Patient satisfaction in the KSA

This section discusses KSA-based research on patient satisfaction, particularly patients’ satisfaction with the quality of care provided to them. The current study uses the frequently cited dimensions of quality; safety, effectiveness, equity, patient centredness, efficiency, and timeliness in combination with process and structure to investigate how they impact a specific outcome which results in patient satisfaction. In order to further contextualize and justify the current study, this section of the literature review describes research studies conducted in the KSA on patient’s satisfaction with quality of care based on IOM’s 6 dimensions of quality.  

The studies discussed in this section are summarized in the table below. After the table, structure and process of care are each discussed in separate sub-sections.

Table 2.1 : KSA studies on patient satisfaction and quality of care

Few studies were found which focused on the quality of hospital-care in the KSA, and most research that deals specifically with the country was shown to be focused on the quality of primary care services (Mansour and Al-Osimy 1996; Alahmadi and Roland 2005; Al-Doghaither and Saeed 2000; Al-Faris et al. 1996; Saeed and Mohammad 2002). Results from these studies demonstrated wide variations in quality of care in the primary care setting, and all recognised the need for further research.

One study of note assessed patient satisfaction in a tertiary care centre in the KSA (Alaloola and Albedaiwi 2007), and another focused on quality of cancer care, specifically, assessing the quality of breast cancer care in a KSA health care institution (Akhtar and Nadrah 2005).

Notably, certain studies that used quantitative methods, based on patient satisfaction surveys or opinions of health care experts, appeared to have a number of flaws. Although the review included the studies assessed as robust, there were some weaknesses in study design or methodology, for example, small sample sizes, retrospective analysis, use of non-validated tools or poor transferability of results (Akhtar and Nadrah 2005; Alaloola and Al Bedawi (2008); Saeed and Mohamad (2002); Mahfouz et al. (2004). Also, there has not been any previous KSA empirical study that has focused specifically on patient satisfaction in oncology settings. It is also worth noting that there has not been any previous qualitative study that has explored the issue of patient satisfaction in KSA. 

Despite a paucity of published literature and some flaws in the existing research in the KSA, there is a general, overall trend evident across the published literature. That is, there was evidence that patient satisfaction was adversely affected by (1) poor access to care and treatment availability, (2) poor service coordination between different units and professionals, (3) lack of communication within the multi-disciplinary team required for oncology care, (4) lack of patient communication and awareness, and (5) a general lack of adherence to standardised guidelines related to diagnosis, treatment and monitoring of cancer patients (Akhtar and Nadrah 2005; Al-Doghaither and Saeed 2000; Almuzini et al. 1998; Younge et al.1997; Brown et al. 2009; Diab 2010; Shamieh et al. 2010).

To date, research on patient satisfaction in the KSA suggests that patient satisfaction generally varies according to various factors, in particular, the age of the patient (Al-Faris et al., 1996) and the healthcare providers’ disclosure practices (Al Ahwal et al. 1998; Younge et al. 1997; Aljubran 2010; AlAmri 2009).

.2.6.1. Structure

The structure of care involves the manner in which a patient accesses and receives care. The way that care is provided and structured is important, particularly with respect to how patients conceptualise their satisfaction with their experiences in a health setting.  A retrospective study by Al-Sirafy et al. (2009) indicated the need to improve access to palliative care services in the KSA, and revealed that patients could not identify evidence of improvement in their quality of life or health. Al-Muzaini et al. (1998) also found that improvements in structure and the manner of delivery are challenged by the lack of knowledge of evidence-based cancer care, and by drug shortages. It was concluded that there is a need for provision of an effective framework for palliative care services in the KSA health system.

The recent widespread recognition by Arab countries that the status of palliative care is poor and lacking in structures has given rise to the ICCAW initiative (Initiative to Improve Cancer Care in the Arab World). As part of this initiative, Shamieh et al. (2010) led a panel of experts tasked with recommending modifications to the Comprehensive Cancer Network (NCCN) Guidelines. These guidelines made various suggestions for improvements in the structures of palliative care provision. Shamieh et al.’s (2010) report also concluded that there was little research data from the KSA upon which to recommend changes.

In terms of access to services, Diab (2010) was tasked with finding out how to improve access to cancer care facilities, with the objective of identifying key issues, including concerns about excessive waiting times, prevention and screening, diagnosis and treatment, quality of life, and palliation. The findings were clear that there are problems with regard to the structure for the delivery of, and access to care in the different Arab countries, including the KSA. The need for an initial assessment to develop a database of baseline information for cancer care facilities was identified.

Lack of satisfaction from a patient’s perspective has been reported in a number of other KSA studies that evaluated various dimensions of the quality of care. Mansour and Al-Osimy (1996) identified patients’ dissatisfaction with the resources and care provided, whilst Al-Ahmadi and Rolands (2005) identified poor access to adequate chronic disease management programmes and inadequate health education, along with ineffective systems for referral and for prescribing. Research in breast cancer tertiary care health care institutions also indicated dissatisfaction with the quality of the general standards of cancer care and the significant underuse of radiotherapy; both were recognised as being below internationally accepted standards (Akhtar and Nadrah 2005).

A major study in the KSA, conducted by Alaloola and Albedaiwi (2008), highlighted that patients’ perspectives on service delivery are a core service quality indicator. Their study focused on the level of patient satisfaction or dissatisfaction in a tertiary centre in Riyadh using a cross-sectional survey of 1,983 inpatients, outpatients, and emergency care patients. It was the first report of service quality and patient satisfaction of the KSA health care systems to appear in a peer-reviewed journal. One limitation of this otherwise invaluable study was that not every service was studied separately, so the patients’ answers may not represent any one hospital setting. The researchers recommended that further studies on patient satisfaction in the KSA are needed.

There is also a need to explore related aspects of cancer treatment within the KSA, including unacceptable side effects (like osteoporosis) caused by current chemotherapy drug use (Al-Amri and Sadat, 2009), and the need to focus on the significant number of patients failing to attend medical appointments (Brown et al., 2009). In the study by Brown et al. (2009) in Riyadh, which involved patients with malignant lymphoma, communication problems were responsible for 34.1% of missed appointments, while another 17.6% were found to be the result of patient communication errors. One area identified as problematic was the movement of patients with limited access to outpatient appointments and hospital facilities. Addressing such problems represents an essential role of a service organisation.

These studies demonstrate the potential for considerable patient dissatisfaction with certain structural aspects of healthcare in the KSA and, hence, the need to further investigate patient perceptions of a range of specific key indicators of service organisation in the KSA.  It should also be emphasised that much of the data presented from the KSA are not derived through primary research, but arise from retrospective analyses of data from patient files or records. The need for robust, reliable evidence from empirical research provided a rationale for the current study to examine the quality of patient care in oncology wards in the KSA.

2.6.2   Process

Research suggests that the processes by which healthcare is delivered in the KSA are inconsistent in nature and quality, which may give rise to inconsistencies in patient satisfaction. A lack of consistency in the quality of the clinical care processes has been clearly identified in the KSA. Research in Riyadh (Saeed and Mohamed 2002) established that the patients were largely satisfied with the doctors and the nurses, but this research was undertaken in a context where experienced Muslim physicians and an Arabic-speaking health team were offering free services near patients’ homes. The findings of the current study may not then be generalizable with regard to patient’s conceptualisations of their satisfaction in the KSA.

A number of studies have also shown high levels of patient satisfaction in other specialties. The study by Mahfouz et al. (2004) showed that elderly patients were largely satisfied with the doctors and the health care givers’ attitudes and behaviours, but patients were generally dissatisfied with long waiting times, lack of speciality care, and lack of information provided to them. Al-Faris et al. (1996) studied primary health care centres (PHCC) in Riyadh and found that the satisfaction levels varied according to the factor investigated. Although patients were generally satisfied with the service provided and with the respectfulness of the staff, they were significantly dissatisfied with the interpersonal skills of some health care staff and with poorly explained procedures.

The KSA’s Ministry of Health regulates both the governmental and private health sectors. The Ministry of Health has the capacity to set standards for national-level strategies for health reforms through change management and allocation of financial resources. Raising the health level of the population is informed by the government’s health research, which is included as a strategy within the National Health Program/Plan. In 2005, Al-Ahmadi and Roland (2005) acknowledged that there was a deficit in the literature on the effectiveness of quality primary care in the KSA, even though the Ministry of Health argued that high quality of care is a key to the national health strategy. The available evidence shows that clinical effectiveness in the KSA has historically been considered to be low.

A study of satisfaction among primary health care patients in the KSA by Mansour and Al-Osimy (1993) indicated low satisfaction with the quality of care of the referral system. More recently, research has showed that patients have developed poor perceptions of the effectiveness of primary health care in the KSA (Al-Ahmadi and Roland 2005). Ineffectiveness and inefficiency in primary care were reported in relation to disease management programmes, prescribing patterns, health education, referral patterns, and some aspects of interpersonal care, including those caused by language barriers. In addition, Al-Ahmadi and Roland (2005, p. 331) also identified other determinants of the ineffectiveness of primary care such as ‘poor management and organisational factors’, ‘poor implementation of evidence-based practice’, ‘low  professional development’, ‘lack of structured approach to use of referrals to secondary care’, and ‘use of healthcare professionals that were not sensitive to the culture of Saudi Arabian patients’.

Hopeful changes are underway in the KSA. Recently, a report by the Ministry of Health (MOH 2010) identified failures in health care in the KSA, which were largely people-related and not technology-related; they were also linked to complexities in management of health information (Ministry of Health, MOH 2010). This led to a Ministry drive towards improvements in primary care practice in a number of regions. One important and positive change has been the adoption of an e-Health approach, as part of the wider KSA focus on e-Government, aimed at improving the efficiencies and effectiveness of health care. The KSA’s use of e-Health has been identified as a strategic objective for the Ministry, which should not just improve health, but enhance how patients perceive the effectiveness of care and availability. The approach involves linking regional health directorates, hospitals, and hospital management centres. The KSA e-Health governance model claims to improve service design through alignment of health care with dimensions of quality of care, management of relationships (doctor-patient relationships, nurse-patient relationships), and by ensuring delivery of value to patients. However, despite this drive to provide high-quality health care services in the KSA, evidence of patients’ perceptions of quality care in the KSA is lacking, and a gap in the knowledge remains. These findings highlight the need for research on patients’ concepts of satisfaction as one of the key indicators of quality of care from the perspective of clinical effectiveness. Specifically, it would be pertinent to conduct research to investigate how doctors’ or nurses’ skills could be developed to help improve perceived clinical effectiveness of care and other care processes The current study will help achieve such objectives.

In order to determine a practitioner’s clinical effectiveness, the use of evidence-based practice is important. Evidence-based Clinical Practice Guidelines (CPGs) are important tools to help improve patient care and health outcomes. Al-Ansary and Alkhenizan (2004) conducted a review of CPGs and of the tools that have been employed in CPGs in Saudi Arabia for the last two decades. Their findings demonstrated the need for good quality, effective CPGs in the KSA to enable alignment with expected standards for quality of care. Ideally, to reduce work and costs, this could be accomplished through local adaptation of good-quality international guidelines. There is a dearth of information in the literature on the way CPGs could provide a basis for improving dimensions of care in the KSA. Recent studies have focused on quality measures/indicators which are known to improve care outcome. Al-Moajel (2012) showed how improving the effectiveness of quality of care relies on the development of hospital performance indicators in the fields of accreditation or the certification of health care structures and processes of care.

One potential problem identified in the KSA is accurate measurement of performance indicators. This is in line with the call by Bilimoria et al. (2009) in the US for a framework for policies and procedures to outline the best approach for such measures. In addition, there is a need for implementation of standardised, quality indicators in daily practice through effective strategies to reduce variability and enhance the level of improvement obtained (Vos et al. 2009). Indeed, Al-Moajel (2012) maintains that quality indicators are essential to improve the quality of health care services. Al-Moajel’s (2012) study also recommends accreditation of hospital care services as a step towards aligning quality of care dimensions with set standards, as part of clinical governance. Despite the clear need for such measures, there is currently no literature on how accreditation and certification systems in the KSA have affected patient satisfaction or impacted on clinical effectiveness.

2.7    Conclusion

 This narrative synthesis approach to literature review has demonstrated the difficulty of defining and measuring quality of care and patient satisfaction. The review also demonstrated the gaps in current scholarship on patient satisfaction in the KSA.

A key element of this discussion has been the relationship between patient-centred care and patient satisfaction. This will be the main factors that are analysed in the current study using the mixed methods research approach as discussed at great length in chapter 3. The literature review has provided a direction for the current study by which research can be conducted to ensure that relevant information is drawn in order to provide meaningful results in terms of patient satisfaction that are discussed further in chapter 4, 5, and 6.

This review has evaluated the knowledge base of patient satisfaction, with particular focus on the oncology care setting in the KSA. By expanding the understanding and knowledge base of patient satisfaction in the KSA, this review has identified significant gaps in the research. This review has consequently provided justification for the current research, and given rise to the following research question: 

What factors contribute to or hinder patient satisfaction with care in an oncology ward setting in a Saudi Regional Cancer Centre in Riyadh?

The identified gaps in knowledge highlighted in this review can be addressed by effectively interpreting the relationship between patient experience/satisfaction and quality of care, while maintaining a focus on oncology patient satisfaction in the KSA which is conducted for the current study. The ultimate intention of the current study is to contribute knowledge to a hitherto poorly researched area.

Chapter 3 - Methodology and Methods 

3.1    Introduction

The literature review indicated the need for empirical research on patient satisfaction in the KSA, particularly patient satisfaction in oncology wards. As indicated in the review, it is important to address these gaps by exploring, understanding, and interpreting the influential processes in oncology patient satisfaction in the KSA. Studies from outside the KSA offer insights into ways in which patient satisfaction varies in different care settings internationally. However, few studies to date have explored patient satisfaction in oncology ward settings in the KSA. This indicates that there is a need to consider how, in the cultural context of the KSA, various influencing factors might determine satisfaction of care, and why and how a patient is satisfied or dissatisfied with the care provided in the KSA.

By focusing on this important gap in the literature the following research question was developed:

‘What factors contribute to or hinder patient satisfaction with care in an oncology ward setting in a Saudi Regional Cancer Centre in Riyadh?’

In this chapter the methodology and research methods selected to answer this research question and to meet the aims of the  current study are outlined and discussed. A sequential mixed methods approach was used for this research, to answer most effectively the research question and to address the aims of the study. The first, quantitative phase of the research provided data from questionnaire responses. The results of the analysis of this data were then used to inform the second, qualitative phase which employed semi-structured interviews.

Following this brief introduction, the research question and study aims are considered in more detail before the rationale for the study design is presented. Additionally, the theoretical reasons for using a pragmatically informed, mixed-method design to explore the complex and multifaceted issues of patient satisfaction in the KSA are discussed. The chapter continues by providing a detailed description of how the study was conducted; this includes a description of the study setting, the procedures for recruiting and selecting patients, and the means of data collection and analysis for the two phases. The chapter concludes with an exploration of the ethical issues associated with the current study and a description of how these were addressed.

3.2    Research question and study aims

The primary research question driving the current study was as follows: What factors contribute to or hinder patient satisfaction with care in an oncology ward setting at the Saudi Regional Cancer Centre in Riyadh (SRCC)? This primary question was broken into three more specific sub-questions to be answered during Phase 1:

1. Does the clinical effectiveness of health care (doctors’ and nurses’ skills, information provision, availability) influence adult oncology inpatients’ satisfaction with care at the SRCC in Riyadh?
2. Does accessibility to health care (service organisation) influence adult oncology inpatients’ satisfaction with care at the SRCC in Riyadh?
3. What are the socio-demographic characteristics of adult oncology inpatients at the SRCC in Riyadh?

Informed by the responses in Phase 1, another series of specific questions was asked during Phase 2:

1. How do interpersonal aspects of care influence adult oncology inpatients’ satisfaction with care at the SRCC in Riyadh?
2. How do socio-cultural communication factors influence adult oncology inpatients’ satisfaction with care at the SRCC in Riyadh?

The specific aims of the study were as follows:

1. To determine the likelihood that clinical effectiveness is associated with patient satisfaction in adult oncology ward settings in SRCC.
2. To determine how likely the accessibility to health care is associated with patient satisfaction in adult oncology ward settings in SRCC.
3. To describe the characteristics of patients in adult oncology ward settings in SRCC.
4. To explore the extent to which interpersonal aspect of care influence patient satisfaction in adult oncology ward settings in SRCC
5. To provide recommendation for enhancing patient satisfaction in oncology ward settings in KSA
6. To discuss the extent to which and in what ways the qualitative findings help to explain the initial quantitative results of patient satisfaction in oncology settings in KSA

3.3    Research methodology: Overview of mixed methods

The use of a mixed-method design enables quantitative and qualitative methods to complement one another and allow for a more thorough analysis of the research problem (Creswell 2003). As the purpose of the current study is to explain the impact of various factors on a patients’ satisfaction in oncology wards in KSA, the mixed-methods design is best suited for the research. This sequential mixed methods design was chosen for various reasons; which will be justified throughout the current chapter. Firstly, the research problem is qualitatively-oriented; a rational qualitative instrument was used to gain insight into the various factors that may influence patient satisfaction. Secondly, the results of the quantitative research are thought to aid in explaining and gaining insight into the qualitative findings (Creswell and Plano-Clark 2011).

Creswell and Plano-Clark (2011) have argued that the use of combining qualitative and quantitative approaches provides amore absolute and complete understanding of the research problem than the use of only a single method. It is true that a quantitative method is able to identify the variables that are systematically or statistically correlated, but the method fails to provide insight into the reason why the variables are related in the first place. Furthermore, Polit and Beck (2008) states that a qualitative explanation can clarify the imperative ideas and substantiate the findings from the statistical analysis, and also provide guidance that helps in the interpretation of results. Therefore, the researcher had chosen the integration of the two methods to provide a more robust understanding of the research problem as either methods would be inadequate to do so alone.        

3.3.1   Key issues in mixed methods research

Mixed methods research is where quantitative and qualitative techniques are combined in a research project and the level of interaction between the techniques used. The method is based upon the premise that such a mixture of quantitative and qualitative methods is both practical and compatible. A mixed methods approach can help the researcher to overcome problems in the collection of data and provide reliable findings as quantitative results provide concrete statistical facts which are supported through detailed insight provided by qualitative findings (Creswell 2003). The combining of the two research methods namely, quantitative and qualitative complement each other and the data collected can be integrated and also limits the weaknesses in each separate technique as discussed above.

According to Creswell and Tashakkori (2007 p.4) mixed methods research can be described as:

“Research in which the investigator collects and analyses data, integrates the findings and draws inferences using both qualitative and quantitative approaches or methods in a single study”

Some researchers claim that MMR results in clarity in understanding the complexities of the social phenomena that are under investigation (Ponterotto and Greiger 1999).

There are several benefits in using a mixed methods approach to research, namely, (1) triangulation (using multiple data collection methods to corroborate findings and to validate these methods); (2) complementarity (elaborating, and clarifying the results of one method using another); (3) initiation (uncovering contradictions that lead to re-framing the research question); (4) development (using the findings from one method to inform the other); and (5) expansion (expanding the breadth of research by using different methods at different stages of research) (Greene et al. 1989).

Some of the strengths of mixed methods designs that have been of particular benefit to the current study are that (1) interviews have extended and deepened the survey data, and (2) the conclusions of the study were stronger due to the synthesis of the findings from both methods, thus strengthening the recommendations for improvements to enhance patient satisfaction. There are, however, certain weaknesses in the use of MMR. Using different methods can result in different types of answers to a research question. Moreover, a practical limitation is the amount of time required to conduct such a study (Creswell 2009). 

The MMR method needs a research paradigm to provide a framework for the research to be able to adequately address the research questions. Creswell and Tashakkori (2007) maintain that a research paradigm represents a belief system or theoretical assumptions and propositions that provide guidelines on how to answer a research question. Four foundations of research paradigms exist, namely, (1) positivism (built on experimental testing); (2) post-positivism (viewpoint arising from the need for a research context and a recognition of the insufficiency of context-free experimental designs); (3) critical theory (viewpoint that ideas relate to specific ideologies, and biases ought to be articulated; and (4) constructivism (viewpoint that every individual researcher creates his/her independent reality, and therefore, multiple interpretations exist). 

