An opening question was asked at the beginning of each interview to assess each participant’s perception regarding being a novice nurse. Most of their answers included their feelings of making a difference in the nursing society in Saudi Arabia. One participant had described it as follows: “since I was a kid, I had a passion for helping people who are in need.” Another one described it as follows: “I like taking care of the patient who needs our help.” Another one had said, “I love to care to other people.” Moreover, all participants described the environment in Saudi Arabia as unique because it has a lot of diversity; thus, nurses are able to interact with people who are from different cultures, races, religions, and nationalities. Each person who participated in this study had different barriers with regard to dealing with dying patients. Moreover, during the interviews, the participants described the barriers in depth; they provided the researcher with valuable information about their experience regarding critical situations to help the researcher to obtain significant results for the study. The barriers faced by novice nurses in Saudi Arabia, when working with dying or the sudden death of a patient, were identified and classified into four themes: (1) lack of experience with dying patients; (2) language barrier with patients and medical staff; (3) inadequate staffing, and (4) patients’ cooperation. The facilitators were placed into three themes: (1) caring/compassion, (2) teamwork/collaboration, and (3) mentored/experienced colleagues (
Table 3).
3.1. Barriers
3.1.1. Lack of Experience with Dying Patients
The participants felt that there were limited opportunities in clinical training to care for dying patients, so that, when they started working in the hospital, they were not ready to be involved with dying patients due to a lack of experience with these situations. The participants reported that their nursing program did not provide sufficient clinical hours. After graduation, they did receive a year of training as an intern; however, the internship program was not structured, so they did not receive enough one-on-one mentoring. The medical team did not want to be responsible for any mistakes made by the student. As described by one nurse, “…. I just wished that I had more experience in dealing with these situations, because during my bachelor’s degree, I was not exposed to many real-life situations, and our education does not focus on the practical side of nursing. In other words, our educational system does not make us 100% ready to practice nursing after graduation”. Another nurse commented that, “I did not have much experience dealing with critical patients”. The lack of guidance led to the students not receiving a proper education. This barrier could pose a serious threat to new nurses’ performance, if they were not well prepared before caring for patients.
3.1.2. Language Barrier with Patients and Medical Staff
A significant barrier faced by all the participants was language. Nurses and medical teams in Saudi Arabia are required to communicate in English, but this was not the issue because all medical providers speak English fluently. However, Saudi Arabia has a significant level of diversity among both patients and medical teams, so there was an issue in communicating among them due to the different languages and nationalities; moreover, initially, their native language was not English. It is challenging to communicate with foreign patients correctly due to the patients’ languages; they do not speak Arabic or English, so the nurses do not know whether they are providing the best care for the patients or not. In addition, there are some who speak English, but sometimes the nurses cannot understand what the patient is saying due to their accent. Moreover, patients usually have different religions, beliefs, and cultures; so, if the nurse cannot understand the patients’ language, he or she would not be successful as a nurse.
Furthermore, most patients in Saudi Arabia speak Arabic as their first language, and they do not understand English, which makes communicating between patients and foreign nurses difficult. Caring for patients who speak a language in which the medical teams are not proficient in can decrease the quality of health services in Saudi Arabia. One participant commented in regard to the language barrier and stated, “Foreign language barrier because I am Filipino, and I can’t speak well in Arabic, so I can’t understand what the things that my patients are saying mean”. Another nurse stated, “We have foreign people who do not speak Arabic or English, and we also have many different accents that are hard to understand. That plays a vital role in affecting our communication with patients”.
Lastly, the language barrier is not only limited to the patients, but also affects the medical teams, who sometimes have difficulties in understanding each other due to the different dialects. The medical teams in the hospital usually have diverse employees from different countries—such as the Philippines, Egypt, India, Pakistan, and Saudi Arabia—and everyone speaks English in a different accent. One participant stated that “during critical situations…there are some…sometimes it’s hard for us to understand each other because all the people are in stress, so they cannot convey well what they are trying to say so there will be a communication problem”. This barrier can make the process of caring for patients difficult and incomplete. As described by another nurse, “one of the major issues we have in the hospital is that we must deal with a diverse population which made the communication difficult with patients, especially in critical situations”.
