Significance of Therapeutic Relationships between Nurses and Patients - Research Paper Example

Significance of Therapeutic Relationships between Nurses and Patients with Different Cultural Background in Saudi Arabia Table of Contents I. Introduction ………………………………………….………….. 3 II. Literature Review ……………………………………………..… 4 a. Importance of Developing Nurse-patient Relationship as a Nursing Therapeutic Intervention ………………………. 4 b. Significance of Spirituality as a Core Component of Holistic Nursing Care ……………………………………. 6 c. The Different Stages of Nurse-Patient Relationship as Described by Hildegard Peplau ………………………… 9 c.1 Orientation Phase ……………………………… 9 c.2 Working Phase …………………………………. 10 c.3 Resolution or Termination Phase …………….. 11 d. Significance of Culture in the Development of Nurse-Patient Relationship ……………………………… 12 e. Strategies that will Improve Nurse-patient Therapeutic Approach particularly with Regards to the Patients with Different Cultural Background ………………………..…. 14 e.1 The Application of Humour and Laughter When Caring for Patients …………………………….. 14 e.2 The Use of Good Communication Skills ……. 15 e.3 The Ability of the Nurses to Tolerate the Patients’ Negative Attitude ………..………….. 17 e.4 The Application of Cultural Leverage ……….. 18 f. Real-life Examples that will serve as a Guide in Improving the Nurse-patient Therapeutic Relationship with the Patients in Saudi Arabia …………………..……………. 19 III. Conclusion and Recommendations ……….…..…………….. 21 References …………………………………………………………… 22 - 25 Introduction Caring for the sick individuals is not limited to the administering of medications, symptom management, and personal care. Depending on the health status of the each patient, some patient may end up becoming partially or totally dependent on nurses when performing their own activities of daily living (ADL) such as walking, bathing, dressing, and feeding. When providing holistic care to the patients, it is essential for nurses to know that their health care services should be delivered not only to the patient but also the patient’s family members especially when it comes to the provision of emotional and spiritual care. Spirituality has been considered as a part of the nursing practice when providing holistic care to the patients since managing chronic illnesses can be very time-consuming, emotionally disturbing, and inconvenient on the part of the patients’ family members (Dyson, Cobb, & Forman, 1997; Sawyer et al., 2003). For this reasons, caring for the patients and their family members has to be considered as a ‘unit of care’ (Hudson & Payne, 2008). As part of providing holistic care to the patients, establishing a strong nurse-patient relationship could result from a constant or regular interplay or covert negotiation between the nurse and the patients until both parties are able to reach a mutual and satisfying relationship (Morse, 1991). Depending on the time spent between the nurses and the patients, nurses are expected to be able to build trust and meet the individual needs of each patient. As a nursing student who does not have actual work experience in dealing with patients, this study will discuss the nurse-patient therapeutic relationship in relation to different culture. In relation to religious beliefs, this paper will first discuss the significance of spirituality as a core component of holistic nursing care. After discussing the importance of developing nurse-patient relationship as a nursing therapeutic approach, the different stages of nurse-patient relationship as described by Hildegard Peplau including the best nurse-patient therapeutic approach particularly with regards to the patients with different cultural background will be tackled in details. Religion and language are significant part of each individual’s culture. Discussing the cultural practices in Saudi Arabia is useful in terms of allowing professional nurses to have a better insight on different cultures. After discussing the significance of culture in the development of nurse-patient therapeutic relationship that will hasten or speed up the recovery period of the patients, this study will provide some real-life examples that will serve as a guide in improving the nurse-patient therapeutic relationship with the patients in Saudi Arabia. Importance of Developing Nurse-patient Relationship as a Nursing Therapeutic Intervention Several studies revealed that caring is the central force in developing nurse-patient relationship that could protect and enhance the patient’s dignity (Kozier et al., 2004, p. 72; Astedt-Kurki et al., 2007). In line with this, the main purpose of developing a strong nurse-patient relationship is to establish an intimate relationship between the nurse and the patients (Koviak, 2010). By developing nurse-patient relationship, the patients and their family members could somehow feel that there is really someone assigned to oversee the nursing care of the patient. Developing trust between the nurse and the patient is important part of caring and nurse case management (Yamashita & Mound, 2005). In line with this, it was Hildegard Peplau who was the first person to give importance to the nurse-patient relationship as one of the most basic foundation in nursing (Lakeman, 2010). In order for nurses to be able to successfully perform the seven nursing roles known as: the stranger role, resource role, teaching role, counselling role, surrogate role, leadership role, and technical expert role in caring for the patients, Peplau emphasizes the need for