According to Sale (2002), ‘one cannot be both a positivist and an interpretivist or constructivist’ (Sale et al. 2002 p.47).  Similarly, Hammersley (1996p.160) argues that:

Quantitative and qualitative methods have been presented as opposing paradigms, to be used as and when appropriate, depending on the focus, purposes and circumstances of research

The primary question of this debate is whether, when using quantitative tools in a mixed methods design, one adopts a positivist interpretation, or whether the overall research design remains constructionist or interpretivist. The latter position implies that use of quantitative data collection tools means it is still important to develop conclusions using constructivist approaches.

The logic behind the use of MMR in the current study is driven by practical considerations such as study design, skills and resources as well as theoretical reasoning (i.e. study aims) (Bryman 2006). The primary aim and research question of the current study is to establish a relationship between how the factors uncovered impact patient satisfaction. Keeping in mind the primary aim it is evident that it is necessary to comprehend which major factors influence patient satisfaction which can be revealed through a quantitative measuring instrument, in this case a survey. However, to fully comprehend the factors further insight is needed in terms of understanding patient opinion on the healthcare delivered to them and ultimately how that impacted their satisfaction. This is consistent with the perspectives of Snape and Spencer (2003), who argue that ‘quantitative and qualitative methods can and should be seen as part of the social researcher's ‘toolkit’ (p.15). This view echoes work by Feilzer (2010), who maintains that methodological choices should be based on the aim of the study.  

While Onwuegbuzie and Leech (2005) and Creswell (2009) stress the importance of pragmatism in MMR, some researchers maintain there is still lack of clarity in how pragmatism can shape and define the mixed methods approach (Tashakkori and Teddlie 2003). Nevertheless, the general consensus in the literature is that some versions of pragmatism represent the most useful philosophy for supporting MMR. For example, Johnson et al. (2007) contend that pragmatism is a suitable philosophy for integrating different perspectives and mixing approaches through application of epistemological justification and logic. According to Johnson et al. (2007), by mixing approaches and methods, the outcome would more readily be able to address and provide tentative answers to one’s research question(s). Similarly, Morgan (2007) provides a holistic view, describing how researchers can vary their approach depending on the research question and draw on pragmatic approaches as a philosophical and practical basis for conducting MMR. This approach enables a multiplicity of perspectives, which enables a deeper understanding of the research problem (Eaves and Walton 2013). Therefore, the current study adapts  pragmatism as philosophical framework  underpinning this mixed methods research.

Notably, it has been asserted that neither qualitative nor quantitative methods alone are adequate or robust enough to provide a complete analysis of the complex nature of research in areas such as health care (Sale et al. 2002). This is especially true in this investigation of patient satisfaction in an oncology setting in the KSA since cultural, political and communication problems may all play a role, yet may be difficult to explain through using either a survey or interviews alone. This is at the heart of my decision to use a MMR design which has already been successfully used to understand patient satisfaction in other studies (Hyrkaas and Paunonen 2000; Merkouris et al. 2004). Moreover, an important advantage of mixed methods is that it allows triangulation between two or more types of data to assess the same problem, so that different perspectives can be corroborated, thus giving weight and validity to the interpretation of the results (Green et al. 1989; Bowling 2007). The convergence of two or more datasets increases confidence in the results (Bogdan and Biklen 2006). Complementarity uses the results of one research method to elaborate or clarify the results of another, thus achieving a fuller understanding of the phenomenon (May et al. 2000; Sale et al. 2002; Creswell 2003; Bowling 2007). One practical issue of complementarity is the sequencing between the phases and whether the quantitative and qualitative methods are adopted simultaneously or sequentially (Creswell 2009). A common approach suggested by Bryman (2006, pp.106) is that corroboration through the use of qualitative data helps to ‘put meat on the bones of dry quantitative findings’. However, Pope and Mays (1995) emphasise a key point about using qualitative research to corroborate quantitative research in a mixed method study:

…is not simply a matter of joining two techniques, or tacking one on the end of a project. Researchers need to be aware of the different types of answers derived from different methods (Pope and Mays, 1995, p.44). 

An alternative approach to combining data is described by Creswell (2009), namely, the explanatory design. The explanatory design involves two-phases where qualitative data helps to explain and expand upon initial quantitative results (Creswell et al. 2003), and is especially useful when such data is needed to explain significant/non-significant results, or outlier results (Sale et al. 2002).

3.3.2   The applicability of explanatory mixed methods to this research

The following four key factors were examined as proposed by Creswell (2009) to determine if the MMR methodology was warranted for the study:

Timing

The collection of qualitative and quantitative data may be scheduled and timed so that the data are collected simultaneously or sequentially. As shown in the current research questions, the sequential data collection methods was adopted within both phases. According to McNabb (2012) the strength of a survey is identified with its ability to collect large amounts of responses over a specific period of time and its ability to represent the target population. In the current study, a reliable and validated instrument (phase 1) was used and then followed with semi structured interviews   to examine the factors influencing patient satisfaction (phase 2) of cancer patients in SRCC.   

Weighting

Weighting refers to the priority and emphasis given to both the qualitative and the quantitative methods. Giving greater emphasis to the quantitative method was   necessary to ensure that the maximum amount of data was collected and analysed prior to seeking explanation by using interviews in the qualitative phase allowing to keep focus on its application.

Mixing

Mixing involves merging two forms of data into a structure that allows for reliable evidence to be drawn upon with relation to the research question and aims. Mixing in the current study involved analysing the complementary quantitative and qualitative data sets and then combining the findings from both into the study.

For the current study mixing was conducted by analysing the qualitative data and then using the conclusions from that data to support the quantitative data. The two sets of data were complementary and could be combined to provide information on the complex construction of patients’ concepts of their satisfaction.   

Theorising

Theorising requires consideration of whether mixed method research is suitable for the chosen research paradigm – the pragmatic paradigm in this instance. The MMR methodology was deemed suitable because it could generate a large amount of data from different perspectives which was needed to represent and understand how the patient constructed satisfaction with their care.

MMR methodology was deemed to be appropriate for this kind of research and is justified with respect to the ten criteria suggested by the Health Foundation ‘when planning how to measure patients’ experience’ including satisfaction (Health Foundation, 2013, p. 28). The current research meets the Health Foundation criteria as follows:

• The term patient satisfaction was defined in ways that can be assessed by both quantitative and qualitative data.
• The patient satisfaction being measured allowed for a good understanding of how patients construct their experience and it was possible to use data on their responses in this respect to answer the research question.
• It was considered useful to combine both qualitative and quantitative data in order to maximise the data collected.
• The MMR method was suitable as it enabled samples to be selected rather than all the general population, which was impractical in a study of this size. The MMR approach allowed the researcher to draw from the samples the maximum amount of data possible.
• The MMR method allowed for a significant amount of data to be collected within a tight time frame. This helped to address the particular challenge that I faced of a limited period permitted for field work
• The MMR methods used were tested before they were implemented and they are all well established and proven data collection instruments as used in previous patient satisfaction studies (Hyrkas et al. 2001;Merkouris et al 2004).
• The data collected by MMR methods could be merged in such a way as to allow the information to be analysed robustly and reliably.
• The MMR methodology was chosen because it could present information in a suitable way for the intended audience.
• The MMR methodology allowed people to express their opinions freely and to feel comfortable providing information to the researcher.
• As there is no single measurement of patient satisfaction, there needs to be several ways of measuring it. Therefore, by providing more than one perspective, the MMR can provide the data needed to address the research question (Health Foundation, 2013, p. 27).

3.3.3   Summary of the MMR approach taken

The primary research question of the current study focuses on the factors that contribute to or hinder patient satisfaction with care in an oncology ward setting in a Saudi Regional Cancer Centre in Riyadh. The use of sequential mixed methods design was considered the most appropriate for reaching the aims of the study and answering the research questions.

Accordingly, in the current study, an explanatory approach was adopted, but with complementarity in mind, whereby the patient satisfaction survey was conducted first and, after analysis of the quantitative data, one-to-one interviews (both by phone and face-to-face) were carried out with oncology patients to provide an assessment of patient satisfaction and assess the relationship between the various factors identified and connected to patient satisfaction. As this method is applicable in both the social and health disciplines, the methods was considered as most appropriate for assessing the relationships between variables that influence patient satisfaction for patients in oncology wards in KSA (Creswell and Plano-Clark 2011).  Integration takes place at the intersection of quantitative phase1 and qualitative phase 2. The qualitative Phase 2 interviews explore further the quantitative Phase1 results in order to provide deep understanding of patient satisfaction. Figure 3.1 shows the visual model of the explanatory mixed method design used in the current study.

In summary, the sequential explanatory mixed methods approach provided an explanation of the findings that are later identified in the quantitative phase, by a set of participants using semi- structured interview questions. The data allowed for a richer understanding of the relationship between patient satisfaction, patient experience, quality of care, and health care delivery for oncology patients in SRCC, KSA. The findings of the current study are expected to provide a significant contribution to the literature of patient satisfaction and patient experience to improve healthcare service delivery in KSA. 

Figure 3.1 The visual model of explanatory mixed methods design used as adapted from Creswell (2009):

 3.4    Phase 1: Quantitative method

3.4.1   Quantitative design: Cross-sectional survey 

The first phase of the study comprised a quantitative, cross-sectional survey. According to Hennekens and Buring (1987), a cross-sectional survey examines the relationship between disease, or other health state, and other variables of interest that exist in a defined population at a single point in time. Cross-sectional studies are descriptive in nature. For example, they are used to describe certain characteristics of a population, such as prevalence of illness, or they may be used to support inferences of causes and effects (Rothman & Greenland 1998).

Phase 1 of the  the current study involved a cross-sectional survey of an adult oncology inpatient group. It was administered to determine their levels of satisfaction with the care provided to them at the time of their participation. A validated EORTC IN-PATSAT 32 Questionnaire (the inpatient satisfaction quantitative questionnaire, as developed by Bredart et al. (2005), was therefore distributed to adult oncology inpatients in a Saudi Regional Cancer Centre in Riyadh. This questionnaire was deemed a reliable data collection instrument as it has a track record of being used in similar research (Arrora et al. 2010; Obtel et al 2012) and it has been designed to provide information on patients in an oncology setting which was the context for the current study. Section 3.4.5 describes the questionnaire in details

The setting of the current study was adult male and female oncology wards in one of the main KSA regional referral cancer centres in Riyadh (SRCC). The bed capacity of the oncology wards is a total of 42 beds. This setting was appropriate, as the centres admitted adult male and female patients with varying types of cancer. Geographically, this area included a diverse population from which potential participants of various ages, and socio-demographic and cultural backgrounds could be sampled. This sampling was done to ensure that the data collected was not only representative of the inclusion and exclusion criteria detailed below.

3.4.2   Sampling strategy

3.4.2.1      Population

The population of interest for the current study was all adult male and female inpatients admitted to the SRCC in Riyadh.  

3.4.2.2      Inclusion criteria

All participants in the research were required to meet the following criteria:

1. Had a confirmed diagnosis of cancer
2. Was aged 18 years or older
3. Had been hospitalised for at least three days (to maximise number of patients)
4. Was mentally fit to answer the questionnaire
5. Was aware of their medical condition

3.4.2.3      Exclusion criteria

Likewise, those who met the following criteria were excluded from the research.

1. Was unaware of their diagnosis
2. Was aged less than 18 years old
3. Had been hospitalised for less than three days
4. Was unaware of their medical condition
5. Did not wish to participate

3.4.3   Recruitment procedures

Following ethical approval from the University of Stirling, School of Health Sciences’ ethics committee, and from the Saudi Regional Cancer Centre (SRCC) ethics committee, I initiated contact with the clinical site in Riyadh. Senior managers, including the oncology nurse managers, head nurses in adult oncology wards, and the medical director were contacted to provide them with an explanation about the study’s aims and methodologies, and to enlist their assistance.

Recruitment and consent took place on the ward by direct contact with oncology ward staff, this personal approach was considered best, to secure cooperation and the help of the staff. One nurse educator in particular was responsible for distributing the questionnaires and surveys on the researcher’s behalf. Patients were given an information sheet and an invitation to participate (see Appendix 7 for the patient information sheet). They were given time to consider whether they wished to participate and to discuss this with their relatives. Those interested in participating were informed of opportunities to be selected for a follow-up interview for the qualitative phase of the current study

I communicated the criteria for inclusion and exclusion of potential participants to the nurse educator leading to her being aware of those criteria.  Consequently, she was able to determine those eligible to participate and distributed the questionnaire to those who met the criteria.

An invitation letter, along with an information sheet, was distributed to eligible patients, who had a confirmed diagnosis and those who wished to participate stated their intention to the nurse educator depending on who was present in the ward. Patients took one to two days to state their intention to participate. Patients who agreed to answer the questionnaire were asked by the nurse educator to sign the consent form (see Appendix 8 for the patient consent form). Patient information was entered into a recruitment log to maintain the transparency of the research process. The recruitment log included a non-identifiable number for all participants and the following: age, gender, date of admission and the date of data collection were coded. The log facilitated the anonymity and confidentiality of the received data, and also managed the time scale for the recruitment process (see Appendix 9 for the recruitment log). The recruitment continued until a target of 100 patients who consented to participate was attained.

When the questionnaires were issued I was passed the details of those willing to be approached to be interviewed. The questionnaire itself informed the participants the procedures they needed to undertake, if they were interested in participating in the study. A contact number was provided and the potential participant could, or someone acting on their behalf could contact me using a number on the questionnaire. This allowed the participant to arrange a second interview for the qualitative phase of the study.

Since I am a native of KSA, I was very sensitive to the cultural issues in the collection of data, particularly patients’ cultural expectations. Privacy and respect for their opinions was considered essential and this was deemed necessary to ensure the cooperation of the sample population. Therefore I assured the potential participants know that their privacy was respected and that all of their responses would be treated confidentially. In order to ensure that patients understood the research process and that their participation was kept confidential it was essential to explain to each of the participating patients the purpose of the study. This included highlighting to patients how their input and opinions can contribute to the study. Furthermore, patients were informed that all information regarding their illness, diagnosis, and other personal information will not be included in the current study and the patients’ participation will be kept confidential.   

During the initial data collection phase, there were certain limitations that became apparent. The relatively small sample raised issues over acquiring adequate data to analyse. Also, generalising the conclusion drawn from the data formed another limitation to develop a general theory of patient satisfaction. That is, the question of how (and to what extent) the findings from this location were representative of the general levels of satisfaction of oncology patients in the KSA receiving such care. There was also the issue that this was the first study of its kind. This meant that there were no previous examples to base the research upon and no way to learn from others’ experiences and indeed the limitations of such studies. A further limitation was caused by the restricted time available for conducting the research.

However, the findings are generalizable in the sense that the Saudi system is becoming more westernised and this means that the findings are more generalizable to oncology patients internationally. Research conducted elsewhere was a useful resource that helped to guide me the collection and analysis of data.

3.4.4   Sampling methods and response rate

A convenience sample (non-probability sampling) (Teddlie and Yu 2007) was used to select patients for the first, quantitative phase of the study. This sampling technique meant that only available people could be surveyed. However, the number of participants would depend on the study setting, including the bed occupancy of the oncology ward settings, research timing, and resources. A limitation of one month (from the end of November 2012 till early January 2013) was placed on data collection for the first phase of the current study. Therefore, convenience sampling was chosen to fit the aims of the current study.

A total of 122 questionnaires were distributed to adult oncology patients in the SRCC in Riyadh, of which 100 completed questionnaires were received. The response rate was high at 82%, even though the recruitment period was time-limited due to the need to adhere to the timeframe, which had been set by my sponsors (Saudi Cultural Bureau office in London), at three months to enable completion within a reasonable period.

3.4.5   Quantitative data collection

3.4.5.1 Instrumentation

The European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Group has developed and cross-culturally validated the EORTC IN-PAT-SAT32 questionnaire to assess patients’ perceptions of the quality of hospital-based cancer care (Bredart et al. 2005, Bredart et al. 2007; Arraras 2009). The development of the IN-PATSAT32 was based on existing patient satisfaction questionnaires, as well as interviews with oncology specialists and cancer patients (Bredart et al. 1998). The psychometric properties of this questionnaire have been tested and have been used in different countries (Bredart et al. 1999; Bredart et al. 2003; Arrora et al. 2010; Pishkuhi 2014) and translated into different languages using the EORCT translation guidelines (Cull et al. 2002).

The EORTC IN-PATSAT32 was constructed as comprising eleven multi-item and 3 single-item scales. These include the doctors’ technical skills (items 1–3), interpersonal skills (items 4–6), information provision (items 7–9), availability (items 10, 11) scales; the nurses’ technical skills (items 12–14), interpersonal skills (item 15–17), information provision (items18–20), availability (items 21, 22) scales; the other hospital staff’s interpersonal skills and information provision scale (items 24–26); the exchange of information single-item scale (item 23); the waiting time scale (items27, 28); the hospital access scale (items 29, 30); the comfort single-item scale (item 31); and the general satisfaction single-item scale (item 32) (See Appendix 10 for the IN-PAT SAT32 Questionnaire).

Items are all rated on a five level Likert scale with the category labels ‘poor’, ‘fair’, ‘good’, ‘very good’ and ‘excellent’. This response scale has been proved to have methodological advantages over other types of response scales (Ware and Hays 1988). Additionally, the socio-demographic data were collected for each patient including age, gender, marital status, educational level and place of residency. The choice of this survey instrument was justified because it is a well-validated measure of oncology patient satisfaction in the Western context and still applicable to Saudi Arabia’s healthcare system as this instrument has been used in another dominate Arab country; Morocco (Obtel et al. 2011).

3.4.5.2   Questionnaire distribution

For the first phase of the current study, data was collected through use of the abovementioned EORCT IN-PATSAT32 questionnaire. It took approximately fifteen minutes for each participant to complete it.

The distribution of the questionnaire was an important part in the data collection process. I was aware of the potential of bias in the distribution that could introduce bias into the data collected. Eligibility was based upon the fact that a person was being treated in an oncology setting and that they could understand the questions being administered. The nurse educator coordinating the administration of the questionnaire was careful not to coerce or pressurise potential participants. This was done by making clear that participation was not mandatory and there was no effort to persuade or compel a person to take the questionnaire.

The questionnaires were expected to be completed by the patient by themselves but also with the help of their family or others, if required. This was possibly an issue for those who felt unwell or had poor literacy. The issue of literacy was a potential problem for many older and less educated patients. In practice, there were some participants who needed to receive assistance in order to complete the questionnaire. This may have introduced a level of bias, but as long as the patients gave their views freely to those filling in the questionnaire and they faithfully recorded them, then the possibility of bias was limited.

To further reduce the potential for researcher bias, there was no effort to restrict the questionnaire to any pre-selected group or type of individuals and this limited researcher bias in the selection of participants.

However, there is always some measure of unintentional bias in even the most objective research. The manner in which the data was collected could be unintentionally biased. According to Efron (2010) the sample obtained was through convenience sampling; that is the sample is composed of individuals that are available for the survey. Efron (2010) asserts that such forms of sampling are always biased as they include people whom the researcher chooses based on established criteria that they create on their own. . Often time, such a technique results in oversamples people who have strong opinions and under-sample individuals who do not care much about the topic of the survey. The use of this specific sampling method has caused a degree of self-selection bias. The self-selection bias makes determination of causation more difficult to comprehend. For this particular study, the decision to participate in the study may reflect some inherent bias within the characterization or traits of those participating. 

For instance, older patients, because of their cultural expectations may have felt compelled to participate in the study, even though it was made clear to them that participation was voluntary.

There was a concern over confidence in patients answering the questionnaires truthfully as nurses were collecting the questionnaires from them. From a scale of 1-10 with 1 being the lowest confidence and 10 being highest confidence of patient truthfulness, I rate my confidence as being 7. It is possible that patients had not answered the questionnaire truthfully in fear of being scrutinised by the nurse. Then there is the issue of a patient receiving help from family members and this could lead to potential distortions in the collection of data. There was always a possibility that a family member could not record a patients’ response to a questionnaire faithfully. This could introduce a measure of bias into the findings.

There is concern that many participants were not have adequate literacy skills to comprehend and answer the questions. There is also a possibility that family members also did not possess the needed literacy skills to comprehend and answer the questions. This may have led to distorted results as a clear and concise picture quantitatively is not obtained due to a bias that arises from non-comprehension of questionnaire.

The high scoring in the questionnaires could be related to the fact that the nurse educator collected the completed questionnaires. This has been shown in the literature to skew the responses of the patients. When nurses collect data the scoring is usually higher. This limitation in the distribution and collection of data is acknowledged.  The completed questionnaires were placed in a sealed envelope by the patients before being handed to the nurse educator. The restricted timeline for the research meant that I was unable to collect the completed questionnaires in any other way.