3.1.3. Inadequate Staffing
Another barrier found from the interviews was the shortage of medical staff in the hospital. Most of the sample agreed that a lack of medical teams is one of the most challenging aspects that they face when working with critical situations. Moreover, the shortage of medical teams in the hospital made the process of caring for dying patients quite challenging, especially with the high influx of patients. Thus, lacking staff can affect the caregivers in providing holistic and complete care for everyone. As stated by one nurse,
“…Shortage in the medical teams made it hard to provide full attention to the dying patients. Collaboration in the nursing environment means covering shifts, assisting each other, and training new staff to be professionals. However, I believe that the reason for the shortage of medical teams in Saudi Arabia is free health care and that increases the number of patients over the medical teams…”
The shortage of medical teams in hospitals can affect the welfare of dying patients, leading to their premature death. Moreover, hospitals with inadequate staffing can exert a negative impact on nurses’ behavior during the process of caring for others, and nurses cannot perform their job if they are in an exhausting work environment. One participant pointed this out:
“…of course, we have a lack of staff, we cannot deliver sometimes…doctors’ orders will be delayed because we are with other patients helping the most critical situation first which is going to affect the other patients and not just the medications, but also the routine which is the laboratories, the ECGs are also delayed because of the lack of staff…”.
Nurses in the hospital cannot cover all patients’ needs due to the deficits in medical teams and supplies there. The approached hospital is considered one of the largest hospitals in Saudi Arabia, and it requires enough staff to cover all patients’ needs perfectly to improve the quality of healthcare. Moreover, the participants believed that the lack of hospital staff played an important role in affecting nurses’ performance and rendering them exhausted from working with patients, because they cannot bridge the shortage gap alone if the hospital does not have enough workers.
3.1.4. Patients’ Responses or Cooperation
The final barrier was found to be the most challenging aspect to deal with, which was the beginning of a treatment, because there is a long process involved in diagnosing the patients’ situations accurately, especially with dying patients. Moreover, it was difficult for the participants to ensure that the patient would be able to collaborate with them in order to facilitate the treatment and to not place the nurses under pressure when they perform their job. Moreover, when patients arrive at the hospital, it is usually difficult to obtain enough information from them, especially with dying patients’ situations, due to their conditions during the treatment, and this may affect its quality. New nurses in Saudi Arabia tend to be afraid and nervous when they are involved with dying patients, especially with those who are unconscious. They believe that they cannot ensure that they are choosing the best treatment to protect the patient or not. One nurse commented that, “It is always challenging at the start of the treatment…. in order to move critical patient status from dangerous positions to a stable situation…” This barrier can negatively affect the nurses’ performance if they are not well prepared, and it may affect the trust between the patient and the medical team.
Additionally, new Saudi nurses face huge pressure and fear when they deal with a car accident patient, because they refuse to be the reason for the patient’s death. Usually, nurses feel more emotional towards the patients and this may affect the quality of the treatment. The most challenging part was described by one nurse as follows: “Those patients who have just come out from a horrible car accident specially when they have a lot of broken organs...it is really hard to work with them as it is emotionally challenging…” In addition to this, the patients’ families or companions sometimes cannot imagine that they may lose their patient, so they may interrupt and distract the healthcare givers by asking many questions about their patients’ status, which plays an important role in decreasing the medical team’s focus on the situation.
Furthermore, some families and companions tend to blame the medical for the outcome of the situation and this can cause a negative impact on the medical team’s behavior. Therefore, the quality of healthcare will decrease due to the huge pressure in avoiding any mistakes towards the patient. As described by one participant, “when the patient and his or her family are convinced that we are doing everything possible to help the patient, but we cannot control death, it makes it easier for us, because sometimes they blame nurses and doctors”. Finally, patients’ responses or cooperation with medical teams play an important role in changing the process of caring from the nurses’ side, and this may affect their passion for helping others negatively if patients do not show any improvement after receiving the treatment.
