Nurses are the lamp and light of the healthcare world throughout the history. They are the front liners of health care delivery and patient care. Nurses provide holistic and dynamic patient care regardless of the race, gender and social status of the patients. Nurses deliver primary healthcare services most of the time instead of doctors and this may even lead to similar or better patient health and even higher patient satisfaction and healing outputs  . Nurses also tend to provide a longer consultation and hands on period with patients. Nurses approach their respective patients with compassion and care. In the Middle East, a lot of multi-religions nurse practitioners are currently employed providing quality and none prejudiced health care delivery to non-Muslim and Muslim patients. Most of the nursing staffs who work in the said locality are mainly non-Muslim expatriate nurses, accounting for about 68% of Saudi Arabia’s Nursing work force  . In Saudi Arabia, nursing is not that prevalent as a career of choice for Saudi nationals in comparison with the other professions.
Several factors may include the type of how work or labor is done, the working time and conditions, and the perceptions of scarce monetary compensation by nurses are the prime culprit for this inclination. Nursing as a profession in the Middle East has a very poor or truncated image; the gender standards and the rapid population progression have attributed in the heavy reliance on expatriate non-Muslim nurses in health care delivery. In fact, population growth in Saudi Arabia is considered to be one of the highest in the world  . Saudi Arabia has only a total of 32% of nurses that are Saudi nationals, and this is based on a data of the Ministry of Health of Saudi Arabia conducted last 2010  . Muslim patients are often cared for by the non-Muslim staff nurses and allied health professionals that come from other countries, namely, the Philippines, Malaysia, India, South Africa, USA, and the United Kingdom.
Nursing care approaches may vary from one patient to another. In the nursing profession, nurses are imbibed with the attributes of multicultural care competencies that would empower the nurses to be adaptive and mindful of how they provide and go with their curative nursing managements. In this accord, non-Muslim nurses that are immersed in a Muslim country or locality in theory can be able to adapt and adjust in accordance with the norms and standards of that locality.
1.1. Culture Care Diversity and Universality
This study used the Leininger’s Theory on Culture Care Diversity and Universality. The theory of Leininger addressed the nurse-patient relationship in a diverse world. It educates nurses to address the need of the patient who is culturally different from their own, since nurses are the primary caregivers and implement nursing care. Leininger objective is for nurses to immerse themselves in cultural education and implement a style of care that is suitable to the cultural expectation of their patients. This theory of Leininger served as a guide for this study especially for nurses caring Islamic believer patients  .
1.2. The Crescent Care Models
The Crescent of Care nursing model suggests that the value is an impression on the care of Muslim patients and the mechanisms of the nurse caring action. The primary aim of the nursing care is to reestablish the complete well-being of the patient. The center of the model are the patients and family as the focus of and the primary recipients of the care, cultural importance of family as the initial and foundation of the social unit in Arab culture. The dimensions of the model includes the professional nursing care, which encompasses the spiritual aspects of care (these are the actions that meet the spiritual needs and well-being of the patient and his/her family members), the psychosocial aspects of care ( these are the actions that meet the psychological and social necessities of the client), the aspect of cultural care (these are the actions that establishes the cultural aspects that may include the values, the patient’s belief mechanisms and the traditions of the patient and his/her family members), it also embraces the interpersonal care aspects (these are the facets of care that are linked to the connection between the nurse and the patient, these may also include the different patterns of therapeutic communication) and lastly, the aspect of clinical care (which includes the physical technical or the skills delivery of the nursing care)  .
1.3. Cultural Competence in Caring for Muslim Patients
The provision of quality patient care for Muslim clients must denote that non-Muslim nurses must be equipped with the right knowledge and wisdom towards the practice of the Islamic faith, beliefs and traditions. Non-Muslim nurses must be able to grasp and know by heart the associations of spiritual and cultural mechanisms in their delivery of quality patient care. The non-Muslim nurses must be virtuous enough to know the need for privacy and decorum, the appropriate and acceptable use of touch, food restrictions and medication usage of their Muslim patients. This ensured a more relevant nursing approach that provides a more efficient and respectable manner of nursing care towards the Muslim patients  .
The study aims to identify the care approaches given by non-Muslim nurses working in the Arab world and how they elicit and provide a universal approach in caring Muslim patients. Keeping in harmony that the beliefs, practices and traditions that the Muslim patients are instilled and accustomed. This would entail that the non-Muslim nurses must be aware and be sensitive enough in their approaches and communicative exchanges with their Muslim Patients.