About eight of the questionnaires were incomplete and there was some missing data. This could also lead to a bias in the data collected. The responses to the questions even in the incomplete questionnaires were accepted and used in the study. There was no need to impute the values, delete a question or to reject a questionnaire from the study since the missing data was not sufficient to distort the findings. This was because the sample size was sufficiently large. The missing data did not affect the coherency of the data.

3.4.5.3      Cultural considerations 

It must be acknowledged that the use of a translated questionnaire has the potential to present difficulties. Strauss and Corbin (2008) suggest there are four criteria to consider when using a translated questionnaire: (1) fit, (2) understanding, (3) generality, and (4) control. As IN-PATSAT32 is considered to meet these requirements, the existing Arabic Moroccan version of this questionnaire, first used by Obtel et al. (2012) when assessing Moroccan cancer patient satisfaction, was used. As it had been piloted in Arabic, it was regarded as a validated tool (Serhier et al. 2011) and suitable for use in the current study. Slight adaptations in the Arabic were required due to differences between Moroccan and Saudi Arabia, and EORCT has translation guidelines for forward and backward translation (Cull et al. 2002). Any adaptations for language were undertaken cautiously with the assistance of an expert advisor, Dr. Obtel, who is an oncology doctor.

The questionnaire was reviewed by the Saudi ethics committee chair in the SRCC. Also, the questionnaire was tested to determine language suitability with Arabic speaking university students at the University of Stirling before data collection for the current research was conducted. This process helped to identify any cultural barriers and ensure the language used in the questionnaire was fully understandable to Saudi patients.

3.4.6. Quantitative data analysis

The IN-PATSAT32 data were scored according to the available validated scale module (Bredart et al.2005) (See appendix 11 for the Scoring module).   Scores for each of the fourteen subscales of the questionnaire were determined for each patient. All the scores for all items in a particular subscale are summed, and then divided by the number of items in that subscale.  The scale scores are then linearly transformed to a 0-100 scale with a high score reflecting a higher level of satisfaction.

The data collected from the questionnaire (INPAT-SAT32) was then entered into a statistical package (SPSS, version 19), for processing and statistical analysis. The statistical analysis resulted in descriptive statistics of the questionnaire items, which are described and presented in chapter four. Information presented includes the percentage of respondents, the means and the standard deviation.

The data from the original Likert scale is also presented, together with that data having been subjected to a linear regression. The original data from the Likert scale presented a range of scores and these are analysed. Linear regression involves identifying and determining the relationships between variables. In the data collected in the original Likert based questionnaire, there were questions related to patients’ satisfaction with their care. The linear regression allows statistical analysis of the relationships between the various variables (that is the individual responses to the Likert based questions). This then allows the researcher to describe the relationships between the variables in the responses to the Likert questionnaire. Such relationships thus help to achieve a description of the samples’ satisfaction with regard to individual issues that are encapsulated in the questions, and in doing so these allowed me to build up (and then evaluate) an overall picture of patient satisfaction among this sample.

3.5    Phase 2: Qualitative method

3.6.1   Qualitative design: Semi-structured interviews

Data was gathered through interviews with the participants selected from those who had answered the questionnaire used in Phase 1 and had agreed to be interviewed. It was also important to test the interview schedule in the initial interviews through a test interview conducted between the researcher and a university colleague (Ritchie and Lewis 2003). Interviews are deemed suitable to explore attitudes and beliefs (Gordon 1975), and they can be structured, unstructured (open), or semi-structured (Mason 2006; Walliman 2005).

Semi-structured interviews were used in the current study for the following reasons: (1) to elicit the participants’ perspectives on what areas were deemed deficient, satisfactory, or excellent regarding the care they had received, or to fill in the gaps that had been highlighted following analysis of the questionnaires; and (2) for complementarity. There are some researchers who argue that the credibility of research is often affected when it is based on semi-structured interviews (Creswell, 1998; Patton 2002), for example, because the meaning or wording of questions may be interpreted differently by the respondents. However, other researchers (Barribal and While 1994; Opie 2004) lend their support to the use of semi-structured interviews. Careful consideration was taken throughout the research process to keep both perspectives in mind. The questions were developed keeping in mind the comprehension level of participants can vary so very layman words were used and omitted any particular jargon. During the test phase of interview testing, the questions were securitized to ensure that a single interpretation is concluded by participants. This means that the participant was able to comprehend what the question is asking of them. This had ensured that the respondent provides an answer that is on target to the question. Semi-structured interview questions in a healthcare setting are not uncommon but for this particular study, there were many factors and concerns that influenced them. One of the major factors kept in mind was the varied literacy rate and comprehension levels of the respondents. Therefore, during the test phase of interviewing, all questions were examined and discussions that took place from the questions were closely monitored to ensure that participants were comprehending the questions asked of them.     

3.6.2   Participant recruitment

Participants who responded to the questionnaire during Phase 1 were invited to participate in follow-up interviews. Participation was invited at the conclusion of the quantitative questionnaire by asking patients to indicate if they were interested in a follow-up interview. I contacted those who agreed to interview by telephone to arrange an appointment and obtain verbal consent (see Appendix 8 for the interview consent form). Patient information and contact details were entered into the interview recruitment log to manage the research recruitment process (see Appendix 9 for the interview recruitment log).

3.6.3   Sampling methods

The sampling approach for Phase 2 was based on the results from Phase 1, but also relied on the agreement of the participants to be interviewed. Thus, selection of the sample for the interviews was largely based on convenience sampling. That is, the selection was based on those who were actually most readily accessible when conducting the study (Burns and Grove 2007). Such convenience sampling uses non-probability sampling techniques based upon accessibility and ease of access to participants (Marshal 1996).

Throughout the study, convenience sampling was used because of issues of access and time. These restraints meant that the researcher could only identify a sample based upon those who she could conveniently approach in the oncology ward and those who were willing to participate. The convenience sampling method was also used since participation was based on the patients who had already completed Phase1. That is, only those who had previous access to the questionnaire were included in the sampling.  

Of those who completed the quantitative questionnaire, 100 were invited to participate in follow-up, qualitative interviews. Of these, 38 expressed their interest, with 23 subsequently leaving contact details, and one person dropping out because of personal reasons, making a total of 22 participants for the interviews. This is a relatively small sample, but, representative as discussed later in chapter five. It was sufficient to gather rich data so that it became common in the later interviews to be presented with views and experiences similar to those that had already been reported.

3.6.4   The development of the interview schedule

The aim of Phase 2 of the mixed methods study was exploratory in nature, to help gain a deeper understanding of patient satisfaction in the KSA. The interview design was informed by several practical considerations, including a need to ensure each interview took no more than 30-45 minutes to avoid tiring the patients (Rhemtulla and Little 2012). An interview schedule was prepared to elicit the participants’ perceptions of patient satisfaction. The interview schedule included a brief discussion on an outline of issues, a list of topics and subtopics relevant to the research, and the primary research question (Green and Thorogood 2009); the questions were adapted and refined based on the results of Phase 1.

It is important to recognise that researchers should use interview schedules with caution, as they can challenge the exploratory aim of qualitative research (Arthur and Nazroo, 2003). Accordingly, the interview schedule was derived from the quantitative phase by identifying a number of key issues. The areas of interest that were coherent with the research question were selected based on the INPATSAT 32 results. It was anticipated that the broad areas of interest would be evaluated and explored in the interviews, for example, clinical effectiveness and accessibility to health care.

These broad areas were then broken down into more specific and manageable concepts in order to facilitate further exploration. For example, the doctors’ skills, nurses’ skills, information exchange, service organisation/accessibility, and general satisfaction were identified as the specific areas of interest that were essential to be covered during the interviews. This led to a semi-structured interview schedule built around the results from Phase 1, but the actual interview used open-ended questions to allow scope for the patients to present their own views and provide answers in their own words (Bryman 2004). The interview questions in the schedule were checked and approved by my supervisors, ensuring the questions were not leading questions focused towards generating responses that reflected my personal opinions.

Following approval, the English version of the interview schedule was then agreed by my supervisors and prepared for translation to Arabic. As mentioned previously, translation was an important step as there was a need to ensure that the questions and wording were consistent with cultural considerations. It was also important to test the interview schedule in the initial interviews (Ritchie and Lewis 2003). Therefore, in the first couple of interviews, it was possible to assess how well the interview schedule was working according to the types of data that I was generating and whether these data met the study aims. The prepared interview schedule can be found in Appendix 20. 

3.6.5   Qualitative data collection

A majority of the interviews conducted were through telephone rather than face-to-face. The use of telephonic interview came about from various reasons. Firstly, there was a need to adhere to a specific timeframe in completing field work for the current study. Also, many of the oncology patients who were discharged after the survey was completed gave rise to difficulties in transport as face-to-face interview meant travelling a great distance. It was also observed that a majority of the participants felt more comfortable with telephonic interviewed. The face-to-face interviewed conducted within the oncology ward provided a great deal of insight into the participants behaviours during the interview which clarified patient satisfaction to a great extent from observing non-verbal gestures and cues.

3.6.5.1      Telephone interviews

Telephone interviews were administered to oncology patients who could not be reached for face-to-face interviews due to distance, or because of the patient’s own preference for a telephone interview. It is noteworthy that problems with recruiting participants for face-to-face interviews (even for practice interviews) are common (Mann and Stewart, 2000). Telephone interviews have been previously used successfully for qualitative semi structured interviews (Bowman et al. 1994; Barriball et al. 1996). However, one advantage of telephone interviewing is that it extends access to participants (Mann and Stewart, 2000).

Telephone interviews are considered to be a credible and robust method, although the researcher is unable to see non-verbal and social cues such as body-language (Novick 2008). This lack of visual cues is considered a minimal loss in the context of the patients under study, as they were all familiar with the issues raised (Opdenakker 2006). Indeed, there are other social cues available in telephone interviews such as voice and intonation (Opdenakker 2006). In addition, the patients seemed more relaxed, reflective and able to freely discuss sensitive topics during telephone interviews (Sturges and Hanrahan 2004; Irvine et al. 2013). For example, participants were very comfortable in discussing their doctor’s attitude towards them and openly spoke of lack of compassion exerted by doctors to their patients. The telephone interviews, arranged over the phone, especially suited the cultural context, where privacy is valued.  A total of 20 telephone interviews were conducted.

3.6.5.2      Face-to-face interviews

Face-to-face interviews were conducted with two patients in the oncology ward setting of the SRCC in Riyadh. Use of face-to-face interviews provided a basis for determining changes in patients’ moods and tone and voice inflection with regard to their satisfaction with the dimensions of care offered by the oncology department (Pop et al.2002). The interview process is described in more detail in the following section.

3.6.6   Interview process

Although face-to-face interviews were desirable, in practice, for most patients, it was not possible to agree a mutually convenient time for interviewing in hospital prior to their discharge. This was because most of the patients had been already discharged from the hospital oncology ward and so had returned to their families. In such contexts, they were often not at liberty to speak because of cultural restrictions. Additionally, the majority of patients resided outside of Riyadh, making visiting them post-discharge difficult, not only in terms of distance but also because it was time-consuming and costly.

In a sequential mixed method study, it is important to maintain a short time interval between the first and second phase and this was managed by the use of telephone interviews. This increases the likelihood of aligning the quantitative questionnaire with the interview schedule (Harris and Brown, 2010). A short interval between the phases was therefore chosen in order to maximise patients’ recollections of the underlying reasons behind their responses in the quantitative questionnaire (Cronoholm and Hjalarsson 2011).

Follow-up hospital appointments for these patients were six to eight weeks post-discharge, and this meant they were interviewed between discharge from hospital and their next appointment. There was also a possibility that patients’ conditions might deteriorate over time, which could have made participation at a later date highly unlikely. Accordingly, under the circumstances, in order to extend access to discharged patients and maximise recruitment for the qualitative phase without compromising the quality of the information, telephone interviews were performed with these patients at a mutually convenient time.

Although it was originally planned to record interviews, this was not possible since the ethical committee of the SCCR in Riyadh insisted on a separate patient agreement if audio was to be used. Since interviews were not recorded, this placed substantial emphasis on effective note taking to accurately capture all participants’ responses. Good notes must preserve interview information by providing an accurate account of the verbal responses and dialogue. A potential disadvantage to note taking over tape recording or videotaping is the possible inability to capture all relevant details (Muswazi and Nhamo 2013).

Additionally the writing process can mean long gaps or pauses in the interview plus the interviewer may find it rather challenging to combine concurrent note taking with guiding the conversation (Beebe 2001). Similarly, Muswazi and Nhamo (2013) describe how note taking disrupts the effectiveness of communication between the interviewer and the respondent.  Conversely an advantage of note taking is that it can facilitate data analysis since the interviewer may already have already classified the information into appropriate response categories (Burnett et al.1998). To guard against potential problems I undertook practice interviews, with Arabic students at the University of Stirling and note taking before conducting real ones. The first interview was conducted on the 6^th of March 2013 and the last one on the 24^th April 2013.

Each interview started with introducing myself to the participant as a research student and healthcare professional not associated with their care. Before starting an interview, a brief review of the aims of the study was performed as a reminder to the participant. This served to further highlight to the patients the importance of their participation in order to generate valuable research data, hence help improve the quality of health care in the future. The fact that the study information would be made anonymous and kept strictly confidential was also emphasised at the outset. I tried to make the participant as comfortable as possible by consciously attempting to establish an informal atmosphere and a rapport with the participant. I also reminded the participants of the voluntary nature of taking part in the study and that they could withdraw at any time. I also encouraged them to ask for clarification if they did not fully understand any of the questions. I emphasised that they should not feel embarrassed to refuse to answer any question should they feel uneasy.

A number of areas of concern became evident during the interview process, which initially appeared to affect the openness of the participants’ responses. Anonymity was one of these, since participants were concerned that any negative perspective they voiced might filter back to the health care professionals caring for them, thus affecting any future care that they might receive in the hospital. All participants were therefore assured of anonymity many times. I also sometimes sensed nervousness and hesitation and a tendency towards formality in the way the participants responded to my questions. This was understandable given Saudi culture and the fact that Saudis tend to be reserved and respectful, granting considerable authority to health care workers and holding them in high regard. Moreover, in the KSA, strong family ties and the hierarchical structure within the family unit means women might feel inhibited about criticising people in authority. Indeed, some Saudi women must seek permission from a male guardian before openly communicating their needs and wishes to health care professionals (Walker 2009). It was therefore not surprising that some people initially felt uneasy about describing negative health care experiences or raising concerns and voicing dissatisfaction over their doctors. 

I became increasingly sensitive to these potential barriers, and soon learned how to adapt my interview techniques to encourage informality and transparency. In particular, this meant respecting the patients’ own cultural choices, ensuring an informal ethos, and treating them as individuals, in order to minimise stress. Thus, in order to encourage participants to continue talking and elaborate on particular issues of interest, I used verbal prompts such as, ‘tell me more about’, ‘please explain’, and ‘why do you think that?’ I also followed recommendations made by Fontana and Frey (1994) and ensured I was courteous, friendly and pleasant. As the interviews proceeded, participants appeared to become increasingly relaxed and tended to open up more.

During the beginning of some interviews, patients made many positive comments which might have been interpreted as their having considerable satisfaction with their hospital care. However, as the interviews progressed, participants started voicing concerns over their care, making several negative comments and pointing to areas where they thought improvement could be made. This honesty is consistent with an emotional shift as the interview-interviewee relationship evolves and a rapport develops (King and Horrocks 2010). Nevertheless, the extent to which the participants’ culture adversely affected the transparency of the answers they provided remains unknown. There was awareness that culture was a potential factor that needed to be addressed in the discussion. The context of the findings needs to be accounted for when discussing them. It was important to make clear that the participants were from the KSA and what they expressed was based on how its culture influenced their responses. Any findings derived from these responses are therefore in themselves a reflection of these cultural influences. By introducing the issue of culture as a variable in the discussion of the findings ensured that was at the least acknowledged.

Because of my training in communication as a nurse and my professional skills, this led to an awareness of these constraints and limitations and was important when analysing and interpreting the data.  I had an understanding of the difficulties and challenges involved for a patient and how this could have influenced their views. My experience as a nurse in KSA was also helpful as it had provided me with an insight into the cultural assumptions of my patients. My training in communication allowed me to interact with people and to an extent allowed me to overcome any cultural barriers. This and an awareness of the influence of culture allowed for a fuller and more complete discussion of the findings. To a certain extent it was a bit difficult to separate roles as a researcher and nurse particularly in terms of developing rapport that maintains the limit of a researcher. Rapport building as a nurse is more focused on building relationships with patients to ensure quality of care and comfort throughout the delivery of healthcare services. However, as a researcher it is essential to only divulge in communication building to the extent that it provides appropriate information to the researcher. Also, as a researcher it is essential to abstain from bias by favouring specific participants over another. As a researcher it was essential to refrain from emotional attachments, this is also true for a nurse but to an extent. Therefore, a middle ground was struck which ensure that participants that I valued their input without becoming too emotionally attached to them.  

3.6.7   Qualitative data preparation 

Generally, interviews create a large amount of data in audio or textual format (Pope et al. 2000). Whilst translating the transcribed interviews from Arabic to English, problems were encountered. Literal (word-for-word) translation can often be inappropriate and lose the actual meaning behind the original narrative (Rubin and Rubin, 1995). The bias inherent in transcript translation in qualitative research has been extensively discussed in previous publications (Brislin et al. 1973; Rubin and Rubin 1995; Temple 1997).

A noted primary methodological dilemma is to use literal translation, or ‘free’ translation, that changes the wording in order to improve the readability and understanding of direct participant quotes. Two risks of free translation are the potential loss of information about the participant, and the possibility of misinterpreting the meaning of their words (Rubin and Rubin 1995). In an attempt to reduce these risks, I used literal translations as far as possible, but with minor modifications to improve grammar and enhance understanding of their meaning in English. It should be noted the extracts drawn from patients’ interview narratives and presented in chapter 5 should not be regarded as verbatim translations. All extracts represented by translated notes taken during interviews were then imported to NVIVO 10 software, which is an electronic package for qualitative data designed to manage data and assist data organisation (Bazeley and Jackson 2013).  

3.6.8   Qualitative data analysis

In qualitative research, there are diverse approaches for analysing qualitative data. However, it is argued that qualitative data analysis should be aligned with the research aims and theoretical framework that underpins the research (Pope and Mays 1995). I chose thematic analysis which allowed the themes that were present in the data to merge both from the quantitative and qualitative was helpful in (Fereday and Muir-Cochrane 2006). Thematic analysis is defined as a search for themes that emerge as being important to the description of the phenomenon (Daly et al. 1997). Thematic analysis helps to describe and organise the content of interviews through coding and categorisation of data into themes and sub-themes (Creswell 1998). By taking a hybrid approach it is possible to facilitate both inductive and deductive development of coding, which means a combination of the data-driven inductive approach (Boyatzis 1998) and the deductive a priori code template, as described in the next section (Crabtree and Miller 1999). Accordingly, it fits the research questions by allowing the phenomenon of patient satisfaction to be fundamental to the deductive thematic analysis, whilst also allowing for themes to emerge from the data by inductive coding. Additionally, it is aligned with the mixed methods framework of the current study, as connecting theory and data by moving back and forth between theories and data (both quantitative and qualitative) is an essential part of creating a theoretical understanding (Morgan 2007).

3.6.8.1      Thematic analysis using coding

Six major stages are identified by Fereday and Muir-Cochrane (2006) in the use of a process thematic analysis: (1) development of the coding manual; (2) testing for coding reliability; (3) identifying the preliminary themes which have emerged from the data; (4) applying templates of codes and additional coding; (5) connecting the codes and identifying themes; and (6) corroborating the identified themes by the process of confirming the findings. The coding process was carried out based on these stages as described next.

Stage1: Developing the coding manual

A coding manual is important because it helps a researcher to clearly recognise the textual data from the transcribed interviews (Crabtree and Miller 1999). In addition, it enables the researcher to divide the textual data into segments, to label each identified segment, and to further assess the developed interview segments for evidence of reoccurring themes (Miles and Huberman 1994; Janesick 2003). 

I developed the coding manual based on the research questions and the results from Phase 1  then compared it to the qualitative data received in phase 2. For example, coding was categorised into three components. The codes were identified as those factors that were influential in determining a patient’s level of satisfaction with their care based upon the Donabedian (1980) quality of care model. The coding was based on the findings and the themes that emerged were somewhat different from the initial expectations. This is a common feature of research and it is an expected part of the research process. With regard to clinical effectiveness the analysis clarified the measure of clinical effectiveness for the purpose of the study.