nurses to communicate and be a good listener to the patient (Courey et al., 2008). By listening to the specific needs and personal experiences of the patients, nurses will be able to have a better understanding on how nurses will be able to provide caring and treatment without causing any unnecessary internal conflict between the two parties involved (DiJoseph & Cavendish, 2005). With the purpose of determining the impact of nurse-patient relationship in the patients’ satisfaction, Coatsworth-Puspoky, Forchuk, and Ward-Griffin (2006) conducted a semi-interview based research study to determine the patients’ point-of-views with regards to nurse-patient relationship. Based on the interview results, nurses who are friendly, nice, and are able to tolerate the patients and their feelings were more likely to be able to develop a strong nurse-patient relationship as compared to nurses failed to develop a good relationship with the patients tend to make patients lose their trust on the nurses. As explained by Morse (1991), nurses who are not willing or failed to commit themselves to the patients would end up forming a unilateral relationship rather than a nurse-patient relationship. The problem with establishing a unilateral relationship between the nurse and the patient is that the patient may end up using manipulative and coercive behaviours which may lead to failure to establish a mutual relationship between the nurses and the patients. As a result of deteriorating relationship between the nurse and the patients, there is a higher chance that the patients will maintain a distance or totally avoid communicating with the nurses (Coatsworth-Puspoky, Forchuk, & Ward-Griffin, 2006; Morse, 1991). The act of minimizing or lessening the patients’ anxieties is important in terms of helping the patients cope with their illnesses and pain. Even though patients are experiencing pain due to their illnesses, nurses could minimize or lessen the patients’ anxieties by developing and maintaining a strong nurse-patient relationship. Other than the need to develop a good nurse-patient relationship with the adult patients, it is equally important to develop nurse-patient-family relationship with patients between the ages of 1 to 12 years old. Compared to adult patients and patients below the age of 3 years old, it is more difficult to win the trust of infants and children without the approval of their parents. In line with this, it is important to use family-centred care as a way of establishing nurse-patient relationship between the nurses and children (Barnsteiner et al., 1994). Significance of Spirituality as a Core Component of Holistic Nursing Care Spirituality is a phenomenon regarding the “wholeness of individuals and their connectedness to a higher being that integrates the quest for meaning and purpose of life” (Cavendish et al., 2000). Given that spiritual healing is widely practiced in Saudi Arabia (Zafir al-Shahri, 2002), nurses are obliged to incorporate the concept of holistic care with the spiritual needs to the patients. Despite knowing that human beings are spiritual beings, it is seldom on the part of most health care professionals to incorporate the concept of spirituality with the provision of holistic care. One of the emotional comfort that the health care professionals could deliver to the patients is to uplift their spiritual distress. This concept is applicable especially in the case of patients who have been diagnosed to have only few months left to live. By making the patient become spiritually balanced, it would be easier on the part of the health care professinals to provide them with less burden during the last few months or days of their lives. To be able to effectively incorporate the concept of spirituality in the holistic care for Saudi Arabian patients, nurses should be aware that the body of Arabs need to be clean and clothes free from urine, stool, or blood stain before they can recite their prayers (Zafir al-Shahri, 2002). Similar to the positive emotional and psychological impact of integrating spirituality over the care for patients with life-threatening diseases, the application of this type of health care practice on Arab patients with chronic illnesses could also develop a sense of hope and enthusiasm to be healed from the patients’ illnesses. To avoid making Arab patient and his/her family members feel disrespected, Nurses should be aware that the culture of Saudi Arabia is heavily dependent on Islamic religion. Therefore, nurses should avoid the practice of making sign of the cross when providing holistic care to the Arab patients. It is not advisable for health care professionals to consider that spirituality is synonymous with religion (Dyson, Cobb, & Forman, 1997). In line with the idea as suggested by Dyson, Cobb, and Forman, Crisp et al. (2005) revealed that “spirituality and religiousity are often referred to as being synonymous. But for an accurate assessment of clients’ spiritual needs, it is important for the nurse to realise that they are not the same and to be able to make that distinction” (Crisp et al., p. 539). Instead of trying to understand the meaning of spirituality in the point-of-view of religion, health care professionals should focus more on using the concept of hope, relatedness/connectedness, and belief(s) when trying to understand the meaning of spirituality as applied to the practice of nursing (Dyson, Cobb, & Forman, 1997). A good way of providing spirituality in holistic care is for the health care professionals