG 2).

Moreover, some participants in the focus group discussions stressed that many patients felt reluctant to take strong pain medications like opioids, as the Saudi patients described that enduring pain would help them to get rid of their sins. Many patients, therefore, substituted analgesic medications with practising religious rituals, such as praying to God and asking God for cure (making Dua'a), drinking from the holy water ( Zamzam) [ a holy water from Mecca that is used by Muslim people for treatment] to

relive their suffering from severe cancer pain. However, participants from the same Islamic and cultural background as the Saudi patients tended to support and respect the patients' religious beliefs and encouraged them with some of these practices to relieve their suffering. As this clearly mentioned with one of the participants:

I find out that most of the people here prefer to read Quran or drink zamzam water or sometimes eating honey, olive, and date instead of taking the prescribed pain medication. We as Muslim nurses sometimes have similar things believes ….we respect the patient belief and we acknowledge sometimes what they are eating or drinking. (Moaueh, FG 3)

However, it was clear from the data that not all of the nurses were comfortable with the beliefs of Saudi patients who insisted on avoiding any pain medication, mainly the opioids, describing this as a ‘forbidden drug’ or ‘haram’. Participants mentioned that the patients replaced with following religious rituals, as previously mentioned. One nurse described this as:

Yes, they think its haram. Some of our cancer patients refuse to take narcotics because it causes addictions, so they will not take it because it is forbidden in Islamic culture. Some of them are thinking, okay, instead of taking medication for the pain I can read from the Holly Quran or do things to please God.

(Muneerah, FG 2)

As can be seen from these quotations, nurses almost felt that they had therefore failed to provide adequate care from a medical/nursing viewpoint and were

consequently conflicted. The reason for this conflict, as discussed by the participants in the focus group discussions related to the cultural differences with nurses being

confused between respecting the patient’s right to decide what is important from their own perspective, and the priority to manage the patients’ pain using the available analgesic medicine and follow the guidelines. In other words:

Yeah but in the end, we need to focus on the pain because as a healthcare team provider, we try to manage the pain this is our goal … so we have differences between their belief as a patient and our belief as a healthcare provider, we have the guidelines and what we learn in school of nursing. (Fatima, FG 4)

The participants commented that the goal of nursing is to relieve the patient’s pain and to manage it effectively, but ultimately nurses need to respect the wishes of their patients, and therein lies the conflict:

That is the rights of our patients. We have to respect their beliefs we feel with them … in Saudi Arabia, if you are living far from the cities in the urban areas they will have common beliefs that we should respect. (Cecily, FG 5)

A confounding factor to the effective management of pain that was identified from the data was that patients were not necessarily providing honest and truthful responses, due to their fears about treatment or medication, and/or cultural beliefs. For instance, nurses mentioned that many Saudi patients did not ask for relief, or ignored their pain due to the fear of being regarded as addicted, which adversely affected the care they provided. This was described by several participants in different focus groups:

Sometimes, the patients are ignoring the pain, for example, not asking for medication, because they feel guilty. They are afraid of being accused by nurses and doctors as addicted. So they will deny the pain … So it affects us as nurses

to manage those patients … they give you a wrong pain score so they will avoid taking this medication. (Hadi, FG 1)

In addition, the participants also identified that they found family beliefs about pain management could form an obstacle to effective pain management. Participants commented that the family’s fears about drug addiction made them intervene in the process of administering pain medication. This is clearly illustrated in the following quotation:

Sometimes the patient’s family are also afraid that their son or daughter would be addicted so they say, don’t give this medication … so they interfere with our role and delay the administration of drugs to relief the patient’s pain. (Asefa, FG

5)

It can be understood that generally the nurses’ ability to effectively manage pain was greatly influenced by the various cultural differences and the beliefs about pain management by the patients and their families.