The themes that emerged were (1) clinical effectiveness, (2) structure of care (accessibility to health care), and (3) outcomes of care (patient satisfaction). Within the domain of the three main codes, five sub-codes were identified: (1) doctor skills as a process of care, (2) nurse skills as process, (3) information exchange as process, (4) service organisation as structure of care, and (5) general patient satisfaction as an outcome of care.

However, it is argued that a credible code must capture the qualitative richness of the phenomena (Boyatiz 1998). Therefore, codes were identified by label, definition of what the theme concerns, and a description of when the themes occurred. Table 1 provides an example of the coding manual that was developed.

Table 1 - Example of a Priori Coding Developed from Templates of Codes Related to Patient Satisfaction

In applying a NVIVO computer-assisted method in qualitative data analysis, I coded the interview data based on initial key topics in the coding manual. NVIVO was used because it is easy to use and it is easy to import data from the MS-Word processing package (Morrison and Moir 1998; Richards 1999). Further use of NVIVO makes it possible to determine coding stripes from the margins of the document, an aspect that made it possible to determine which code had been used at which point.

However, computer-based data analysis and coding were implemented with full knowledge of the limitations of computer-assisted coding methods (Bourdon 2002). For example, there are concerns that use of computer-assisted methods may result in ‘guiding’ the researcher only in a particular direction. This disadvantage occurs due to the capacity of computer-assisted methods to create a sense of detachment from the actual data (Bazeley and Jackson 2013). Despite these limitations and critiques, computer-assisted methods promote accuracy and transparency in the data organisation processes.

Within the NVIVO software, the creation of codes is achieved through use of free nodes present in the navigation view window or by using the ‘create and analyse’ tab that is located in the ribbon of commands (Richards 2009).  For example, interview data related to clinical effectiveness generated 32 free nodes. If a new code was identified, I re-read the annotated extracts from interviews to ensure the new codes were appropriate to textual data.  Thus, I repeatedly reviewed and refined the coding manual before I generated the final coding framework.

Stage 2: Testing codes reliability

In order to achieve coding reliability, it is recommended that two or more researchers individually code an interview transcript, rather than relying on single researcher (Stewart et al. 2007). Therefore, I checked the coding framework with my supervisors and compared it with the interview data. Overall, agreement of coding was high, and the few minor issues were discussed and resolved before proceeding to the actual analysis.

 Stage 3: Summarising data and identifying initial themes

Summarising the data was achieved through repeatedly reading and re-reading the raw data and outlining key points in relation to the questions I asked during interviews. Table 2 demonstrates the process of summarising data.

Table 2 - Example of the Process of Summarising Data

Stage 4: Applying template of codes and additional coding

The template of codes was applied to facilitate the template analytic technique, as suggested by (Crabtree and Miller 1999). The coding manual was used to ensure systemic application and to identify the important sections in the text. All the codes from the coding manual were entered into the NVIVO software as free nodes. From this basic structure, the free nodes were organised and categorised according to four groups of data: (1) clinical effectiveness of doctors, (2) clinical effectiveness of nurses, (3) accessibility to health care, and (4) patient satisfaction as outcome of  care.  Table 3 demonstrates the method of coding three data sets by applying codes from the coding manual.

Table 3 - Deductive Coding Using Codes From The Coding Manual

Data analysis was not only guided by the coding manual, but also involved inductive coding from annotated extracts that identified new themes (Boyatzis 1998). For example, the concept of power dynamics of doctors that affect patient satisfaction emerged from data during the coding of the clinical effectiveness (doctor skills). An example of this is provided in Table 4.

Table 4 - Example of Inductive Coding from Data

Stage 5: Connecting the codes and identifying themes

The process of connecting codes is critical for discovering themes which identify a pattern in the data to describe the observations and then interpret features of the phenomena (Boyatzis 1998; Crabtree and Miller 1999). By connecting similar free nodes, themes were identified and similarities and differences between sets of data were found at this stage, which indicated areas of relevance to the research questions. Additionally, themes started to cluster within the differences identified between the views of participants regarding varying situations. For example, Table 5 shows the process of connecting the codes and identifying themes. 

Table 5 - The Process of Connecting the Codes and Identifying Themes

Stage 6: Corroborating and legitimating coded themes

In this final stage, it was important to confirm the findings by ensuring that the themes identified were representative of the original data (Crabtree and Miller 1999; Fereday and Muir-Cochrane 2006). Before the analysis moved to the interpretative stage, in which the themes were connected to the explanatory framework, the clustered themes that were identified from the previous stage were reviewed in order to check if they captured key aspects of the phenomena. Also, re-reading the text from original extracts helped to illuminate agreements and disagreements in views between segments of data. Further, the analysis tools in NVIVO, such as queries, text searches, and models, were used to develop the analytical process. Thus, the patterns of meaning, similarities, and differences could be explored and set out. Lastly, core themes that captured the phenomena of patient satisfaction in an oncology ward setting in the KSA were identified. The qualitative findings, including all identified core themes that related to the aspects of patient satisfaction as phenomena, are presented in chapter 5.   

3.7    Ethical considerations

3.7.1   Informed consent

It was essential that patients understood that participation in the study was voluntary, and that declining to participate did not mean that they would be disadvantaged in any way regarding their health care provision (Parahoo 2006). All willing patients were asked by oncology nurse educator to sign an informed consent form (see Appendix 8), and were provided with an explanation of the study,  participant information sheet (see Appendix 7), to enable them to make an informed choice about participation. Informed consent was also required from those patients willing to participate in the follow-up interview. I contacted participants by phone to apprise them of the possibility of the interview and to discuss with them participation issues.

3.7.2   Anonymity and confidentiality

The identity of participants was protected in the current study through complete data anonymity and confidentiality (Polit and Hungler 2001). Patients and their associated results were assigned study identification numbers, and participants’ answers, records, notes of interviews, and completed questionnaires were kept confidential in a locked cabinet during the study. Data was only shared with my PhD supervisors, and participants were not identifiable at any stage.

3.7.3   Data protection

To ensure adherence to legal requirements (Data Protection Act 1998) and ethical guidelines, I ensured data protection by keeping all data in a secured cabinet. Following completion of the current study, these will be stored in the Archive Section of the University of Stirling for ten years.

3.7.4   Cultural and linguistic barriers

Sand et al. (2007) note that it is important that the researcher be fully aware of the barriers that can affect their research, and, where possible, take preventative actions. One important potential barrier in this research was the form of Arabic used in the KSA. All correspondence, including the patient consent form, information sheet, and letter of approval from the University of Stirling, were translated into Arabic, reviewed by the authorities at the SRCC in Riyadh, and the translation was officially verified. This process of approval took some weeks to complete, and was longer than anticipated and had a bearing on the timings of the study.

An important cultural barrier to consider was that some women who are diagnosed with cancer in the KSA may be influenced by the involvement of a male guardian, as discussed previously. To obtain consent from such women (Rashad et al. 2004; Walker 2009) required having to fully explain the study to the male guardian, which could have adversely affected the woman’s decision to participate. The implications of these socio-cultural issues conflicted ethically with, and would be contrary to, the UK guidelines on good clinical research practice (GCRP) (Medical Research Council, 1998). A further problem in this regard was the inconvenience of having to ensure the availability of a suitable male guardian.

3.7.5   Potential distress

Mcllfatrick et al. (2006) point out that non-malfeasance, justice, and respect for human dignity are the guiding principles for interacting with the vulnerable, and that a researcher’s well-developed sense of reflectivity should go some way to mitigate problems arising. For this reason, consideration was given to the health status of patients throughout the study. For example, those who participated in Phase 1 of the study were first judged to be well enough by gatekeepers and checked by the nurse educator and ward staff before being asked to proceed with the interview in Phase 2. I was fortunate in being able to liaise with oncology staff and the attending physician, because this helped to inform my decisions regarding patient vulnerability. I was also vigilant to detect any sign of patient distress becoming apparent during the study participation. Had this happened, I would have immediately considered withdrawing patients to protect them from any exacerbation of their already poor health. In practice, during the conduct of the study, there were no instances of patient distress, and no evidence of any adverse impact of the research on any participant, hence there was no need to consider any withdrawal. 

3.7.6   Researcher skills and resources

Appropriate skills for implementing both quantitative and qualitative data collection and analysis were required in the current study, thus I attended a wide range of university courses during my PhD studies.  Further training in the use of SPSS software was also undertaken.  For the qualitative phase of the current study, I attended the University of Stirling NVIVO training program. Other skills which I developed during the current research years included managing electronic databases and, English being my second language, I tried to improve my academic writing. Workshops in these areas were attended during the course of the current study.

As a native Arab, I had good understanding of potential socio-cultural barriers which might arise during interviews. I was also able to communicate with the patients in their mother tongue as it was convenient and practical. These positive aspects of my skills helped me build a rapport with the patients, and also helped enhance their trust in me and their willingness to share their views. Potential negative aspects were related to my inexperience in conducting formal interviews, although certainly my experience as a nurse had helped develop skills for interviewing patients which would be transferable to the more formal research setting. To overcome any potential difficulties and to address my novice interviewer status, I practised my interview technique through workshops and through guidance and encouragement from my supervisors, from whom I learned techniques for ensuring there was consistent focus on relevant areas of enquiry. Developing an interview schedule also kept me focused.

As I was an oncology nurse prior to beginning my PhD, I was more comfortable in the oncology setting than someone who had no experience in such an environment. This allowed me to interact and communicate with patients very successfully when seeking a sample. It also helped to secure the informed consent of participants and furthermore it allowed me to create an informal and relaxed atmosphere for the interviews. I had previously worked in this setting and this familiarity was helpful in the distribution of questionnaires, which was useful for the collection of reliable data.

However, interacting with cancer patients as a former nurse is different from studying them. In the interviews, it could be argued that I was interacting with them as much in my familiar role as a nurse as I was acting as a detached researcher. This could have led to potential bias in the data collected, although in many respects the model of the fully objective and detached researcher is not sustainable in the context of informal and semi-structured qualitative interviews. Furthermore, despite having previously worked as a nurse and having considerable experience in dealing with cancer patients, it did not help to establish a rapport with a patient. I had to work hard to establish a rapport with the participants, despite my previous experience. In sum, I would argue that my previous experience as an oncology nurse did not harm the validity of the research but contributed to its reliability.

3.8      Chapter summary

This chapter has provided an overview of the research design employed in the current study and a theoretical rationale for its use. The major aim of the study was to assess factors influencing patient satisfaction in an oncology ward in the KSA. Specifically, the study first sought to identify what factors contribute to or hinder adult oncology inpatient satisfaction with care at the SRCC in Riyadh. Second, it explored why and how these certain factors influence adult oncology patient satisfaction.

The study employed a mixed methods approach in the form of an explanatory sequential design to complement the quantitative and qualitative nature of the research aims.

The research was divided into two phases: Phase 1 made use of a quantitative method, which involved conducting a cross-sectional survey of the satisfaction levels of adult oncology inpatients in the SRCC at Riyadh. Phase 2 focused on the qualitative aspects of the study, including the semi-structured interviews that were carried out with adult oncology inpatients who had answered the initial questionnaire.

The chapter also identified patient recruitment issues and data collection methods, including the sampling technique and data analysis used for each phase.  It also highlighted the ethical issues behind the current study.

The findings for both phases of this mixed methods study are presented in the following two chapters.

Chapter 4 - Quantitative Results

4.0       Data Presentation and Interpretation of Results

This chapter presents the findings of data collected using a structured questionnaire to assess the satisfaction of cancer patients in an Oncology ward setting. The variables measured against patient satisfaction included: socio-demographic characteristics, clinical effectiveness of doctors and nurses (skills of doctors and nurses, availability and access to information by patients), and accessibility to health care (services and care organisation) by patients. 

The chapter begins with the descriptive statistics of patient characteristics followed by exploratory factor analysis (which is used to reduce the number of variables to those that explain the observed variance in the dependent variable). This was followed by multiple binary logistic regression analyses to examine the degree of association between the components and the socio-demographic variables on patients’ overall satisfaction. This chapter concludes with a summary of findings.

4.1                   Socio-Demographic Distributions of Respondents and Patient Satisfaction

4.1.1         Demographic Distribution of the Respondents

This section illustrates the distribution of respondents in regards to their gender, age, educational level, marital status, and residency location. The sample consisted of cancer patients from an Oncology ward setting in Riyadh (N=100). In order to simplify data analysis some variables were standardized.  Age variable was collapsed into two categories: younger < 45 and older patients > 45. Educational level variable was also classified into two categories: low education represents patients with primary and intermediate educational level. Higher level of education included patients with high school and university degree or more. Table 6 revealed the majority of respondents were female (58%) who fell within the younger age group (52%). Also, a large percentage of them were married (65%), with only 21% single. Most of the respondents had high levels of education (60%) and resided outside of Riyadh (56%).

 Table 6 - Distribution of Respondents’ Gender, Age, Education, Marital Status & Home (n=100)

4.1.2         Patient Satisfaction

In order to capture patients’ overall satisfaction, they were asked to rate the general level of healthcare received during their stay in the Oncology ward. Most patients reported they were generally satisfied (87%) with the healthcare services, while only 13% were less satisfied (See Table 7). To further analyse patients’ overall satisfaction, cross-tabulations using each socio-demographic characteristic were also performed.  In Table 8, the results showed respondents who were female (50%), married (58%), highly educated (52%), and resided outside of Riyadh (48%) were more satisfied than respondents who were male (37%), single (16%), lowly educated (35%), and lived in Riyadh (39%), respectively. Still, overall patient satisfaction only slightly differed between the older age group (44%) and younger age group (43%).

Table 7 - Distribution of Respondents Overall Satisfaction (n=100)

Table 8 - Cross-tabulation of Gender, Age, Marital Status, Education, Home, and Patient Satisfaction

4.2       Clinical Effectiveness of Doctors and Nurses

The following set of questions were used to capture doctors and nurses effectiveness. The questions under each of these headings were grouped into the following four categories:

Table 9 - Differential Measurement of the Effectiveness of Doctors and Nurses

The respondents’ views on the clinical effectiveness of doctors and nurses are discussed in this section. Overall, these results indicate broad patient satisfaction with the technical and interpersonal skills, information provision, and availability of the doctors and nurses during their hospital stay in an Oncology ward in Riyadh.

4.2.1         Respondents’ View of Doctors Clinical Effectiveness

As shown in Table 10, respondents were most satisfied with the doctor’s medical follow-up (88%) and knowledge of illness (87%) in terms of their technical skills. Patient satisfaction ranged from 84 to 89% and 84 to 85% regarding the doctor’s interpersonal skills and information provision, respectively. Overall, respondents were least satisfied with the availability of doctors. Only 77% of them were pleased with the visitation time and 79% were happy with the frequency of doctor’s visits. 

4.2.2         Respondents’ View of Nurses Clinical Effectiveness

Almost all of the respondents were satisfied with the nurse’s physical examination (94%). However, other technical skills (attention to comfort and care handling) only ranged from 81 to 84%, respectively. The majority of patients were satisfied with the nurse’s human quality (89%), but fewer patients were satisfied with their other interpersonal skills (74-78%). In terms of information provision, more respondents expressed satisfaction with the nurse’s information about treatment (82%). Overall, respondents were least satisfied with the availability of nurses representing 75% of satisfaction. Only 73% of respondents were happy with buzzer promptness (See Table 10).

 Table 10 - Respondents’ View of Clinical Effectiveness and Service Organisation   (n=100 patients)

 4.3       Other Services and Care Organisation

Respondents were asked to rate other hospital services and care provided by the organization as a whole. The main categories of other services and care organization analysed are listed below.

Table 11 - Differential Measurement of Service and Care Organisation

4.3.1         Respondents’ View of Other Service and Care Organisation

As shown in Table 11 above, the respondents were more satisfied with discharge information provision (86%) and hospital cleanliness (85%). Respondents were less satisfied with the waiting time for medical test (68%), speed of treatment (68%), and department access (65%). Still, only 62% of them were satisfied with parking accessibility to the Oncology ward.

4.4       Factor Analysis of Observed Variables

An exploratory factor analysis was carried out in order to reduce the number of variables to useful factors and to identify the correlation among them. This section highlights the main results of factor analysis, which included descriptive statistics, reliability measurements, correlation matrix, total variance explained; communalities (i.e., proportion of variability of a variable that is explained by the factors); factor loadings (i.e., interpreted as Pearson correlation   of an original variable with a factor); and extraction (i.e. variable reduction using principal component analysis)

4.4.1         Descriptive Statistics of Observed Variables

The above percentage results were also evident when calculating the mean of the observed variables. The highest mean indicates the less satisfaction level.   In regard to doctors’ clinical effectiveness, respondents were more satisfied with their support (M=1.11, SD=.314) and least satisfied with their visitation time (M=1.23, SD=.423). In regard to nurses’ clinical effectiveness, respondents were more satisfied with their physical examination (M=1.06, SD=.239), but less satisfied with their buzzer promptness (M=1.27, SD=.446), and interest in personality (M=1.26, SD=.441). With respect to other services and organization, respondents were more satisfied with discharge information provision (M=1.14, SD=.349) and hospital cleanliness (M=1.15, SD=.359), but less satisfied with parking (M=1.38, SD=.488), department access (M=1.35, SD=.479), speed of treatment (M=1.32, SD=.469) and waiting time for medical test (M=1.32, SD=.469). (See Table 12).

Table 12 - Descriptive Statistics of Observed Variables

 4.4.2         Reliability Measurements

The Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy index should be greater than 0.5 in order to support the use of a factor analysis and ensure that it is satisfactory. Large values for KMO commonly indicate that a factor analysis of the variables is considered a reasonable step to be taken. On the other hand, Bartlett’s sphericity test was used to test the null hypothesis that the population correlation matrix is uncorrelated (Mertler and Vannatta, 2010). Once the observed significance level is 0.0000 it is considered to be small enough to reject the hypothesis. The KMO coefficient was .820, which is close to one and the associated Sig. value of the Bartlett’s test was significant, p <.001; therefore, the null hypothesis is rejected. The results obtained confirm the sample size is adequate for conducting a factor analysis as the relationship between the variables is strong. The variables have some degree of correlation between them making it a rational idea to proceed with a factor analysis. See appendix 12 for KMO test Table1.

4.4.3         Correlation Matrix

 A correlation matrix was utilized to further examine the strength, direction, and significance of the relationship between the variables. The strongest positive correlations were between nurse’s information about care and nurse’s information about medical test (r = .79, p <.001); and nurse’s information about treatment and nurse’s information about care (r =.69, p<.001), which were both statistically significant. The weakest positive correlations were between doctor’s information about illness and doctor’s medical follow-up (r =.02, p =.87); and nurse’s human quality and doctor’s information about medical test (r =.02, p =.83), which were not statistically significant. In contrast, the strongest negative correlations were between patients’ overall satisfaction and doctor’s support given (r = -5.29, p<.001) and patients’ overall satisfaction and nurse’s physical examination (r= -5.28, p<.001), which were statistically significant. The weakest negative correlations were between nurse’s human quality and doctor’s support given (r = -.02, p = .83) and patients’ overall satisfaction and speed of treatment (r = -1.81, p=.07), which were not statistically significant. 

4.4.4         Total Variance Explained 

The Total Variance Explained provided the eigenvalues of any contributing components and the percent of variance explained by the each component. A total of eight components were retained because they had eigenvalues which exceeded 1, as shown in appendix 13.  After rotation, Component 1 accounted for only 12.39% of the total variance explained by the original variables, while Component 8 only accounted for 6.41%.

4.4.5         Communalities

Communalities show how much of the variance in the variables has been accounted for by the extracted factors. High communalities indicate a more reliable factor analysis.  Communalities results shown in appendix 14 revealed nurse’s information about medical test explained 82.7% of variance, followed by other staff helpfulness (80.6%), nurse’s information about care (79.5%) and doctor’s information about illness (79.4%). Only three variables (doctor’s knowledge of illness, nurse’s buzzer promptness, and doctor’s willingness to listen) fell below the recommended .60.

4.4.6 Factor Loadings

Factor loadings (see appendix 15) illustrates how variables were loaded into components after rotation based on their coefficient size. An assessment of component loadings was necessary in order to label each component. The variable with the highest loading was hospital cleanliness (.825), followed by doctor’s information about illness (.818) and nurse’s information about care (.795).