3.2. Facilitators
Facilitators are assisting factors that help to overcome barriers faced by individuals. The facilitators that novice nurses in Saudi Arabia have encountered during the process of caring for dying patients were identified in terms of three themes: (1) caring/compassion, (2) teamwork/collaboration, and (3) mentors/experienced colleagues. This section will describe the themes in detail.
3.2.1. Caring/Compassion
A passion to help and care for people in need is the most common facilitator that the participants reported. The participants had expressed a passion for helping others since they were young, which helped them to decide on becoming nurses as a suitable career for them. Moreover, they believed that a passion for helping others is essential in the nursing field to ensure that nurses are creative and successful in their job. One participant commented, “I have chosen to be a nurse because I love to care for other people”, which played an important role in facilitating the process of caring in this nurse. Moreover, each participant expressed their feelings towards helping patients in a different way, such as the following comment by another participant: “I decided to be a nurse because I like taking care of the patient who needs our help as professional.” The “caring/compassionate” element of their work helped the participants manage their roles as professional nurses, as well as encouraging them to work hard to satisfy all the patients’ needs accurately—especially with dying patients. The participants believed that if they were not able to “control their fear of death”, they would not be able to handle a large amount of pressure, thus not deserving to be called nurses. Caring and compassion enabled the participants to overcome any barrier that could affect their performance. As discussed by one nurse, “since I was a kid, I had a passion towards helping people who are in need whether their need was medical or something else, so I found nursing the perfect career for me”. Although most nurses tend to be creative and skillful in their workplace, they sometimes need motivation to increase their efforts, so the participants used their compassion for others to provide the best care for their patients. Caring/compassion was considered as a great facilitator that helped them to manage their roles as professionals.
3.2.2. Teamwork/Collaboration
Good collaboration between medical teams is believed to be an effective strategy to facilitate the process of caring for all patients. All participants agreed that the hospital environment is a healthy one for nurses to be successful, and their management is helpful for new staff to improve their performance. Moreover, medical teams in the hospital work collaboratively with others, to cover all patients’ needs adequately. One nurse commented that “Kindness and good collaboration between colleagues is the most positive advantage in our hospital which is the best facilitator to improve our ability to receive and protect the patients…”. Teamwork/collaboration is another effective facilitator that helped the participants to become successful in their workplace.
Moreover, they believed that in order to provide the best care for all patients, good collaboration between medical teams is essential to meet all patients’ needs accurately and to improve the healthcare society further. One participant pointed out, “I think collaboration is an amazing thing and it is essential in our career, because we need to save time sometimes, but at the same time, accuracy is a must which can only be done by teamwork”. Furthermore, the participants believed that the role of nurses is to protect, help, and diminish patients’ pain. Therefore, this cannot be achieved unless they work together as a team to accomplish this goal. As stated by one nurse, “fortunately, our hospital has a very healthy environment and our management is always trying to improve our facility more and more…which helps us respond to patient needs…”
3.2.3. Mentors/Experienced Colleagues
The support of friends, administrators, colleagues, and experienced nurses was found as one of the most potent and effective ways to facilitate the process of caring, which helped the participants to overcome challenges during their work. The subject nurses in this sample stated that whenever they experienced difficulties in dealing with certain situations, they tended to seek help from their superiors to learn and improve their performance: “Our mentors and experienced colleagues were the greatest facilitators for us to improve our skills and increase our confidence and this helped to enhance the quality of health care in the hospital…”
As stated by another participant, “…we have mentors as well as experienced colleagues, and we are always welcome to discuss our feelings with them or any difficulty that we face. Besides, if a nurse’s performance drops, he gets called by his mentor to explain the reasons whether they are related to feelings or something else…”
Having this support from mentors and experienced colleagues helped the participants to manage their roles and be successful in their workplace. Moreover, this support enhanced the participants’ experience in dealing with barriers associated with critical situations. One participant commented, “When I asked for help, my colleague did not hesitate to help me and educated me while treating the patient”. This played an important role in developing the participants’ performance and made them ready to face any situation. As stated by one participant.
“…I relied on my colleague to help me to control cases. However, over time, I became an expert because I have learned from my colleague a lot such as I am in a place that requires me to save people not to be the reason of making their situations more complicated. That encouraged me to improve my confidence when I treat patients…”