This study “Care Approach (CAp): Connecting Differences among Nurses to Islamic Believer Patients in the Arab World” utilized a mixed methodology specifically the explanatory sequential design which involves a descriptive-comparative quantitative research design and eidetic qualitative research design. Descriptive research design describes and interprets what is and reveals conditions and relationships that exist or do not exist, practices that prevail or do not prevail, procedures that are continuing or otherwise, effects that are being felt or trends that are developing. The study used a purposive sampling technique in the selection of the research participants. Purposive sampling technique is a non-probability sampling technique in which the researcher chooses the participants grounded on a personal judgment about which one is appropriate in data gathering for the study. The bulk of Muslim patients are found on the following areas of the hospital, emergency room, out-patient department, medical-surgical unit, obstetric and gynecologic unit and oncology unit and majority of non-Muslim nurses are assigned in the identified areas, and therefore, the respondents were picked.
Nurses who were caring admitted patients in any unit at Dr. Soliman Fakeeh Hospital, non-Muslim, either novice, advanced beginners, competent, proficient or expert in the field were included. For the quantitative aspects of the study, the researcher employed a survey questionnaire that was divided into three (3) parts which directed towards gathering data on the quality of Care Approach provided by Non-Islam Nurses and the type of care given by the non-Muslim Nurses. First part of the questionnaire identified the demographic data and the type of care given by the non-Muslim nurses. The second part was an evaluative questionnaire on the quality of care approach given by non-Muslim nurses. For the third part, it focused on deriving qualitative data from the respective respondents, narrative form of response was gathered regarding how the care approach of non-Muslim nurses connecting the differences to Islamic believer patient in the Arab world. The 4-point Likert scale was used for this tool. The result of the study yielded to the development of Nurses’ Care Approach (NCAp). The data was gathered from the evaluative questionnaire and undergone statistical treatment using the SPSS. The weighted mean was used in determining the type and quality of care approach provided by the non-Muslim nurses as perceived by Islamic believer patients. The study was reviewed and approved by the Institutional Review Board. Ethical considerations were observed all throughout the study. The respondents answered the questionnaires and the results were considered strictly confidential.
3. Results and Discussion
Table 1 shows the demographic profile of the respondents in terms of their age. Based on the result majority of the respondents belongs to age group of 26 - 30 with a 40.7 % of the total population followed by the age group of 31 - 35 with a 22% of the total number of respondents. On the other hand, only 1% of the respondents belong to age group of 51 - 55. Employers prefer younger employees because they are more flexible in working more than the allotted hours given to them and they are more enthusiastic since that would be their first job, they are more policy abider and sincere at the workplace  . Millennials can wield lots of pressure on a healthcare industry and they are the largest generation in the workplace nowadays. More than one third of the workforces in the US, about 53.5 million were millennials ages between 19 and 36  . As age of workers increases, their ability decreases. Same through in the differences of the physical abilities of the workers who are older, their physical abilities decrease compared to the younger ones which can perform essential responsibilities  .
Table 2 shows that 73.6% of the respondents are single while only 26.4% of the total number of respondents are Married. Many nurses were single due to the fact that in being alone they are able to focus more on their career growth, they are less stress when it comes to money matter, they are in charge of their own happiness, they have their own free will, and can create their own routine  .
Based on the Table 3 38.5% of the respondents belongs to the area of MS unit, while 22%were from Oncology unit, 15.4% came from the OPD unit and OB-Gyne unit, and only 8.8% were from the ER unit, many of the nurses prefer
Table 1. Age of the respondents.
Table 2. Civil status of respondents.
Table 3. Area of designation of the respondents.
to work in Medical-Surgical Nursing. True enough since this subject in the Nursing Program was the foundation of all nursing practices. This area had been a stepping stone of nurses before but through the passing of years, it became a specialized science and an extraordinary field where nurses molded as they enhance critical thinking skills, improve capability to work well under pressure, and demonstrate outstanding management skills. Nurses on this area are honed not only their mental state, but also their emotional, spiritual and physical aspect, and that is why most nurses prefer to start with in this area in the hospital.
Table 4 reveals that 52.7% are competent in terms of level of expertise, while 25% are proficient, 18.7% are advanced, and only 3.3% are novice. The five levels of expertise were novice which has a less than 6 months clinical experience and in terms of clinical decision, novice nurses look to the hospital or unit protocols to assist with decision making while advanced beginner usually works from 6 to 12 months in the clinical area and looks to the preceptor to guide the decision  . On the other hand, competent usually had a 1 to 3 years’ clinical experience and bases his or her decision on previous real-life clinical experience, while proficient had a 4 to 5 years’ clinical experience and make a decision very quickly and move forward with that decision. Lastly, the expert who had over 5 years’ clinical experience and expert nurses look at a given clinical situation and act with conscious thought. There is no need to guide the expert nurse in this decision since she has the confidence and knowledge to do a particular work. As you can see in Table 1―Age of the respondents, majority of the age belonged to 26 - 30 years old with a percentage rating of 40.7% and this age group had a clinical experienced of 1 to 3 years only but viewed themselves fairly and based their decision on previous-life clinical experience.