4.4.7         Extraction

Principal component analysis was conducted utilizing a varimax rotation. The analysis retained the eight components. Table 13 provides the assigned names given to each component based on the highest factor loadings. The first component comprises items 12, 13,17,21,22 named Nurse Skills.  Second component, includes items 18-20 named Nurse Information provision. Third component contains items 2, 4, 9 named Doctor Skills. The fourth component includes items 23, 24 named Staff helpfulness. The fifth component comprises items 27, 28 named Promptness of and accessibility to health care. The sixth component includes items 10 and 31 named doctor support and hospital environment. The seventh component contains items 7, 11 named doctor information provision and availability. The last eighth component comprises items 25, 26 named staff information provision.

Table 13 - Component Loadings and Eigenvalue by Varimax rotation

 4.5 Binary Logistic Regression

Using the resulting factor scores from the factor analysis and the socio-demographic variables, four binary logistic regressions were performed to evaluate the degree of association in these determinants on patients’ overall satisfaction.  The findings are presented in the subsequent sections.

4.5.1         Doctor’s Clinical Effectiveness and Patients’ Overall Satisfaction 

For this analysis, the independent variables were Doctor Skills (FAC3_2), and Doctor Information Provision (FAC7_2) and dependent variable was overall satisfaction. Model fit statistic shown in appendix 16 Table 1 indicates a fairly good-fitting model -2 Log Likelihood = 58.427. The two components, Doctor Skills and Doctor Information Provision and Availability, accounted for nearly 32% of the explained variance in patients’ overall satisfaction.

The final model did not significantly differ from the empty model (i.e., model without variables). The Chi-square value was 11.309 and its associated Sig. value was not statistically significant, p = .13. Appendix 16 Table 2   presented the classification results, which indicated the model correctly classified 89.0% of cases.

The summary of model variables displayed in Table 14 revealed the odds ratios; however, the Wald statistics for one component (Doctor technical and interpersonal Skills) was not significant, p = .16.  Therefore, the null hypothesis was retained for this component.

 Table 14 - Regression Coefficients

 The logistic regression coefficients give the change in log odds of the outcome based on a one unit increase in the variable. For every one unit change in Doctor Information Provision and Availability, the log odds of overall satisfaction increases by 0.312, as seen in Table 14 above. This was the only component that significantly contributed to the model, p<.001.  

4.5.2         Nurse’s Clinical Effectiveness and Patients’ Overall Satisfaction 

For this analysis, the independent variables were Nurse Interpersonal and Technical Skills (FAC1_2) and Nurse Information Provision (FAC2_2), and the dependent variable was overall satisfaction. Model fit statistic shown in appendix 17 Table1 indicates a fairly good-fitting model -2 Log Likelihood = 54.396. The two components, Nurse Interpersonal and Technical Skills, and Nurse Information Provision, accounted for 38% of the explained variance in patients’ overall satisfaction.

The final model did not significantly differ from the empty model (i.e., model without variables). The Chi-square value was 6.940 and its associated Sig. value was not statistically significant, p = .44. As shown in appendix 17 Table2, the results of the classification table revealed the model correctly classified 90% of cases.  

The summary of model variables displayed in Table 15 revealed the odds ratios; however, the Wald statistics for one component (Nurse Information Provision) was not significant, p = .54.  Therefore, the null hypothesis was retained.

Table 15 - Regression Coefficients

 The logistic regression coefficients give the change in the log odds of the outcome based on a one unit increase in the variable. For every one unit change in Nurse Interpersonal and Technical Skills, the log odds of overall satisfaction increases by 0.277, as seen in Table 15 above. This was the only component that significantly contributed to the model, p<.001.

4.5.3         Service and Care Organisation and Patients’ Overall Satisfaction 

For this analysis, the independent variables were Promptness of and Accessibility to Healthcare (FAC5_2), Staff Information Provision (FAC6_2), Staff Helpfulness (FAC4_2), and Hospital Environment and Doctor Support (FAC8_2), and the dependent variable was overall satisfaction. Model fit statistics shown in appendix 18 Table 1 indicates a fairly good-fit, -2 Log Likelihood = 68.020. The four components, Promptness of and Accessibility to Healthcare, Staff Helpfulness, Hospital Environment and Doctor Support, and Staff Information Provision, accounted for about 16% of the explained variance in patients’ overall satisfaction.

The final model did not significantly differ from the empty model (i.e., model without variables). The Chi-square value was 6.307 and its associated Sig. value was not statistically significant, p = .61. As shown in appendix 18 Table 2, the model correctly classified 87% of cases.

The summary of model variables displayed in Table 16 provided the odds ratios; however, the Wald statistics for three components (Staff Helpfulness, Promptness of and Accessibility to Healthcare, and Staff Information Provision) were not significant (p>.05).  Therefore, the null hypothesis was retained for these components.

Table 16 - Regression Coefficients

 The logistic regression coefficients give the change in the log odds of the outcome based on a one unit increase in the variable. For every one unit change in Hospital Environment and Doctor Support, the log odds of overall satisfaction increases by 0.574 as seen in Table 16 above. This was the only component that significantly contributed to the model, p=.03.

4.5.4         Socio-demographic Characteristics and Patients’ Overall Satisfaction

For this analysis, the independent variables were gender, age, marital status, residence, and education, and the dependent variable was overall satisfaction. Model fit statistic shown in appendix 19 Table1 indicates a poor fitting model, -2 Log Likelihood = 72.798. The five socio-demographic variables accounted for approximately 8% of the explained variance in patients’ overall satisfaction.

The final model did not significantly differ from the empty model (i.e., model without variables). The Chi-square value was 5.762 and its associated p value was not statistically significant, p = .67. Appendix 19 Table 2 presented the classification results, which indicated the model correctly classified 87.0% of cases. 

The summary of model variables displayed in Table 17 revealed the odds ratios; however, the Wald statistics for the socio-demographic variables (gender, age, marital status, education and residency) were not significant (p>.05).  Therefore, the null hypothesis was retained.

Table 17 - Regression Coefficients

4.6       Summary and Interpretation of the Results

 The quality of the data was important in assuring the reliability and validity of the results. The quality of the data was established by selecting a representative sample of participants. The data was collected from participants who were all patients in oncology wards. The data collected was through the adapted EORTC 32 INPATSAT validated, Arabic pilot test and questionnaire. The sample size was evaluated using a KMO test and found to be of an adequate size. The data analysis was carried out in such a way that no data was lost or distorted

Generally, most respondents’ satisfaction level with the services received was very high (87%). These results support previous findings mentioned in the literature review that high scores are usually reported in patient satisfaction surveys. The study showed that females (50%), married (58%), highly educated (60%), and resided outside of Riyadh (56%) were more satisfied with the services received during their stay in the Oncology wards.

The exploratory factor analysis was conducted to determine what, if any, underlying structures existed for 32-items of the EORTC IN-PAT32 questionnaire, and to describe and summarize the relationship between this given set of variables. Principal component analysis identified eight factors and they are as  follows: Nurse Interpersonal and Technical Skills (5 items), Nurse Information Provision (3 items), Doctor Skills  (3 items), Staff Helpfulness (2 items ), Promptness of and Accessibility to Healthcare (3 items) , Hospital Environment and Doctor Support (2 items) ,  Doctor Information Provision and Availability (2 items), and Staff Information Provision (2 items).   These components enabled relationships between responses of patients with regard to their satisfaction to be analysed and allowed for the measurement of the patient’s level of satisfaction. The identified components may assist future research on patient satisfaction in a KSA oncology ward settings.

Binary logistic regression analyses were performed to determine which component loadings and socio-demographic characteristics were significant contributors to patients’ satisfaction. Regression analysis indicated that the factors that were important for overall patient satisfaction were: 1) Doctor Information Provision and Availability, 2) Nurse’s Interpersonal and Technical Skills, 3) Hospital Environment and Doctor Support However, none of the socio-demographic variables were important for overall patient satisfaction

Further exploration into why patients seemed generally satisfied with the care and services provided was necessary. In order to gain deeper insight and understanding, semi-structured interview questions were developed based on the resulting component loadings from the factor analysis. The integration at this intersection of phase 1 quantitative analysis and phase 2 qualitative semi structured interviews was designed to collect high quality data on patient satisfaction.

A discussion of the findings presented here, along with those from Phase 2 (chapter 5), is then provided in chapter 6, where the complementarity of the quantitative and qualitative data is shown. The process of integrating the findings on patient satisfaction in oncology ward settings which was collected from both phases is thoroughly detailed in chapter 6. The implications of the findings and considerations for practice and future research are also considered in chapter 6.

Chapter 5 - Qualitative Findings

5.1    Introduction

In this chapter, the findings from Phase 2 are presented. The organisation of this chapter compiled in order to produce information that will help in answering the research question of the current study; what factors contribute to or hinders patient satisfaction with care in oncology wards in the SRCC? The chapter is organised thematically based on themes that emerged during the interviewing process of the participants. The chapter begins with a summary of socio-demographic characteristics of the respondents which provides insights into the demographic trends of the respondents from which data on patient satisfaction is drawn. The remaining sections of the chapter (5.3.1-5.3.4) categorise the findings of the interview data using themes based on the results obtained from the interviews. These themes are considered as factors which impact patient satisfaction.

Each of the subsections under section 5.3 provide an in-depth understanding of interpersonal aspects of care and accessibility of health care as influential factors that formulate adult oncology patients’ perception of their satisfaction. The findings within these subsections aided in fulfilling the aims of the current study.   

To further achieve the aims of the current study, each key theme is presented separately, with relevant examples from the translated interview extracts. These interview extracts were selected based on the coding process and also to represent the wide range of participants’ views. Commentary is provided to link these findings with the literature, where appropriate, and also to highlight any similarities and differences between participants’ responses. The chapter concludes with a summary of the key findings from this second phase of the study. 

5.2    Socio-demographic patient characteristics

In Table 1, the socio-demographic details of the participants, outlining their age, gender, education level, marital status and place of residence are presented. It should be noted that there were a high number of young people participating in the study. This high proportion of younger people (<45 years) was due to the largely self-selecting aspect of this part of the research, since the choice of interviews was based on those who volunteered. This may have made the sample unrepresentative of the general target population, since the average median age of the diagnosis of cancer for a man was 58 years of age and 51 for women, in 2010 ( Saudi  Cancer Registry 2010). While the current study portrays an age for a man as 46-55 years old or 66-75 years old and for women a median age of 36-45 years olds. The current study’s sample is not reflective of cancer incidence/prevalence in KSA but is a mere reflection of the participants that had volunteered to take part in the study. 

Table 1 - Patient socio-demographic characteristics

Based on Table 1, of the 22 participants only two were male. Both of whom were married and resided in Riyadh. However, of the two male participants, one aged between 66- 75 years had only attained primary education while the other male participant aged 45- 55 years old attained intermediate education. The remaining 20 participants were females of varied age, marital status, and education level. The median age of females within the sample was 36-45 years old. Of the female participants 13 were married, 3 were single, 2 were widowed and one was divorced. A majority of the female participants resided outside of Riyadh (11) while the remaining (7) resided in Riyadh. All the female participants except one had attained some level of education. A majority of the participants (7) had attained a high school level education, while the remaining were dispersed with 3, primary, 3 intermediate, and 5 university level education amongst the participating females.  

5.3      Key themes emerging from the interview data

The four primary themes identified from interview data are shown in Table 2 and are discussed in extent in the sub-sections.  

Table 2 - Themes and Subthemes that Emerged from the Interview Data

5.3.1 The doctor-patient relationship

The analysis of participants’ descriptions of their interactions with their doctors provides insights into the aspects of the doctor-patient relationship that are especially meaningful to the patient and influence their understanding of their experiences and the satisfaction with the care they receive.

The doctor-patient relationship in KSA is somewhat different to the western model. The family often needs to be consulted concerning the doctor’s disclosure of information to a patient. Doctors are often required to inform a patient’s family of their treatment and health. This means that the doctor-patient relationship is more complex and that a doctor needs to consider the family in their relationship with their patient. Many patients in the KSA are comfortable with this, because of cultural considerations. However, this particular take on non-disclosure has a significant impact on patient satisfaction and restrains the KSA healthcare delivery from becoming patient-centred. This in turn may have a significant impact on the findings of the study. It is possible that since females are not participant in the delivery of their healthcare they will be less satisfied than compared to male patients. However, although male patients are involved in their healthcare and treatment options, they may not be as satisfied as ultimately the decision for treatment and discussion of patient health status is discussed by the patient’s family. The issue of  non-disclosure causes patient dissatisfaction due to their experience with having their health information disclosed to people other than themselves and treatment decisions making be left to individuals other than themselves.     

Four main factors were identified that represent aspects of interpersonal communication between doctors and their patients:

• Listening: listening to and addressing the patients’ questions and concerns
• Information provision: providing adequate information about the patients’ conditions and treatments
• Motivation: being encouraging and motivating to the patients
• Care and compassion: being caring and compassionate, with attention to the patients’ psychological as well as medical needs.

These aspects are important to the relationship between patient and doctor despite the requirements for non-disclosure. Based on the analysis of the findings, doctors functioning within the KSA healthcare delivery environment are unable to appropriately deliver these interpersonal communications due to the distraught non-disclosure policy that is family centred. There have been attempts by doctors to do so as evident from the analysis of the findings. Non-disclosure in the KSA setting is influenced by cultural norms, religious beliefs, and attitudes of the doctors. For example, female patients need to have a male guardian who makes the ultimate decisions regarding their healthcare, this will include deciding between treatment options. Therefore, patient information is disclosed to the male guardian of the patient which is ultimately against the philosophical and legal context of non-disclosure. However, this necessary for the doctor to do as it conforms to cultural beliefs of KSA.         

The following section presents the participants’ general perceptions of the doctor- patient relationship in the oncology ward at the SRCC in Riyadh. In the subsequent sections the four sub-themes are examined in detail. 

5.3.1.1  General perceptions of the doctor-patient relationship

The current study produced varied views among participants regarding the doctor-patient relationship experience. Many built their relationship with their patient in a way that was satisfying, although they were dissatisfied with some aspects. 

Fourteen of the twenty-two research participants in the study were positive about their experiences of the doctor-patient relationship. They expressed appreciation and gratitude for their doctors’ personal qualities and interpersonal skills, which had clearly contributed to satisfaction with their hospital stay, despite the non-disclosure requirements that were implemented on all patients including the current study’s sample of 22. Those reporting positive experiences described their doctors in terms such as comforting, trustworthy, helpful, kind, co-operative and patient. For example, two participants stated the following:-

They are so patient and obliging, and dealing with them is easy and comfort(able). (Participant 2)

However, eight participants were critical of some aspect of the doctor-patient relationship. They commented that, although the doctors’ medical expertise was of a very high standard, they were lacking in interpersonal skills, including communication skills, kindness, empathy, and compassion. These views may have been in part influenced by the non-disclosure requirements of their families. Families were consulted by the doctor in regards to the patient treatment options and updates. The eight respondents were not involved in the decision making of their treatment. Crucial care options and information was not disclosed appropriately to patients but was left to the families. This lack of non-disclosure causes patients to feel that doctors are not communicating with them properly when it comes to disclosing information that aids the patient in decision making in regards to their health. The following extracts from participants’ narratives illustrate this:

They told me about chemotherapy and sent me to the health educator to explain the cycles and side effects, which was good. But the doctors here didn’t give the whole treatment plan or future plan to clarify things for me more. (Participant 3)

Because many families restrict information disclosure this prohibits doctors from disclosing information to some patients, especially females. Doctors often need to consult patients’ families on providing information or what should be revealed. This can lead many patients to not being fully informed of their treatment. In fact, many patients are not aware of this family request and the restrictions that it places upon doctors’ level of communication with their patient, especially with regard to the disclosure of treatment plans. This may cause some patients, especially females, to believe that their doctors are poor communicators, while in fact they are only conforming to the families’ wishes.

Indeed, there was no indication that doctors were avoiding contact with these patients. However, in some cases the doctors’ communications with their patients were not satisfying experiences. Females and males are treated differently under the non-disclosure arrangements. However, several males, expressed their opinion that doctors have ‘poor communication’ and this suggests that some patients perceive their communications with doctors as being unsatisfactory.

5.3.1.2  Listening skills

Participants reported that they often had questions and concerns about their illness or treatment, which, if not answered, caused great anxiety and stress. It was important to them to have adequate opportunities to ask their doctor questions or discuss their concerns, and to feel comfortable in doing so. The fourteen participants who mostly expressed satisfaction with the doctor-patient relationship all indicated that their doctors were frequently available to them, encouraged them to ask questions, and provided all the information needed to address their concerns, as the following extracts demonstrate:

They made me comfortable enough to share my concerns with them and patiently listened to me. They answered each of my queries and cleared my doubts. (Participant 15)

They have been very kind and patient. They listen to my concerns and give complete attention to what I say … They answer all my questions no matter how foolish my questions might sound. (Participant 9)

These data show that the majority of the participants were experiencing high levels of personal attention from their doctors, providing evidence of optimum listening skills in the hospital, and indicating that the doctors are addressing the concerns and psychological needs of their patients. This was the case with both males and females and suggested that doctors displayed good communication skills despite the limitations imposed upon them by the non-disclosing cultural attitude. Communication involves issues like ‘listening’ which would not be greatly influenced by any non-disclosure requirements.

In contrast, eight participants reported negative experiences of communicating with their doctors, which they perceived as mainly owing to the doctors’ busy routines and limited time for patient conversations. These participants commented that the doctors seemed unwilling to listen to their questions and concerns, or to provide the information being sought. The following extracts demonstrate this, and also highlight the power dynamics implicit in these doctor-patient relationships:

I … didn’t have the courage to stop them or ask them more as they look busy and just talk quickly during rounds. (Participant 5)

This participant’s concerns and emphasis on his/her own lack of courage convey a state of being afraid to engage doctors in conversation, which may or may not be related to the doctors’ actual listening capacity. However, the subsequent observations made by other participants indicate that this listening capacity may be limited, in some cases:

My talk with them is usually very brief and one sided in which all I had to say was ‘yes’ or ‘no’; they tell and I listen. (Participant 6)

The doctors asked me general questions but were never interested in my specific concerns. (Participant 21)

These comments suggest a power dynamic that is downwards directed from doctor to patient, where the doctor is the one in control of the knowledge that the patients need in order to allay their anxiety. The fact that this anxiety is not adequately listened to, and the knowledge is not shared, highlights an unequal balance of power and control in the patient-doctor relationship here. In particular, the repeated reference to ‘fear’ and ‘courage’ demonstrate the distress some participants felt at not being adequately listened to.

These findings indicate that at least some of the oncology doctors treating the participants in the current study did not give the impression that the participants’ concerns are  not of interest. Previous research by Jagosh et al. (2011) argues that physician listening has three very important functions: (1) clinical data gathering, (2) healing and therapeutic value, and (3) building the doctor-patient relationship. While it is uncertain from my findings whether or not the doctors were actually listening to the concerns of their patients, what the study does show is that some felt that they were not being heard. As Ansmann et al. (2013) found, a busy hospital work environment and heavy workload may hinder physicians’ ability to adequately support patients and they may feel constrained in communicating with patients because of any non-disclosure arrangements.

5.3.1.3  Information provision

Most participants reported positive experiences of receiving comprehensive information from their doctors, and noted the calming and reassuring effects that these had on them. The following extracts illustrate this:

The doctors listened to my queries and clarified my doubts in detail. They took every step to inform me well at the start of treatment and also provided me with relevant information during the course of treatment. (Participant 16)

I even had some misconceptions about radiology but they clarified the concepts and now I’m not scared of my treatment. (Participant 11)

These statements would indicate that despite any non-disclosure arrangements in many cases doctors are, in fact, listening to patients and offering them information on their treatment. They are able to clarify a patient’s treatments in a general way and in doing so keep patients somewhat informed. These participants’ statements provide a contrast to some of the more negative perceptions of doctors’ listening skills described in the previous section. Of note is the frequent referral of participants to their lack of clarity regarding their illness and treatments. The responses here, however, certainly suggest some doctors’ efforts to alleviate patients’ anxiety regarding the course of their disease and treatment (even if the prognosis itself may not be positive) through adequate information provision.