to be able to identify the risk factors that may trigger psychosocial problems among the patient’s family members (Isaacs & Sewell, 2003). In line with this, it is possible for the patient to develop poor communication and social isolation from his/her family members and friends in case these people are not aware of the emotional, physical, and psychological effects of having to go through a particular chronic disease. To avoid having to experience such case, it becomes one of the main responsibility of the health care professional to educate and provide the people close to the patient with supportive counseling especially with regards to the emotional pain and psychological disturbances that the patient may go through because of the chronic illness. According to Nagai-Jacobson & Burkhardt (1989), the provision of holistic nursing “involve the spirituality of both the nurse and the patient and is transformational for both”. To effectively provide holistic and spiritual care to Arab patients with chronic and life-threatening illnesses, nurses should be a good listener and communicator to avoid unintentionally disrespecting the patient in any way possible. The Different Stages of Nurse-Patient Relationship as Described by Hildegard Peplau The theory behind the nurse-patient relationship can be use in empowering the nurses to solve problems with the patients and their family members. Based on Peplau’s theory, the developmental stages of a nurse-patient relationship includes: the orientation phase, working phase, and termination or resolution phase (Lakeman, 2010; George, 2002, p. 75). Orientation Phase As the initial process of establishing trust, rapport between the nurses and patients, and creating a therapeutic environment for the patient, the orientation phase of nurse-patient relationship development highlights the challenges that may occur during first meeting of the nurses with the patients since the patients may be experiencing anxiety due to physical pain as a result of their illnesses (Lakeman, 2010; Shives, 1994, p. 91). Aside from being humble, gentle, and patient; nurses are expected to speak softly as a sign of respect to elderly patients (Zafir al-Shahri, 2002, p. 135). Likewise, nurses are expected to ask permission from the patient before entering the patient’s room (ibid). In general, this is the phase wherein the nurses would introduce themselves to the patients in order to get to know them better aside from clearly defining their roles and expectations as nurse and patient. There are cases wherein some patients may end up testing the nurses’ patience as a way of knowing the personality of the nurses. For this reason, some nurses may feel anxious about their ability to perform their role as a nurse because of fear that some of the patients may reject the health care services they need to deliver as nurses (Belcher & Fish, 1995, pp. 51 – 56). Working Phase Since this is the phase wherein the patient is learning whether to trust or not to trust the nurses, problems with regards to development of nurse-patient relationship may occur in the working phase (Lakeman, 2010). With everyday communication process between the nurses and the patients, clarity with regards to the nurses’ and patients’ expectations and preconceptions occurs as a way of developing acceptance between the nurse and the patient. As a result of strengthening the relationship between the nurse and the patient, nurses are able to explore the patients’ feelings and learn about the patients’ personal problems which are necessary in enabling the nurses develop strategies that can be useful in helping the patients solve the problem (Marriott, 2006). During the working phase, nurses are expected to show their expertise not only in taking the patients’ vital signs but also in regulating the IV line and answering the patients’ queries regarding their prescribed medicine. In line with this, the ability of the nurses to show their expertise in the chosen career is one factor that will contribute to the strengthening of nurse-patient relationship since the patient would end up trusting the nurses about their treatment process (Marriott, 2006; Belcher & Fish, 1995, pp. 51 – 56). Aside from winning the patient’s trust by being punctual all the time, nurses should make it a habit to make use of the patient’s right hand when administering food or oral medication since Arabs preserve their left hand for cleaning their genitals (Zafir al-Shahri, 2002, p. 135). Also applicable in the working phase, nurses should be aware that the social norms in Saudi Arabia strictly prohibit unnecessary touching like hand shaking especially between two unrelated individuals of the opposite sex (Zafir al-Shahri, 2002). Therefore, nurses should always seek permission from the patient before touching them. By asking permission from the patient, nurses could avoid having the patient feel disrespected. Failure of nurses to show their competency as a nurse may lead to patients’ disappointment. Once the patients feel uncertain about the quality of care and treatment they are receiving from the health care professionals, the patient may decide to avoid working with the nurses towards achieving their health recovery (Belcher & Fish, 1995, pp. 51 – 56). Resolution or Termination Phase The resolution phase involves the process wherein the nurses should start withdrawing from the patients in order to give them strength to recover and stand on their own. As soon as the patient is ready to leave the health care