Table 5 shows the type of care given by non-Muslim nurses to their patients. Majority of them were Primary and Specialty care with a percentage value of 21.9% followed by Long term and Rehabilitative care with 13.8% of the total respondents. Lastly, only 4.9% of Hospice care was given by nurses. Primary care is the day to day healthcare attention given by a health care provider while specialty care was given by practitioners that were responsible for identifying, assessing the needs of the patients, and collaborates with the medical team  . However, primary care is the standard level of medical care given to patients that may receive in a physician’s clinic of in community health centers  . As can
Table 4. Level of expertise of the respondents.
Table 5. Type of care given by non-Muslim nurses.
be seen in Table 3, most of the non-Muslim nurses were assigned in the Medical Surgical Ward, so the care usually given in this area are primary care as well as specialty care since it is a medical situation that needs to be given priority in terms of treatment.
Table 6 shows the Care Approach provided by the respondents with a grand mean of 3.40 from the weighted interval with a descriptive equivalent of strongly agree. Based on the result with the highest mean 3.63%, the respondents strongly agree that the non-Muslim nurse is aware of her own culture, 3.60% strongly agree that the non-Muslim Nurse does not discriminate the decisions of the patients regardless of gender, race, culture or belief and 3.58% still strongly agree that the non-Muslim nurse encourages patients to communicate as need arises. On the other hand, the lowest mean was 3.31% with the indicator of the non-Muslim nurse exempts sick Islamic believer patients from fasting in Ramadan (as well as the elderly, children and expecting mothers). If they insist on fasting, compliance with medication can be enhanced by prescribing with Ramadan in mind, though this was the lowest, respondents strongly agree to this care approach. While 3.29% of the respondents strongly agree that non-Muslim nurse does not point the soles of the feet to the Islamic believer patient as this is considered disrespectful and 2.87% agree that the non-Muslim nurse consider using elderly members of the community in the decision-making process for the Islamic believer patient.
For the qualitative aspect of this study there were three themes that had emerged based on the verbal answers of the respondents, namely, 1) understanding and respect of cultures, 2) caring across borders, and 3) caring calmness.
3.1. Understanding and Respect of Cultures
One of the first emergent themes was understanding and respect of cultures. Non-Muslim nurses often have a hard time adjusting themselves when taking care of patients from other countries, more so for patients with other cultural practices and belief systems. The uniqueness of cultural and religious needs of
Table 6. Care approach provided by the respondents.
the patients can be very uncomfortable. Nurses giving care can accidentally offend their patients and their family or significant others by not understanding crucial cultural practices or personal beliefs or convictions of the patients  . Baring this in mind nurses must learn to understand the cultural aspects as well as the uniqueness of the beliefs of their patients. As accounted by respondent “R1: The non-Muslim approach was they respect the belief of the Muslim patients, they are aware to the things they do. They follow the culture of the Muslim”. For patient R1 the nurse must approach the patient with openness towards mutual respect of the culture and beliefs.
3.2. Caring across Borders
As verbalized by respondent R9: “Regardless of age, gender, status and race, nurses have one goal which is to cater the health need of each patient. There should be no discrimination when it comes to health care”. Nurses must provide adequate and holistic nursing care to their patients regardless of the place, or circumstance. Holistic nursing care is caring for the entirety of the person, in which the main objective is to restore the totality of wellbeing of the patient as a whole. Nurses would need to learn and relearn holistic nursing care in ensuring a more comprehensive manner of quality patient care delivery  .
3.3. Caring Calmness
Nurses provide caring characteristics that are encompassing to other nurses as well as the other members of the healthcare team. As verbalized by respondent R6: “Just enjoy and perform your job well”. Nurse must remain vigilantly calm and composed when talking care of patient outside of their known environments. Nurses must be able to keep calm to be able to work well in stressful circumstances, persistent calmness, and strong communication skills are vital. Nurses must also be accountable to provide integrity and a caring attitude when caring for patients  .
To connect the differences between the non-Muslim nurses and their Islamic believer patients, the non-Muslim nurses must be aware of their own culture, must not discriminate the decisions of the patients regardless of gender, race, culture or belief and must encourage patients to communicate as need arises. Non-Muslim nurses have a high regard of respect to their patients. Their actions are always guided by the oath of the profession that focuses on patient’s welfare regardless of culture, religion and belief. Providing a high standard care without discrimination and being patient centered is the ultimate goal in rendering holistic care.