It did appear that information provision was problematic for some participants; some reported having to wait too long to receive the information they needed. This was at least partly due to the doctors’ busy schedules, and partly due to the hospital protocol arising from policies of the KSA health service, which prevents the nursing staff from providing certain information to patients.  As one participant said:

I am waiting longer to get information about results from doctors, while nurses can’t give me this information until the doctors do their round. I sometimes can’t tolerate the nurses saying that they are unsure about my treatment, as they have to wait for the results and for the doctor to read the results and inform me about progress. This process makes me feel more worried and anxious about my stay. (Participant 5)

Even though some data showed a positive trend toward taking patient satisfaction into account, participant responses such as these indicate that organisational factors such as hospital policies or procedures can sometimes adversely affect the experience of patients and have a negative impact on patient well-being (Aljubran, 2010). The following comments highlight this:

It’s worrisome and irritating to wait so long. Especially for cancer patients, it’s even more irritating to wait. I don’t like it when hospital management forget about the psychological state of their patients. (Participant 13)

I had even requested my oncology team twice to come quickly for the referral visit. They didn’t pay any attention and I’m still here waiting for my psychologist session. I feel so dissatisfied and depressed. (Participant 10)

The stark contrast between these perceptions and those of the participants who were satisfied with the quality and timing of the information they had received conveys high variability in the level of information provision among different doctors at the hospital.  What is apparent from these extracts is that long waiting times to receive information can substantially increase patients’ stress levels. Addressing this issue is important since studies have shown that psychological distress has an impact on cancer mortality (Hamer et al, 2008). For example those individuals who expressed dissatisfaction with the doctors’ communication skills could be at risk of poorer health outcomes. This would support the view that non-disclosure could be interfering with a patient’s health.

5.3.1.4 Motivation

The data from the interviews support the evidence that the nature, as well as the level of communication between doctor and patient has a significant influence on patient satisfaction and how it is perceived (Mobiereek et al. 1996; Ezubair 2002). It is clear from participants’ statements that doctors potentially play an essential role in raising and maintaining patient morale, by being encouraging and positive about their recovery:

They advise me to keep myself hopeful. They tell me that I can get healthy again and I’ll be able to live a normal life. I’m so determined to get rid of my breast cancer and I’m thankful to my doctors that they have been helping me so much. (Participant 9)

They were supportive in the success of the treatment. They were encouraging and kind. They sounded like they truly wanted me to get well. (Participant 3)

The key elements here are the nurturing of hope, encouragement, and the perception of genuine well-wishing on the doctors’ part. The doctors’ positive attitudes and the nature of patients’ communication with them may reflect, at least in part, the culture of the KSA, in which physicians are traditionally held in high regard and as figures of authority (Mobeireek et al.1996; Younge et al. 1997; Aljubran 2010). However, in contrast to the negative dynamic of power and control, the findings suggest that there were few doctors who were perceived as listening inadequately to their patients’ needs were not viewed favourably by patients. The doctor’s ability to listen is described as deeply appreciated and seen as responsibly used, i.e. for the psychological improvement of the patient. Being in the position of authority means that compared to other members of the health care team, doctors have a greater impact, either positive or negative, on the health and wellbeing of patients. There were mixed views that appeared in the investigated which included that some of the participants expressed being motivated and encouraged by their doctors which is evident from the quotes below, attesting that communication and relationship with doctors is a significant factor in enhancing patients’ psychological well-being;

I myself didn’t want to stay as I felt depressed, but their motivating words helped me and I started being hopeful. Now, I can proudly say that if my doctors hadn’t stayed positive and supportive, I wouldn’t have been able to come out of my illness ever. (Participant 19)

They have inspired me with their attitude and kindness. They are encouraging, it becomes easier to hope for successful treatment … Their supportive words became my strength and here I’m ready to go home with a healthy body and healthy mind. (Participant 13)

However, the current study had also found contrasting views to those above, these especially surfaced when patients were questioned specifically about their relationships with their doctors.

When doctors are encouraging and motivating, this can be perceived as having a positive impact on the progression of the patient’s recovery. As previous research has indicated, doctors’ communication in an oncology setting can affect the level of patient satisfaction and may also influence the patient’s wellbeing and quality of life (Ong et al., 2000; Wildes et al., 2011).

The practice of non-disclosure could, especially for females, lead to them to build their experiences in a negative way and this in turn could impact upon their health outcomes. The implication of the non-disclosure as a cultural attitude could therefore mean that females are more likely to suffer a negative health outcome than males in KSA oncology settings.

Some participants reported that communication with their doctors had been negative, in the sense that their experiences with doctors were not constructed as encouraging or motivating. This is demonstrated by two participants, who explicitly stated how this had disheartened them and weakened their resolve to recover from their illness:

As medical attendants their behaviour has never been motivating or heartening. (Participant 10)

They have a very casual attitude which I don’t appreciate much. They don’t fill the patient with motivation and determination to fight against their illness. (Participant 6)

These positive and negative examples show the impact that the physician’s manner may have on the psychological state and even on the physical well-being of the patient. These examples also reflect on the connection between a healthy body and a positive mind, as ‘hope’ was a key word emerging in positive descriptions of doctors who were seen as motivating. Previous research argues that a patient’s attitude may be positively correlated with doctor behaviours that are perceived as encouraging and motivating, often resulting in positive medical outcomes such as improved adherence to treatment and self-care (Street et al. 2009). By being motivating and encouraging to the patient, doctors’ communication may have a significant impact on the patient’s state of mind, such as lowering anxiety, and thus, may indirectly influence the overall outcome of the illness episode (Ommen et al. 2010). While it has been argued that an awareness of psychological distress is an essential aspect of patient care, oncology doctors are often unwilling to note the distress in patients, and ask questions regarding patients’ psychological health (Cull et al. 1995; Fallowfield et al. 2001).

The interviews provide insights into the overall impact of a trusting and motivational relationship between the doctor and patient on patient satisfaction and well-being, and particularly on the patients’ abilities to cope with and fight their illness. Participants’ comments tend to support the findings of previous studies that have highlighted the association between a trusting doctor-patient relationship and patients coping with their illness, which may result in improved patient outcomes (Epstein and Street 2007; Arora 2008).

In the beginning of all this I was scared to death and every step of my treatment used to frighten me ... But when I talked about this with my doctors, they listened and gave such kind advice and motivation that finally I started to feel calm. (Participant 4)

The doctors were very friendly and took time to build up my confidence. This provided me with the strength to fight (the) suffering caused by the disease and treatment. I felt comfortable in their presence and that brought a lot of positive energy to me to receive the treatment with great hope and confidence. (Participant 16)

The interview data show a strong link between hope and trust, reiterating the notion of a positive power dynamic between doctors and patients, where the doctors are respected figures of authority who are seen as crucial to reassuring and encouraging the patient with whom they have built up a good relationship. Other research similarly indicates that having a trusting relationship with one’s doctor can have a positive impact on the patient’s mind, generating a more hopeful attitude towards the condition and thus aiding the overall mental state and self-care, which ultimately improves the patient’s quality of life (Clever et al. 2008). Trust could become an issue as a result of the non-disclosure by doctors of issues related to the patient’s treatment. However, there are multiple factors involved in patients’ construction of satisfaction, such as listening and if a doctor concentrates on these then any arrangements between the family and doctor about non-disclosure would not impact too negatively upon patients trust.

Exploring further the connection of trust with patients feeling motivated and encouraged by their doctors, it was found that where there was insufficient trust in the doctor’s genuine interest in the patient’s well-being, feelings of hope and encouragement suffered to the detriment of the patient’s emotional state. For example:

Doctors’ change in behaviour or attitude can make the patient feel ‘unwanted’. Depression and hopelessness take over his mind and his hopes to get healthy fade away. Fear, frustration and sadness fill his mind. (Participant 3)

These findings support evidence from other studies regarding the lack of a trusting doctor-patient relationship, which can negatively influence patients’ levels of satisfaction (Stewart 1995; Parker et al. 2003). It is evident from my findings that, if doctors fail to communicate in appropriate ways with patients, the lack of trust and subsequent lack of motivating and encouraging behaviour may adversely impact on the psychological wellbeing of the patient, and potentially on the clinical outcome.

My findings are similar to those of Fogarty et al. (1999) and Ommen et al. (2010), but additionally provide a deeper, more meaningful contribution to the hitherto poorly researched field of patient satisfaction from the perspective of the KSA context. It would also indicate that more disclosure of health information is important to enhance the doctor-patient relationship and this in turn – based on the evidence that good communications improve patients’ well-being (Aljubran, 2010) – would lead to better health outcomes for those being treated in an oncology setting. 

5.3.1.5  Care and compassion  

The analysis revealed that a further communication aspect that can have a significant influence on patient satisfaction is when doctors show compassion and care. The compassionate behaviour of physicians is defined by Carmel and Glick as ‘strong devotion to the welfare of the patient on two crucial dimensions of patient care: technical and socio-emotional’ (1996, p. 1253). Doctors perceived as caring and compassionate with patients may provide an element of emotional healing, which could be viewed as a determinant of patient satisfaction (Fogarty et al. 1999; Bertakis et al. 1999). 

Many of the participants frequently reported experiences associated with compassion and caring exhibited by their doctors, using terms such as tender, understanding, patient, concerned, and reassuring, and indicating a broader definition of care and compassion. For example:

Doctors have been so tender and (re)assuring. (Participant 13)

The doctors were concerned about me and wanted me recover soon. (Participant 15)

Many also directly alluded to the concepts of compassion, or lack of compassion, when discussing the care they had received from doctors. The absence or presence of compassion clearly had an impact on patients’ overall level of satisfaction with their care. These findings evoke the understanding that an important dimension of patient satisfaction is the ability of the doctor to relate to and engage with the patient as an individual or, as highlighted in the 2001 IOM definition of the patient centred approach, to be concerned with the ‘needs, and values [of the patient], and ensure that patient values guide all clinical decisions’ (IOM 2001, p. 40). 

The perceived lack of compassion may have been attributable to doctors’ avoiding close engagement with some patients due to the practice of disclosure of certain health information to families rather than patients. Another possible explanation is that expatriate doctors for whom Arabic is a second language experience difficulty verbally expressing care and compassion to Saudi patients. These expatriate doctors may feel in particular constrained about communicating with patients in the context of the requirements regarding the non-disclosure of information to patients.

The findings indicated that some participants had experienced compassion and care from their doctors according to these terms, which in turn helped them to feel more comfortable in discussing their concerns with the doctor; this also made them feel the doctor was truly interested in their recovery. The following extracts illustrate this:

The doctors were understanding about my need for a sitter^[1]  and sent me a social worker to facilitate that during my stay. (Participant 20)

The doctors were compassionate enough to give me a few minutes (out of) their busy routine and listen to my concerns. (Participant 10)

These extracts convey that compassion and care was shown towards these patients by showing that the doctors understood and responded well to their personal circumstances, paying attention to their concerns and preferences.

In contrast, other participants commented that the doctors showed inadequate compassion in their communication with them and appeared uninterested in their personal well-being. Thus, these patients felt discouraged from asking questions, and this constraint reportedly made it more difficult for them to cope with their illness:

They don’t have time to talk to patients and everything is so routine to them that they don’t have compassion towards the patient. They just ask routine questions and provide general reassurance. I am suffering so much of it without any psychological support from doctors. It is really difficult for me to cope.  (Participant 19)

The doctors are not compassionate at all. They just asked a few questions about our illness but never appeared concerned with our psychological state. (Participant 21)

Two main findings emerge in relation to compassion and the doctor-patient relationship. First, there is a link made between compassion and coping (psychologically), with the implication being that an absence of compassion impacts negatively on the ability to cope. Second, the appearance of a lack of concern on the doctors’ part is recurrent within the participants’ narrative. ‘Concern’ is here distinguished from basic communication, the implication being that it is more than just asking questions, rather it requires a ‘patient-centred’ attitude that achieves a balance between meeting the patient’s clinical and psychological needs.

Expatriate doctors for whom Arabic is a second language may be hindered in expressing care and compassion by the language barrier between themselves and Saudi patients. The language barrier may mean that they appear detached from their patients and not appear as empathic, especially as they may also lack cultural sensitivity.  The current study’s findings agree with previous research that indicates the positive impact of doctors’ compassion on decreasing the level of anxiety in cancer patients, which in turn increases the level of patient satisfaction and results in improved medical outcomes (Fogarty et al. 1999).

Patients’ satisfaction in an oncology setting was related to the important role that the doctor plays in all aspects of their recovery, and highlighted the need for excellent interpersonal skills in order for them to fulfil this role effectively:

To me, doctors aren’t diagnosticians only but also the ray of hope. Their behaviour, words and facial expressions are important to me, and the means by which I judge the chances of getting well. (Participant 3)

By interpersonal skills I mean the communication skills and compassion. They need to have more kindness and empathy. Here doctors are good — I don’t say they are bad — but in the situation of these skills and characteristics there is a lot lacking. (Participant 18)

A comment from one of the participants summed up the importance of the interpersonal aspects of the doctor-patient role, which appear at times to be disregarded by the medical profession, but which are often the standards by which doctors are judged by patients:

The patients classify doctors on an additional criterion that is ‘behaviour’. The doctor who’s good at his job but isn’t so supportive or caring is designated as a bad doctor, while the doctors are selected by hospitals on the basis of their abilities and experience. (Participant 3)

These findings suggest that it is not only doctors’ medical expertise that is valued but, also their interpersonal communication skills and the level of trust, compassion and ‘felt’ concern that they bring to their relationships with patients. It also suggests a disagreement between what patients value in a doctor and those attributes and values considered by doctors and important to the organisation. Non-disclosure, and language barriers may all interfere with doctor’s expression of care and may make them appear as remote figures, who show ‘detached concern’, rather than empathy. This may be a factor in patients constructing their experiences when interacting with doctors in a negative way.

5.3.2   The nurse-patient relationship

Findings in this theme can broadly be divided into two elements, which interplay to varying degrees, and show varying experiences of the nurse-patient relationship. The first of these is the sub-theme technical competence, relating to nurses’ professional skills at administering medication and other treatment. The second sub-theme is nurses’ perceived level of interpersonal skills, which are defined as encompassing a caring attitude, showing compassion, and being available to respond to patients’ needs. Beginning with an overview of participants’ overall impressions and general perception of the nurse-patient relationship, the following sections outline each of these key areas in turn, analysing their interplay.

5.3.2.1    General perceptions of the nurse-patient relationship

The majority of participants recognised the importance of the nurses’ roles and were appreciative of their help and attitudes. Those reporting positive experiences when describing their relationship with nurses used words such as ‘kindness’, ‘supportiveness’, ‘accuracy’, ‘responsiveness’, ‘trustworthiness’, and ‘understanding’, as the following extracts show:

They are always willing to help us. It’s so inspiring that despite their busy routine they like to wear a kind and reassuring smile on their faces. (Participant 13)

The nursing staff was very dedicated. They provided a great deal of help and support. They attended to each patient with a smile and performed their work diligently. They made my stay comfortable.   (Participant 16)

These comments convey the impact of the nurses’ positive interpersonal attitudes (i.e. being kind and reassuring), as well as their professional qualities and competencies (performing their work diligently), on patient satisfaction.

In contrast, a few participants reported that nurses did not have supportive attitudes, and were sometimes too busy for positive communication. The most noteworthy aspects of dissatisfaction related to issues such as inadequate attention to individual patients’ needs and a lack of psychological support:

Generally, nurses are good but need to recognise the psychological status of the patient by allowing more time to spend with cancer patients when asking questions. (Participant 5) 

The nursing staff is good but there’s a lot of need for further development. They are not able to adapt to patients of different mind-sets, having a generalised attitude which isn’t sufficient at all. And that’s the reason I’m not really satisfied. (Participant 7)

The findings also indicate that, in order to deliver improvements regarding the nurse-patient relationship, there is a need to address organisational constraints. These include the low number of trained nurses at the hospital, which places a strain on their capacity and/or capability. It seems that there is a need to increase the number of nurses and enhance their efficiency so that they can devote more time to effective communication with their patients, as illustrated by the responses of two participants:- 

They are good but they are very busy and there is a real staff shortage. (Participant 1)

The number of nurses is a drawback, as they are limited. Therefore, sometimes I don’t want to bother them to get assistance for the bathroom, so I asked them to teach me how to disconnect the IV plug, and then it was easier for me to help myself. But of course, when I need them they are around and respond well to my calls. (Participant 18)

The last excerpt highlights the awareness that, while nurses’ capacity may be limited, this is not owing to any technical incompetency or lack of care, but is rather an issue of resources. The positive opinions towards the end of the extract indicate that, despite constraints, nurses do make themselves available to help patients with urgent needs.  However, some of participants mentioned a lack of psychological support rather than technical assistance as being the key feature that defined their relationship with nurses:

Nurses need to be specifically trained to deal with cancer patients. They should be aware of our psychological state and their attitude should provide confidence to patients as we sometimes have many questions or are worried about the next appointment or discharge. They should welcome questions and comfort us with patience and kindness.  (Participant 21)

This extract gives the impression that the nurses did not fulfil their role appropriately and failed to offer psychological support, which is important for a patient-centred approach to nursing. Moreover this participant felt that nurses should focus more on communication and relationship building. Overall, it was apparent that a nurse not having sufficient time to interact and communicate with patients was a determinant of patient satisfaction with the nurse/patient relationship. These findings concur with those of Shattell (2004) and Rachiadia (2009), who indicate that patients want nurses who are approachable, available, empathic and willing to talk with them, as well as nurses who are not rushed because of their workload and responsibilities.

5.3.2.2    Nurses’ technical skills

Having confidence in professionals’ technical competence represents one of the most important underlying indicators of patient satisfaction or dissatisfaction with nursing care (Dowling 2008; Wagner and Bear 2009; Zhao et al. 2009). The findings indicate that patients generally have positive attitudes towards nurses’ technical skills. Most of the participants highlighted the proficiency of nurses’ professional and technical competence, also asserting that such competence helped to build trust between them and the nurses. A recurrent notion that was also seen to be important in the doctor-patient relationship, was “trust” built on patients’ perception of nurses’ expertise:

Nurses are with us all day round. Their technical expertise in preparing accurate drugs, administering them properly at the right pace and constantly watching for any alarming symptoms, are vital for any patient. I am happy that the nursing staff attending to me were all expert in their profession and I did not face any trouble during my stay.  (Participant 16)

Their time management and team work impressed me a lot. They were overburdened yet they managed to deliver the correct drug at the correct time to all the patients. They were well organised and very professional in their job. (Participant 17)

The nurses were very professional and have good experience. They took enough care to be accurate with indicated treatment. Whenever they had a doubt they consulted the doctor to be accurate. I am impressed with their competence.   (Participant 15)

These comments reveal a high level of satisfaction with the attendant nurses, which in turn had a positive influence on patients’ constructions of their interactions with nurses.

In contrast, some participants had less positive experiences, in particular voicing uncertainty or concerns over the technical expertise of some nurses. There was often an apparent lack of understanding regarding the nature of the chemotherapy treatment being administered and anxiety over the accuracy of its administration. Such concerns could stem from the fact that the ultimate objective of these patients was to cure their cancer and survive the illness, which depends directly upon the technical skills of the nurses supporting them. The following are examples of these experiences; that is, of problems arising from a deficit in nurses’ skills or knowledge:

In my first visit a nurse had almost given me the very strong tablets intended for my neighbouring patient. But fortunately she realised her mistake in time and I threw up the medicine. Since then I keep a keen eye on my medication. (Participant 6)

Medication administration seems the most important technical skill to me. Nurses should consider the medications they control for patients. They work so closely with patients that they are for the most part the ones who capture drug slips made either by the pharmacist or prescribing doctor. Drug handling is important as well. (Participant 6)

Some participants made several constructive suggestions regarding what could be done to improve the relationship between patient and nurse and implying that more could be done to make their experiences more satisfying in an oncology setting.  Examples of possible improvements in the patient-nurse include better time management, better explanation of medication administration and, in particular, enhanced skills at inserting intravenous lines. It was also emphasised that nurses should be better trained to ensure the optimal skills in intravenous therapy, as one participant states:

Hate anaesthesia, it makes me feel very uncomfortable. And it feels even worse if the nurses have to try 2 or 3 times to insert the medication. I wish that nurses could learn to do it and get well trained at it so they would be able to do it with one attempt. (Participant 13)

Researchers argue that patients often view optimum nursing care as a combination of practical skills and professional knowledge, which are agreed as fundamental to all nursing practice (Halldorsdottir and Hamrin 1997; Calman 2006; Duff 2013). From a nursing perspective, competence has been defined by ICN (2005, p. 6) as ‘the effective application of a combination of knowledge, skill and judgment demonstrated by an individual in daily practice or job performance’. Specifically, in terms of nursing definitions, competence reflects the following: knowledge, understanding, and judgment; a range of skills, including cognitive, technical, or psychomotor and interpersonal; and a range of interpersonal attributes and attitudes (ICN 2005). This definition describes a fundamental requirement which influences the quality of care of the participants. The findings of the current studythe current study suggest that there is a need to address nursing competencies, especially in relation to medication administration and the insertion of intravenous lines for chemotherapy.