institution, the relationship between nurse and the patient will lead to the actual termination (Lakeman, 2010). As part of the resolution phase, nurses may educate the patient on how they can further improve their health condition by providing them with health teachings. Given that the patient requires the need to receive further emotional or psychological support, the nurse can recommend some social support groups that could help the patient regain their strength from the physical and emotional pain that has triggered their illnesses, psychological, or emotional instability. Dissolving the nurse-patient relationship may lead to the development of temporary grief-like reaction between the nurses and the patients. Prior to the termination phase, the nurses should be able to gradually detach themselves from the patients in order to lessen the negative emotions that may arise out of the separation of patients from the nurses (Belcher & Fish, 1995, pp. 51 – 56). Significance of Culture in the Development of Nurse-Patient Relationship Culture forms the way in which social relations of a particular ethnic group are being structured and shaped (Clarke et al., 1976, pp. 4 – 6). In line with this, strong values represent a stable, long lasting belief which could greatly influence the perception and decision-making of the patients with regards to their preferred treatment and care. In general, culture sets a standard in guiding us in determining what is good from bad and what is morally right from wrong (Sagie & Elizur, 1996). Since there are a lot of differences with regards to religion, race, educational attainment, and economic status of each ethnic group, nurses should learn more about the cultural differences of each patient. Upon examining the impact of cultural differences with regards to the overall team performance, the study of Strauch (2010) revealed that cultural factors could lead to team errors especially when the team members have high-level of work load and are highly stressed during the operational phase. In line with this, Wachtler, Brorsson, & Troein (2006) confirmed that cultural differences between the health care professionals and the patients could cause the general practitioners to wrong diagnosis and treatment. As an indirect result of general practitioners’ wrong diagnosis, nurses may end up administering wrong medications to patients with different ethnic and cultural background. Developing awareness regarding the patients’ cultural beliefs and tradition is important part of developing nurse-patient therapeutic relationship. Ethnocentricity is referring to the practice of believing that a person’s ethnic or cultural background such as language, behaviour, religion, and customs is a centrally important as compared to the ethnic or cultural background of other people (Andersen & Taylor, 2006, p. 67). In other words, ethnocentrism views one cultural background as more superior than the others. Given that a strong ethnocentrism on the part of the health care professionals could often times result to professional negligence related to misdiagnosis, mistreatment, and the under-treatment of culturally diverse patients around the world (Greipp, 1995), nurses should improve their knowledge about the impact of different cultural background, beliefs, and traditions in the quality of care given to the patients. In other words, factors that could promote the development of a therapeutic milieu in caring for patients includes the habit of respecting the patients’ cultural background, customs, norms, values, and relationship issues which could positively affect the ability of the patients to recover from their illnesses. Strategies that will Improve Nurse-patient Therapeutic Approach particularly with Regards to the Patients with Different Cultural Background The Application of Humour and Laughter When Caring for Patients There are many ways in which nurses could develop and strengthen their nurse-patient relationship. One of the best strategies is to make use of humour and laughter as part of developing a good relationship with the patients. When we talk about humour, we are referring to the ability of the nurses to “help the patients perceive, appreciate, and express what is funny, amusing, or ludicrous” in order to relieve the patients’ emotional tension and anger (Kozier et al., 2004, p. 233). By doing so, nurses are given the opportunity not only to develop a good relationship with the patients but also encourage the patients to cope with their painful feelings as well as facilitate their learning abilities (McCloskey & Bulechek, 2000, p. 380). Through the use of this strategy, it is expected that the patient can experience a decrease in heart rate, blood pressure, respiration, and muscle tension since the use of laughter technique could promote relaxation on the part of the patients and increase in pain tolerance since humour could stimulate the production of catecholamines and other hormones that could release endorphins (Kozier et al., 2004, p. 234). Given that the patient could experience a better mental, physiological, and psychological well-being, nurses can take advantage of the situation in terms of being able to integrate hope, faith, and will to live in the patients’ lives by establishing a strong nurse-patient relationship. The same positive effects were noted in the research study that was conducted by Astedt-Kurki et al. (2007). In line with this, the authors revealed that humor is an important factor that could significantly help