5.3.2.3    Nurses’ interpersonal skills

Participants mentioned several aspect of nurses’ interpersonal skills as significant: 1) being caring, supportive and compassionate; 2) paying attention to the patients’ psychological as well as medical needs; 3) responding appropriately and taking time to listen and understand the patients’ needs; and 4) ensuring they are available whenever patients need them, even when overloaded with work. By embracing all of these, the nurse-patient relationship was seen to have the potential to evolve into a trusting relationship.

5.3.2.4 Care and compassion

Participants generally felt that nurses should be able to understand patients’ needs. Some vital interpersonal skills that were highlighted related to the level of nurses’ supportiveness, care and compassion. A connection was apparent between the levels of care and compassion shown by nurses and the motivation of patients to get better, which, in turn, related to patients’ level of satisfaction with their care:

They spent time talking with me. I found it so lovely and caring and sensitive to my needs, I really appreciate them and their way of dealing and sharing with patients. I see this as very important to cancer patients, to be surrounded by good nurses who are willing to accept and talk and dedicate their time to us.  (Participant 8)

They were caring towards me... Their kindness and sympathetic attitude were always encouraging and helped me to cope during my stay, thank God… They always asked me if I had any complaints or if I needed pain medication. Even if I rang them they were quick to respond and provide me with comfort and help during either their day or night shift. (Participant 20)

In contrast, other participants reported negative aspects of their interpersonal relationship with the nurses, including inadequate attention to the individual patient’s needs and a perceived lack of understanding and failure to supply support. There are several possible reasons for this, including the work load of the nurses. The non-disclosure issue may influence nurses’ attitudes to communicating with patients. They may interpret the non-disclosure requirements of some families as meaning that they must avoid their communications with all patients or they may seek to minimise communication to avoid patients, especially female patients from asking questions, which the nurses are prohibited from answering. This will mean that patients build their interactions with nurses as being unsatisfactory. 

Some participants also noted that nurses did not always have enough time to give patients adequate attention. This was complicated by the fact that some of the nurses were non-Saudi nationals, for whom Arabic was a second language:

Generally, the nurses are good but need to recognise the patient’s psychological state by allowing more time to spend with cancer patients when asking questions. They should also ask for a translator if the patient can’t understand some points in conversations, such as helping with room transfer from a shared to a single room. (Participant 5)

This again raises the issue of resources of time and cost for translation, specifically, the challenge of expatriate nurses, who potentially do not have adequate capacity to develop trust and good communication with patients. This may also be due to a lack of proper language training, specifically Arabic. Previous research indicates that, without a shared culture and language, it is difficult for expatriate nurses to deliver effective nursing care to Saudis (Al-Shahri 2002; Al-Dossary 2008). The language barrier may lead nurses to appear as detached and remote to the patients. This is contrary to the patients’ expectations of how a nurse should behave and act (Rchaidia et al. 2009). Such barriers will lead to patients construing their experiences with some nurses, as being unsatisfactory.

The finding discussed in this section have shown the importance of nurses being perceived as compassionate and caring by patients, features that have been highlighted in cross-cultural studies. For example, a review by Rchaidia et al. (2009), who investigated cancer patients’ perceptions of the ‘good nurse’, indicates that the personal characteristics of being caring, showing compassion and relating to the patient as a person are fundamental traits, which pertain to both western and eastern cultures. My findings would suggest (as in the case of the doctors) that cultural attitudes and the language barrier may interfere with nurses’ ability to express empathy and care that is expected of them by patients. If nurses are perceived as not acting compassionately and expressing care then they are not acting in ways that a patient can construe as appropriate or satisfying.

5.3.2.5    Availability: ‘Being present’

The findings demonstrate that several participants had a positive attitude towards nurses’ availability and their time management during care provision:

Their time management is commendable. They attended each patient with great competence. They performed their duties… dedicated enough time to each patient. (Participant 15)

However, other participants noted that nurses were sometimes too busy to give patients the attention they needed:

They just need more time to spend with patients as they have a staff shortage and the nurse couldn’t spend time with me when I asked or called in the afternoon... Then they do attend…  but they just need to be faster… one nurse who was caring for me had two beds in the room to look after so I always felt too shy to ask her for help with walking or the bathroom as I could see she was busy and couldn’t help me. (Participant 5)

The emphasis was on nurses being present and devoting the appropriate amount of attention predominantly to patients’ physical needs, but also to psychological needs, since the right attitude can make patients feel more comfortable. According to Rchaidia et al. (2009), this state of ‘being present’ both physically and mentally in terms of their openness to patients’ psychological needs, is an important indicator of a good nurse, based on the perceptions of cancer patients.

5.3.3     Contextual factors relevant to cancer in the KSA

 The third theme which is contextual factors seen as specific to the context of cancer in the KSA, also emerged as important to patients’ perceptions of treatment and the level of care being provided. The subthemes of the contextual factors that found are: the patient perception of cancer, culturally endorsed power dynamics regarding the doctor-patient relationship, the influence of religion, the role of family, and the effects of a multi-cultural hospital environment. The next section presents findings from the   analysis of interview data regarding these subthemes that emerged from the current study.     This facilitates identification of key factors relating to the KSA cancer context.

5.3.3.1    Patients’ perceptions of cancer

Patients within the KSA view certain illnesses, such as cancer, as being of greater medical priority than other forms of disease or illness. Therefore, oncology patients believe they are deserving of greater attention from medical staff and require better treatment conditions. The following quotes illustrate this:

Yes, oncology patients must have priority in appointments for labs or x-ray. (Participant 8)

Organisations should learn to treat cancer patients differently to other patients. They should understand that time is of utmost importance in our treatment. Any delay on their part could have a devastating impact. They could help us a lot by improving the pace of functioning. (Participant 1)

These extracts convey some participants’ perceptions that oncology patients should be given priority in accordance with their special requirements. The second extract, in particular, emphasises the urgency with which the need for treatment is perceived, with words such as ‘priority’, ‘delay’, and ‘pace’ in both extracts denoting the importance of timeliness.

Illness, particularly cancer, is perceived in various ways depending on national or regional cultural factors. In the context of the current study, participants’ perceptions that cancer should have priority status in terms of treatment may be drawn from the cultural beliefs of the KSA that cancer is likely to be an imminent death sentence. For example, one participant commented:

I never knew about cancer and its treatment. In my mind it was just one fatal disease and I knew nothing else about it. But when I came here and the tests confirmed that I had cancer, I started believing that I would be dead in few days. (Participant 12)

Similarly, cancer has been found to carry a social stigma worldwide (Goffman 1963; Albrecht et al. 1982; Chapple et al. 2004; Rosman 2004). However, Joffe (2002) has argued that fear of cancer has decreased markedly as medical knowledge and success rates have increased. Nevertheless, the my findings indicate that cancer within the KSA is perceived in ways that go beyond stigma alone; that is, as a fatal disease which can evoke a strong fear of death.

Another factor that has been found in other studies to impact on oncology patients’ satisfaction is the treatment environment (Gotlieb 2000; Ulrich et al. 2004; Rowlands and Noble 2008). Related evidence has emerged in the current study, where patients’ main concern was not being able to have privacy. The following participants emphasised the importance of having a single room, as being in a shared arrangement adversely affected them physically and psychologically:

I feel so shy when I have nausea in a shared room as I can’t tolerate the smells of food during lunch time. That’s why I am so irritated at sharing a room with someone. But if I am in a single room, I feel comfortable and free to request from the nurse that no food should be supplied to my room due to my severe nausea. (Participant 3)

Having a single room is important for me because I feel comfortable when I can sleep and rest with no noise, and can have a quiet place to rest and read the Quran. I prefer to be alone and not to socialise with people during my stay as staying with people increases my worries and fear as other patient have different treatment and stages, which is not always encouraging to me. (Participant 5)

For example, high-quality environments with high levels of support seem to be associated with higher levels of patient satisfaction, especially for the most severely compromised patients (Timko and Moos 1998a). The findings of the current study also demonstrate the importance of a treatment environment that is sensitive to oncology patients’ needs, particularly the need to be able to express the physical symptoms of their illness without fear of shame or embarrassment. Being unable to do so has a negative psychological effect and may even make patients feel uncared for and despondent over whether they will get better, as the extracts illustrate. A central desire was for a private space if they were very ill. These findings indicate that patient preferences are deemed to be an important element in providing patient-centred care, thus influencing the level of cancer patient satisfaction.

As these findings have shown, patients’ perceptions of cancer specifically in the KSA context, and their experience of the treatment environment both contribute to their perception of the treatment they should be receiving, and the quality of actual care they feel they are receiving. The following sections elaborate on the other key contextual factors affecting this perception.

5.3.3.2         The influence of doctor-patient power dynamics

As shown in section 2.5.2.4 in chapter 2 and section 5.3.1 of chapter 5, the doctor-patient relationship in the KSA context is typically mediated by the perception of doctors being powerful figures of authority whose word should be trusted, rather than encouraging dialogue or discussion between doctor and patient for purposes of shared decision-making.

Patients’ perceptions of doctors in the KSA, and the power imbalance that occurs, can be seen as closely related to the conventional role of physicians in KSA culture. Whether or not they are native to the KSA, doctors are considered to be highly respected figures of authority (Elzubier 2002). As one respondent commented:-

The relationship with doctors is important to every patient. We actually give them, after God, the authority over our body and illness, so having a good trusting relationship with my doctors keeps me calm and satisfied. (Participant 9)

Doctors are positioned as the ultimate human authority on health, who, by implication, have the necessary knowledge and skills to administer whatever treatment is best for the patient, and therefore should not be questioned. This view, in turn, lends itself to a top-down power relationship between some patients and their doctors, as the following extracts illustrate:

The doctors were not interested in patients’ mental condition. They took care of treatment and that’s it. We could not feel comfortable enough to express our concerns to them. This has adversely affected the whole situation by making us feel unmotivated. (Participant 19)

In the beginning, I had endless fears and doubts but I wasn’t able to talk about it with my doctors. I had once tried to tell them about it but they shooed me away and since then I never gathered enough courage to communicate openly with them. (Participant 7)

Both of these extracts imply a sense of being intimidated or ‘not comfortable’ with doctors. In particular, the fact that the second participant’s anxiety is not adequately listened to and the necessary knowledge is not shared highlights an unequal balance of power and control in the patient-doctor relationship. Participant seven’s emphasis on (lack of) ‘courage’ suggests a state of feeling intimidated by those who have the power to allay the fears and doubts associated with the illness. The participant’s feelings may stem from the fact that families wish to restrict information, a cultural attitude. This means that patients can feel anxious because they have little or no information on their treatment keeping them in the dark and questioning the treatment options chosen for them. The anxious feeling and the feeling of being shut out of making decisions of their own body leads to their dissatisfaction of the healthcare provided to them. Patients such as participant seven desire to overcome the family restrictions that are placed on them terms of their treatment and giving them the sole right to decide about their healthcare. 

In contrast, several patients mentioned feeling very well-informed by doctors, to the extent of feeling they knew whether their illness would be cured or not. Given the strong cultural context at work, this effect can be seen as part of the high regard in which doctors are held in the KSA. As one respondent stated:

The doctors in oncology were so respectful and helpful, they tell me everything about my condition and options for treatment such as surgery, chemo and radiation, also they were honest about prognosis and this was so important for me to know (whether my disease is) curable or not. (Participant 8)

This finding also reflects a cultural shift in doctors’ information provision to patients in the KSA as evident from the experience of the participants in the current study, indicating that they are increasingly providing patients with full details about their condition, such as the prognosis.

As discussed in chapter 2, studies conducted in the KSA and internationally (Al-Ahwal 1998; Tanaka et al. 1999; Al-Amri 2010) provide evidence that patients prefer to have full disclosure of information about their illnesses. In contrast, surveys of physicians in the KSA (Bedikian et al. 1985; Mobeireek et al. 1996) have revealed their preference for discussing patients’ condition and treatment with patients’ close relatives rather than with the patients themselves. More recently, however, there has been growing public awareness of medical issues, as well as ethical pressures, in the KSA that are reportedly driving a change in doctors’ attitudes and behaviour, with full disclosure of diagnosis to the patient rather than their relatives becoming more common (Sokol 2006; Mobeireek et al. 2008; Al-Amri 2010; Aljubran 2010). The current study’s findings support that doctors in the KSA today provide full disclosure of information to oncology patients which implies that it has become a norm, however, if the family has expressly stated that a patient is not to be informed of about their health or treatment doctors do not do so.   

Considering these cultural factors, it becomes evident that the perceived power imbalance between doctors and patients can affect patient satisfaction with care either positively or negatively, depending largely on the interpersonal dimension, that is, the capacity and the way in which doctors deliver the relevant information. Some of the participants indicated the ideal power balance they would like to have with doctors, including a preference for an open and trusting relationship in which they could feel comfortable discussing any of their concerns in a sensitive manner. The following extracts illustrate these expectations:

A patient should trust and be able to depend on his doctor. This relationship develops with understanding and interaction. Doctors shouldn’t be the medicine/treatment prescribers but also a counsellor. (Participant 21)

The personal skills of the doctors here need much improvement as they should consider the psychological state of the cancer patient. I want them to deal with me in a kind way and consider that their attitude will affect the patient, like if they didn’t listen or just try to be in hurry during visits. (Participant 7)

This apparent change of attitude where patients wish to build relationships of trust with their doctors and openly verbalise their concerns is surprising in a KSA context. This preference for patient empowerment and advocacy is arguably at variance with cultural norms in the KSA. These patients’ attitudes, and their emphasis on doctors’ ‘kindness’, represent a shift towards the need for a more western and patient-centred approach involving active patient participation in care.

5.3.3.4    The influence of religion

In the current study, a major point to consider was that the religion of Islam is the main aspect shaping the culture of the KSA. Many of the participants indicated that their faith affected their perceptions not only of their disease, but also of the care they received. These findings add to other studies conducted in KSA which have drawn the importance of faith in receiving healthcare, particularly the study conducted by Halligan (2006) who argues that Islam is a contributing influence on patient satisfaction. He highlights the way in which the influence of Islam can be felt in every aspect of patient care. All of the participants in Halligan’s study, who were expatriate nurses, recounted that everything people do is centred on religion, and it is the main way of life. Consequently, Halligan (2006) correlates patients’ attitudes towards their illness with their religion, which is identified as ‘central to the provision of caring’ (Halligan 2006 p1565). The current study adds to the discussion produced by Halligan (2006) as it brings to surface the impact of religion on patient’s assessment of healthcare delivery while Halligan (2006) focused on experiences of nurses.  

In the current study, participants indicated that their belief in God was more powerful than medicine. In addition, some of the participants stated that it is their faith and connection with God through prayer that helps to keep their spirits up, as one person stated:

  I believe that my disease has been gifted from God as a test to see how I will be patient and deal with this fact; therefore, I accept my destiny of cancer and I will be working hard to deal with recovery by praying first to God to help me and then also to help my doctors to cure my disease in the near future, Inshallah. (Participant 8)

These finding are in line with other research which conveys the positive influence of religion on coping with cancer; specifically, some have argued that cancer patients in Islamic countries have better coping mechanisms than those in other countries (Ezzat et al. 1995; Young et al. 1997; Silbermann and Hassan 2011). The current study uses patients directly as participants and adds to other research which used doctors or nurses to assess the impact on faith as a coping mechanism when dealing with cancer.

The emphasis on the spiritual dimension of coping in illness was also evident through the fact that SRCCs have visiting religious scholars, who are on hand to lend patients moral support and spiritual guidance through their situation, and some of the participants commented on this aspect of their care:

The weekly official visit of a religious scholar was very helpful and motivating for me and other patients. I felt so great during religious scholar visits and really need the hospital to consider his visits to be daily for patients, as this reassured me and helped me a lot in my spiritual condition during the treatment. When I felt lost I wished to see someone who could connect my heart with God so I could find some peace. (Participant 7)

Religious lectures on Islamic affairs are needed to bring positive changes for us as cancer patients. (Participant 12)

These extracts demonstrate the importance placed on spiritual health by these oncology patients, and highlights how a visit by a religious counsellor or a lecturer on religious themes can fulfil the spiritual needs of the patients. This fulfilment is also shown to improve their mood and confidence about their situation, as conveyed through language such as attaining ‘peace’ and ‘positive changes’.

However, other participants presented contrasting views by emphasising their belief that the doctors and nurses were the only ones who could help them:

I believe that they are the only ones who could clear my mind about my situation. (Participant 10)

This extract echoes the other dominant cultural context that is relevant here, that is, the conventional perception of physicians in the KSA, who are seen as highly respected figures of authority (Elzubier 2002).

5.3.3.5    The influence of family

The principal idea of family is fundamental to the provision of care within the KSA. This is further supported by Halligan (2006) and Younge et al. (1997), who argue that the importance of family has a direct impact on the perceived level of care by the patient. This is especially the case with the family’s ability to influence doctors’ disclosure of information to a patient. These researchers describe family involvement as pivotal to the experience of the care being delivered and as a significant factor affecting the emotional, social, and psychological well-being of the patient.

In the context of the current study, family members were viewed as the principal decision-makers who often dictate the care that patients receive, including the extent of the care to be given. For example, participants in the current study recounted both how families help to direct their treatment and also offer vital moral support:

Thank God my family are with me; this helps me bear the after effects of the treatment. (Participant 21)

However, while the patient’s family has significant influence on the care to be provided, patients still look to the medical staff, such as their doctor, for ultimate guidance and explanation of treatment prior to making any decisions. In the following extracts, participants underline the doctors’ involvement in the process of informing family members as well as the patient him/herself:

But my mother wasn’t able to understand and she was very afraid. The doctors calmed her down and assured her that they wouldn’t be doing anything wrong to me. (Participant 13)

They explained all about the treatment to my husband. (Participant 22)

These extracts underline the critical role of the family, in that they are physically present at key diagnostic stages; the implication here is that they are then expected to be involved in subsequent decision-making about treatment. This is in line with other findings that, in developed countries, patients often demand more resources, i.e. medical staff attention, to be available to their family (Given et al. 2001). However, these extracts also emphasise the continuing importance of medical staff not only for informing and reassuring the patient, but also for reassuring all members of the family. Thus, while the family can be a determining factor in terms of care, patients are also aware that professionally trained medical staff are essential in providing clarification and ultimately informing treatment decisions (Given et al. 2001; Ezubair 2002).

However, the influence of family, although fundamental is still bias towards females. As noted before, female patients in KSA need the presence of male guardians which can be their father, husband, or son depending on their marital status. The treatment decisions of female patients fall on the father or brother if she is unmarried, on the husband if married, or on the son if widowed or divorced with children. This contrasts to the role that women have when the patient is male. The treatment decision making, disclosure of information, and advise given by a doctor or nurse in the case of male patient is restricted to the male members of the family. In the case of a male patient, the wife is not the sole decision maker for her husband, the male family members of the patient are the ones who are handed the responsibility of decision making and being the main point of contact for information. This is due to the societal hierarchy framed from cultural beliefs within KSA which is male-centric and male dominated. 

5.3.3.6    The influence of the multi-cultural health care environment

The health care environment and its own cultural context play a vital role in patient satisfaction (Rafii et al., 2008). A major cultural factor in terms of the KSA hospital environment, and prevalent in the specific SRCC examined in the current study, is the presence of largely expatriate nursing and medical staff from all over the world (in particular South Africa, India and the Philippines) who are unlikely to speak Arabic (Luna 1998; Al-Dossary 2008). In particular, the expatriate nursing staff were found to affect patient satisfaction in that their difficulties with the Arabic language created some tension in communicating with patients. Many participants noted that they could only express their emotions and needs clearly in Arabic languages, which these nurses were not always able to understand fully. As several participants commented:

Their language is a bit of problem; it would be easier to communicate with them if they were capable of speaking Arabic.  (Participant 10)

Communication skills are the most important, for example, being able to talk freely and ask about treatment, but in my opinion the nurses need to understand more of the Arabic language to be able to deal with patients easily. (Participant 5)

Inadequate communication arising from language barriers can be seen as a determinant of these patients’ satisfaction level, frequently causing a loss of rapport with nurses. Accordingly, Arabic-speaking nurses were deemed more likely to provide the optimum psychological support and to be able to meet patients’ medical needs than non-Arabic speakers. Evidence of language barriers in communication between the patient and their nurses has been reported by a number of studies in the KSA owing to these nurses frequently being non-KSA nationals (Al-Shahri 2002; Attalah et al. 2013). As previously mentioned, there is, however, currently a drive towards employing greater numbers of Saudi Arabian nurses or Arabic national nurses as part of the Saudisation process (Al-Malki et al. 2011). 