the patients cope with difficult situations since laughter as a result of humor could enable the patients rest and have a better perspective about their life situation. Even though patients were experiencing pain due to their illnesses, nurses are able to minimize or lessen the patients’ anxieties which is important in helping the patients cope with their illnesses and pain (Astedt-Kurki et al., 2007). When dealing with Arabic patients, nurses should be aware that laughing before the patient is able to fully understand or comprehend with the humor is a sign of disrespect and lack of empathy towards the patient’s health situation (Zafir al-Shahri, 2002, p. 135). Therefore, nurses who are dealing with Arabic patients should be aware of proper timing. The Use of Good Communication Skills Having competitive communication skills is one of the major factors that could affect the success or failure of establishing a nurse-patient relationship. For this reason, nurses should be aware of their choices of words, sentence structure, and tone of voice in order to enhance the establishment of nurse-patient relationship through the use of good communication skills (Kozier et al., 2004, p. 427). There is a close relationship between improving the emotional and physical status of the patients and the ability of the nurses to communicate well with them. Based on the research study result of Astedt-Kurki et al. (2007), patients who are emotinally happy and satisfied with the development of nurse-patient relationship is more likely to become more open in showing their emotions with the nurses. Once the patient is able to share their personal experiences with the nurses, the nurses will have more opportunity to communicate with the patients and be able to provide them with the comfort they need to be able to cope with their health status. As part of strengthening the relationship between the nurses and patients, Tveiten & Severinsson (2006) revealed that a good communication skill enables the nurses to effectively interact with the patients which normally result to the establishment of trust between the two parties, enable the nurses to look beyond the patients’ health situation, create partnership and equality, and consider the challenges behind making decisions for the best interests of the patients. Given that the patients are not willing to trust the nurse or accept their health situation, the patients may end up manifesting difficult behaviours or be withdrawn from the caring and treatment given to them by the nurses (Morse, 1991). Communication between the nurses, patients, and the patients’ family members can be in the form of verbal or written. With regards to the use of written communication, the research study of Moules (2009) described the importance of using therapeutic letters as a form of family nursing intervention. Depending on how the nurses would write a letter, therapeutic letters serve as an inspirational instrument that can address the nurses’ obligation to provide the patient and patient’s family members some emotional support regarding the patient’s illnesses and suffering (Moules, 2009). Because of the cultural differences between the nurses and the patients, it is possible for miscommunication between the two parties to arise as a result of language barriers. To improve communication between nurse and patients with different cultural background, nurses should learn more about the ways on how to improve their cross-cultural communication with the patients by increasing their knowledge and awareness about the uniqueness in the patients’ culture (Wachtler, Brorsson, & Troein, 2006). The Ability of the Nurses to Tolerate the Patients’ Negative Attitude It is unavoidable for some patients to display their anger and depression because of the emotional or physical pain they may be feeling because of their illnesses. Regardless of the physical and mental health of the patients, nurses should be able to tolerate the attitude and behavior of the patients in order for them to win their trust and eventually develop a better working relationship with the patients. As a result of having a high tolerance level on patients’ negative attitude and behavior, nurses can easily provide them with emotional support by spending some time to see the patients every now and then and ask how they are doing (Yamashita, Forchuck, & Mound, 2005). On the part of the patients, emotional support coming from the nurses means a lot. Based on the research study of Coatsworth-Puspoky, Forchuk, & Ward-Griffin (2006), one of the ten research participants revealed that the ability of the nurses to tolerate patients’ anger and occasional attacks could be beneficial on the part of the nurses in terms of establishing a better nurse-patient relationship between the two people involved. Once the nurses had shown their patience in taking care of the patients, there is a higher chance wherein the mood swings, attitude, and perception of the patients with regards to their assigned nurses would change. Eventually, nurses will be able to effectively control of the situation ones the patients decided to willingly participate with the care and treatment given to them by the nurses. The Application of Cultural Leverage Since differences in culture such as traditions and language could lead to racial disparities between the nurses and the patients, several research studies proposed the use of cultural leverage as a way of narrowing down the racial disparities between the two groups of individuals (Chin et al., 2007; Fisher et al., 2007). Cultural leverage is about adapting with the culture of other ethnic groups by learning more about the culture and traditions of other ethnic groups (Issel, 2009, p. 46). For example: Part of the Arab’s culture and tradition is to visit the sick. Since the patient is expecting relatives, friends, and neighbours to visit them in hospital, nurses should respect the patient by being patient even though the number of visitors inside the patient’s room may interfere with the health care delivery (Zafir al-Shahri, 2002). Considering that the nurses and patients have the same norms and expectations, there is a higher chance for nurses to improve their nurse-patient relationship despite the presence of cultural differences In relation to the importance of cultural leveraging, Fisher et al. (2007) explained that nurses can improve the “health of racial and ethnic communities by using their cultural practices, philosophies, or environments in order to facilitate behavioural change” (p. 245). Given that the use of cultural leverage could enable the nurses to narrow down the racial gaps with the patients, Fisher et al. (2007) revealed that the patients of different cultural background are able to increase their knowledge on self-care by decreasing the barriers that are present in their access to high quality health care service. Real-life Examples that will serve as a Guide in Improving the Nurse-patient Therapeutic Relationship with the Patients in Saudi Arabia The health care team in Saud Arabia is composed of both local and foreign health care professionals (Lovering, 2006; Zafir al-Shahri, 2002). In order to improve the team performance of the health care professionals, each of the available health care institution in Saudi Arabia promotes the importance of cultural diversity by encouraging the health care professionals to share their personal experiences with the rest of the health care team regarding what they personally know about the culture and beliefs of other ethnic groups. According to Lovering (2006), patients in Saudi Arabia are more likely to verbalize their emotional pain as compared to patients who are Afrikaans and Tswana. Knowing that patients from Saudi Arabia are open in expressing their emotions, nurses should take advantage of the situation by opening a communication line with the patient by letting them know that the nurses are there to listen to their emotional concerns. For example: People in Saudi Arabia do not accept the use of narcotics when treating pain because of its sedative effects (Lovering, 2006, p. 392). Knowing that Saudi Arabians refuse to take narcotics in pain management, nurses should make it a habit to inform the patients about the drugs including its side effects before administering medications to the patient. By doing so, nurses can avoid unnecessary misunderstanding or make the patient angry because of the act of violating their cultural differences. Given that the patient refuses to take narcotic drugs, nurses should respect the patient’s decision and ensure that the patient is requested to sign a contract stating his refusal to take the medication. By doing so, nurses can somehow win the trust of the patient. Specifically in Saudi Arabia, Islamic religion forms the culture of Saudi Arabian patients. Although Saudi Arabians strongly believe that illnesses is a way of atoning their sins, people in Saudi Arabia are open in receiving health preventive measures such as the childhood immunization programs (Ministry of Health, 1998). Aside from prohibiting sexual contacts outside marriage, Islamic religion also considers alcohol as an illegal drug and strongly prohibits women from smoking. To prevent unintentional insult to the patient, nurses who are establishing a nurse-patient relationship should avoid asking a female patient whether or not she has a history of smoking or asking questions about having pre-marital sex or sex outside marriage (Zafir al-Shahri, 2002). When dealing with a terminally ill Arab patient, nurses should be aware that part of the culture in Saudi includes the fact that family’s authority overrules the patient’s individual autonomy (Galanti, 2000). For this reason, nurses should make it a habit to let the family members know about the deteriorating health condition of the patient before letting the patient know about the news. Eventually, it is the patient’s family members who are supposed to inform the patient about his/her health condition. Conclusion and Recommendations The provision of holistic care is not limited to the administering of medication and assisting the patients with their activities of daily living. In order to be more effective when rendering care to patients who are chronically ill or is suffering from a life-threatening disease, it is essential for each nurse and other health care professional to be able to effectively apply the concept of spirituality when delivering care to the patients and their family. Establishing a strong nurse-patient relationship is a significant factor that could affect the success of health care delivery to the patients. As part of strengthening the nurse-patient relationship, nurses are obliged to learn more about the cultural differences of each patient. By doing so, nurses can avoid unintentionally disrespecting and make the patients feel angry or emotionally bad. Specifically in Saudi Arabia, Islamic religion forms the culture of Saudi Arabian patients. 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