Because of the multi-national mix of personnel, including many non-Saudi doctors, English was the default language being spoken among professionals in the presence of the patient, and this could create a feeling of anxiety in the patients. The following extract illustrates this:

For example, the doctor saw me and requested some tests or radiology; then I asked the nurse, but she said there was no instruction written by doctors, so I felt lost between doctors and nurses because doctors speak English with them in front of me, which is difficult for me to understand – is he requesting something or just talking? That’s why I felt worried and asked a lot if doctors were requesting tests or x-rays. (Participant 5) 

In this patient’s case, the language barrier negatively affected the way patient constructed their experiences. The use of English rather than Arabic by the medical staff led the patient to feel excluded from discussions about his/her own health, and created a sense of dissatisfaction with the care they were receiving. The issue of the language barrier here overlapped with the requirement of non-disclosure to the patient, thus compounding the potential problems with establishing a personal relationship between expatriate nurses and Saudi patients.

Personal relationships can only be established when communications are possible. The fact that a nurse and patient only have limited communications mean that a nurse can appear as not engaging with a patient or may appear as being inattentive. The ability of a nurse to establish a relationship is further impacted by the fact that they often have to ensure that they don’t disclose information to a patient at the request of the family which is considered a norm of non-disclosure in the KSA healthcare setting. This may make nurses unwilling to spend time and interact with a patient. The language barrier and non-disclosure means that often the nurse-patient relationship is not a satisfying one for both parties.

Language barriers must be addressed in order to ensure quality trans-cultural nursing, given the high proportion of expatriate, non-Arabic speakers in the KSA (Luna 1998; Al-Shahri 2002). It can be argued that the gap, identified here and in previous studies, between patient needs and the language barriers of expatriate nurses may adversely affect the degree of care provided, thus lowering patient satisfaction levels (Al-Shahri 2002; Ezubair 2002; Al-Dossary 2008).

This section has highlighted the importance of nurses and other medical staff in oncology wards tailoring their care to patients’ needs and providing a more patient-centred approach, as this can significantly affect patient satisfaction levels.

5.3.4   Organisational factors impacting patient care

This section presents the findings from the study that highlights the organisational factors influencing patients’ satisfaction or dissatisfaction. Based on the participants’ responses, three main factors were identified as important aspects of the service organisation which influenced their overall satisfaction levels: (1) accessibility to healthcare (i.e. having full access to the hospital and permission to use all the necessary facilities); (2) general service organisation and (3) waiting times (i.e. that they should be reasonable and that the staff should be supportive of patients while they were awaiting treatment).

Prior to a more detailed examination of each of these factors, patients’ perceptions of the general service organisation are detailed in the next section. This is followed by a presentation of the findings relating to each of the three key organisational factors.

5.3.4.1    Perceptions of general service organisation

Overall, there was a mix of views among the research participants regarding their experiences of the service organisation, with many indicating that, while they were generally happy, there was some dissatisfaction with the operational structure of the facility. 

The majority of participants who reported positive feedback on the general service organisation talked about both the medical services and overall service organisation:

The referral system is good here.  Labs and other testing services are very good and prompt. I don’t have any problem with them. (Participant 9)

My overall experience with the service organisation during my stay is good. (Participant 4)

In particular, some of the participants emphasised the high level of effectiveness of cancer support services with regard to the non-medical support they received, including that provided by the social workers:

I wish them all the best as this main referral hospital deals with a large number of patients and still manages to have great services available to us, such as a social worker and Saudi cancer society officer, who always support me. (Participant 16)

I have the ability to connect freely to the Internet during my stay, as well as social worker services that let me feel happy and rest assured. Also the way they approach me is friendly and helps me feel supported and satisfied during my hospital stay. (Participant 8)

However, some of the participants reported negative experiences of the organisation of medical services. The following extract illustrates this factor:

I had to wait for a long time to obtain the approval of referrals.  My treatment was delayed because of a delay at the lab. Sometimes it was really troublesome to get things done with them. (Participant 19)

The previous extract highlights one of the most problematic issues, as several participants reported long waiting times for referrals, admission and for labs. The waiting time for psychiatric services was also seen as problematic:

Other services like referral took a long time, it took a long time to get   appointments and it was very uncomfortable to be seen by psychiatric services after 1 month. Generally, I don’t like this waiting time because I feel more worried and less assured, which sometimes makes me feel unstable and anxious during my stay. (Participant 3)

These findings demonstrate that, while there are positive findings regarding the healthcare services, there may be a need to improve certain aspects of service provision for oncology patients, particularly with regard to waiting times and doctor availability. The following interview excerpts emphasise this point:

It’s worrisome and irritating to wait so long. Especially for cancer patients, it’s even more irritating to wait. I don’t like it when hospital management forget about the psychological state of their patients. (Participant 13)

What is needed is making more doctors available to oncology patients. (Participant 3)

The opinions arising from these excerpts and discussed throughout this section show that there are several organisational policy factors that may be at odds with patients’ preferences for the treatment setting or logistics of care such as referrals that are not seen as fast enough and a shortage of medical staff on oncology wards.

5.4.4.2    Accessibility to health care

Participants in the current study reported positive experiences regarding access:

It was good and I didn’t face any problems with it as it was well arranged. There were always supportive services, for example from the social worker or from the cancer support society. (Participant 20)

The admission process was good, well ordered. I didn’t have problem in waiting for admission or referral; it was perfect during my stay.  (Participant 8)

In contrast to these positive experiences, some reported several problems with accessing the hospital and its facilities; the following is an example:

I remember the trouble I had to bear at my first CT scan. Firstly, it was crowded all the time and the personnel didn’t bother to do things quickly. I had to wait for two hours to get it done. According to them, it was a busy day, but I think if it’s better organised or there is a separate clinic for oncology it would benefit us more and improve our experiences. Also, referrals and labs have been working at a poor pace. My referral to an orthopaedist took three months; I was already on pain medication but still looking to see a specialist as soon as possible to get a clearer idea about the knee pain. (Participant 18)

Sometimes I got correct information but most of the time it was very confusing. There is lack of coordination between departments and nobody is in a position to provide all the information. The people here were also unconcerned with the trouble of the patient.  (Participant 19)

These negative experiences relate mainly to the slow pace at which care was given, and the lack of coordination in information giving or confusion regarding the information actually provided. Timeliness was closely linked with efficient access to services, and impacted adversely on patients’ satisfaction if it was not present. In addition, patients’ criticism of crowded circumstances also denotes the importance of the hospital environment when accessing it, which the following section explores in further detail.

5.4.4.3    Waiting times for services

Waiting times are one of the indicators that have been found to influence patients’ perceptions of the health care service and lead them to construct their experiences with it as satisfactory. In the current study, the waiting times for services were mainly positively assessed by the participants, as these extracts show:

I had a very good experience with the service of the organisation during my stay. There was well organised admission in a timely manner, and that was excellent. (Participant 16)

I feel so comfortable and like the earlier arrangement, such as getting my blood test earlier before going to the admissions office, which means that I can process my admission after the oncology staff confirmation, so that is very well arranged and organised and then I will just be waiting for doctors to be seen directly and treatment to be started. (Participant 8)

In contrast to these positive experiences, some reported that usually admission took longer and they had to spend time waiting in the emergency room for oncology doctors to decide and agree about admission. If patients book ahead for the admission process, it becomes easier and means that they can reach the doctor easily without a further waiting period. The following extracts demonstrate several patients’ dissatisfaction with admission and referral times:

I have been referred to two different doctors – a psychologist and neurologist – and neither of them have any available appointments; it has been almost a month now. It has been really hard for me to wait for so long. (Participant 11)  

My admission had been delayed for 8 days. Isn’t this unfair and troubling? And the reason behind it is the unavailability of beds in oncology wards. I couldn’t be admitted to any other wards in hospital to receive my scheduled treatment. (Participant 6)

By using language such as ‘unfair’, ‘really hard’, and ‘troubling’, these participants display a feeling of neglect that is experienced by patients being left to wait for long periods of time for medical attention and referrals, in some cases to the extent that they need to seek private care. This feeling of neglect can also be seen as connected to patients’ views that cancer is a priority disorder. Similarly, other professionals have argued that inadequate access to KSA cancer services such as the long waiting times negatively affects the level of patient satisfaction with the care provided (Al-Muziani 1998; Al-Sirafy 2009).

In light of this, another important element to assess is the perceived level of supportiveness of the health care personnel during these waiting times. Participants mainly reported positive experiences, emphasising the staff’s supportiveness, helpfulness and willingness to help:

Whomever I interacted with, they were well informed, nice and patient. They always provided us with the correct information about the services.  (Participant 17)

They are cooperative and helpful in guiding me if I need help such as fixing an appointment or changing the time of an appointment; they have been very cooperative with this. (Participant 8)

However, others noted less positive impressions of their communication with the medical staff during the time they were waiting to receive medical help:

They are good but CT staff need to be more kind and patient, especially with oncology patients. Lab services are usually crowded and need more organisation to make sure they have enough space to accommodate all the patients and not have them always waiting in corridors for a lab call as it's not helpful for patients to be in crowds with their pain. (Participant 3)

Another thing is the lack of psychological understanding among medical staff. They don’t try to understand the patient’s individual psyche. (Participant 6)

These criticisms indicate that medical staff need to act kinder and provide more supportive care, especially towards oncology patients, and that they sometimes demonstrate an inadequate psychological understanding of their patients’ needs.

As the following extracts also show, reference to crowded space and a lack of proper organisation indicates that participants felt that having adequate coordination within the health care system was important, yet was perceived as currently problematic and impacting on waiting times. This is illustrated by one who stated:

There is lack of coordination between departments and nobody is in a position to provide all the information. For example, my next readmission date was not provided until after discharge as the clerk was unavailable that day, so we had to follow this up with them after discharge and my son had to go back to get it confirmed. (Participant 21)

Another connected the problem of long waiting times with the shortage of nurses and the approachability of available staff noting that:

Here the situation is dependent upon the individual personnel; some of them are willing to help and some aren’t. No, I can’t reach out to all personnel if I need, they don’t seem easy going. (Participant 10)

The issues of capacity and problems with staff shortages have been highlighted by some researchers attempting to elucidate the impact of the staffing levels of nurses and the mix of nursing personnel in hospitals on patient satisfaction. For example, one study argues that hospital administrators, accrediting agencies, insurers, and regulators should take action to ensure that adequate nursing staff are available to protect patients and to improve the quality of care (Needleman and Buerhaus 2002). The current study found that good accessibility to health care – in terms of waiting times and availability of oncology ward staff (doctors, nurses) – are important factors influencing patient satisfaction in the KSA.

• Non-disclosure in the KSA setting

5.5      Summary of key qualitative findings

The qualitative phase of the current study has explored the ways in which interpersonal aspects of care and accessibility to health care influence patient satisfaction in an oncology ward setting at the SRCC in Riyadh. It has considered the role of cultural and organisational factors relevant to the health care context, as well as within the wider KSA society, in influencing these satisfaction levels. Four key themes have been identified and explored: (1) the doctor-patient relationship, (2) the nurse-patient relationship, (3) contextual factors relevant to cancer in the KSA, and (4) organisational factors.

A strong emphasis on the psychological as well as physical elements of care was evident; with many patients highlighting that doctor should understand and respond well to psychological state. Nurses’ interpersonal skills were deemed important and impacts on the quality of their experience. Largely, nurses were seen as supportive and understanding. However, some patients perceived the nurses as lacking in compassion and responsiveness, although this was also linked with nursing shortages and the observed lack of time that nurses had to interact with patients. In addition, it is attributable to the non-disclosure policies variability that instructs some nurses not to communicate certain health information to patients.

In relation to KSA contextual factors, it is evident that cultural perceptions of the doctor as a figure of authority and power in relation to one’s health often engendered a top-down power dynamic, where patients felt constrained about asking questions or interacting with doctors. However, other patients recognised the need for a more balanced dynamic of trust and rapport. In addition, there was evidence to suggest doctors are increasingly sharing information with patients themselves rather than with their families, as has historically been the norm in KSA. This departure from longstanding non-disclosure policies appears to promote patient satisfaction.

The multicultural care environment, comprising mainly expatriate nurses, had an impact on patient satisfaction levels. The language barrier with nurses who did not speak Arabic presented challenges to some patients and lowered their satisfaction with nursing care. In addition, the default English-speaking between doctors and nurses engendered a feeling of exclusion and anxiety among some patients.

The findings were mixed relating to patients’ perceptions of the SRCC’s operational efficiency and its impact on their satisfaction with care. While some participants praised the SRCC for its efficiency, environment and admission processes, many voiced strong views in their criticism of two main organisational factors: accessibility to health care and waiting times. These two factors were closely linked. Many patients noted having had to wait for long periods of time to be admitted to hospital, whether for a referral, or to gain access to a laboratory test or results. This, in turn, compromised their access to the treatment they needed and greatly lowered their levels of satisfaction with the services offered. 

The norm of non-disclosure was considered a common factor that influenced patient satisfaction as seen through the analysis of the all the four themes and their subsequent subthemes. Non-disclosure is complex issue in KSA which contrasts to the general perception of non-disclosure in the Western context. In the Western context, the patient is the key individual who is responsible for the decision making in terms of treatment, interaction with doctors and nurses, and acquires crucial information about their health which they deem sensitive. This Western form of non-disclosure links very closely to doctor-patient confidentiality. However, in the KSA setting non-disclosure is the total opposite as analysed from the findings. Non-disclosure in the KSA setting means that information regarding the health of the patient is disclosed to the family of the patient, and the family decides which information is disseminated to the patient.   

The current study’s qualitative findings add to the plethora of knowledge of interpersonal aspects that was focused on healthcare professionals exclusively. However, the current study expands to the knowledge of how interpersonal aspects of care coupled with service organisation influenced the level of patient satisfaction in the KSA oncology ward settings. Through the evidence extracted from the findings it can be concluded that patient satisfaction is closely linked to specific contextual factors that are related to the themes which have been discussed in this chapter. 

^[1] Sitters are commonly relatives of the patients who, at the patients’ request accompany them during their hospitalisation, offering moral and practical support. Typically, patients are required to ask for their doctor’s permission to have a sitter stay with them overnight. 

Table 8 - Cross-tabulation of Gender, Age, Marital Status, Education, Home, and Patient Satisfaction

Table 8 - Cross-tabulation of Gender, Age, Marital Status, Education, Home, and Patient Satisfaction

4.2       Clinical Effectiveness of Doctors and Nurses

The following set of questions were used to capture doctors and nurses effectiveness. The questions under each of these headings were grouped into the following four categories:

Table 9 - Differential Measurement of the Effectiveness of Doctors and Nurses

The respondents’ views on the clinical effectiveness of doctors and nurses are discussed in this section. Overall, these results indicate broad patient satisfaction with the technical and interpersonal skills, information provision, and availability of the doctors and nurses during their hospital stay in an Oncology ward in Riyadh.

4.2.1         Respondents’ View of Doctors Clinical Effectiveness

As shown in Table 10, respondents were most satisfied with the doctor’s medical follow-up (88%) and knowledge of illness (87%) in terms of their technical skills. Patient satisfaction ranged from 84 to 89% and 84 to 85% regarding the doctor’s interpersonal skills and information provision, respectively. Overall, respondents were least satisfied with the availability of doctors. Only 77% of them were pleased with the visitation time and 79% were happy with the frequency of doctor’s visits. 

4.2.2         Respondents’ View of Nurses Clinical Effectiveness

Almost all of the respondents were satisfied with the nurse’s physical examination (94%). However, other technical skills (attention to comfort and care handling) only ranged from 81 to 84%, respectively. The majority of patients were satisfied with the nurse’s human quality (89%), but fewer patients were satisfied with their other interpersonal skills (74-78%). In terms of information provision, more respondents expressed satisfaction with the nurse’s information about treatment (82%). Overall, respondents were least satisfied with the availability of nurses representing 75% of satisfaction. Only 73% of respondents were happy with buzzer promptness (See Table 10).

 Table 10 - Respondents’ View of Clinical Effectiveness and Service Organisation   (n=100 patients)

 4.3       Other Services and Care Organisation

Respondents were asked to rate other hospital services and care provided by the organization as a whole. The main categories of other services and care organization analysed are listed below.

Table 11 - Differential Measurement of Service and Care Organisation

4.3.1         Respondents’ View of Other Service and Care Organisation

As shown in Table 11 above, the respondents were more satisfied with discharge information provision (86%) and hospital cleanliness (85%). Respondents were less satisfied with the waiting time for medical test (68%), speed of treatment (68%), and department access (65%). Still, only 62% of them were satisfied with parking accessibility to the Oncology ward.

4.4       Factor Analysis of Observed Variables

An exploratory factor analysis was carried out in order to reduce the number of variables to useful factors and to identify the correlation among them. This section highlights the main results of factor analysis, which included descriptive statistics, reliability measurements, correlation matrix, total variance explained; communalities (i.e., proportion of variability of a variable that is explained by the factors); factor loadings (i.e., interpreted as Pearson correlation   of an original variable with a factor); and extraction (i.e. variable reduction using principal component analysis)

4.4.1         Descriptive Statistics of Observed Variables

The above percentage results were also evident when calculating the mean of the observed variables. The highest mean indicates the less satisfaction level.   In regard to doctors’ clinical effectiveness, respondents were more satisfied with their support (M=1.11, SD=.314) and least satisfied with their visitation time (M=1.23, SD=.423). In regard to nurses’ clinical effectiveness, respondents were more satisfied with their physical examination (M=1.06, SD=.239), but less satisfied with their buzzer promptness (M=1.27, SD=.446), and interest in personality (M=1.26, SD=.441). With respect to other services and organization, respondents were more satisfied with discharge information provision (M=1.14, SD=.349) and hospital cleanliness (M=1.15, SD=.359), but less satisfied with parking (M=1.38, SD=.488), department access (M=1.35, SD=.479), speed of treatment (M=1.32, SD=.469) and waiting time for medical test (M=1.32, SD=.469). (See Table 12).

Table 12 - Descriptive Statistics of Observed Variables

 4.4.2         Reliability Measurements

The Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy index should be greater than 0.5 in order to support the use of a factor analysis and ensure that it is satisfactory. Large values for KMO commonly indicate that a factor analysis of the variables is considered a reasonable step to be taken. On the other hand, Bartlett’s sphericity test was used to test the null hypothesis that the population correlation matrix is uncorrelated (Mertler and Vannatta, 2010). Once the observed significance level is 0.0000 it is considered to be small enough to reject the hypothesis. The KMO coefficient was .820, which is close to one and the associated Sig. value of the Bartlett’s test was significant, p <.001; therefore, the null hypothesis is rejected. The results obtained confirm the sample size is adequate for conducting a factor analysis as the relationship between the variables is strong. The variables have some degree of correlation between them making it a rational idea to proceed with a factor analysis. See appendix 12 for KMO test Table1.

4.4.3         Correlation Matrix

 A correlation matrix was utilized to further examine the strength, direction, and significance of the relationship between the variables. The strongest positive correlations were between nurse’s information about care and nurse’s information about medical test (r = .79, p <.001); and nurse’s information about treatment and nurse’s information about care (r =.69, p<.001), which were both statistically significant. The weakest positive correlations were between doctor’s information about illness and doctor’s medical follow-up (r =.02, p =.87); and nurse’s human quality and doctor’s information about medical test (r =.02, p =.83), which were not statistically significant. In contrast, the strongest negative correlations were between patients’ overall satisfaction and doctor’s support given (r = -5.29, p<.001) and patients’ overall satisfaction and nurse’s physical examination (r= -5.28, p<.001), which were statistically significant. The weakest negative correlations were between nurse’s human quality and doctor’s support given (r = -.02, p = .83) and patients’ overall satisfaction and speed of treatment (r = -1.81, p=.07), which were not statistically significant. 

4.4.4         Total Variance Explained 

The Total Variance Explained provided the eigenvalues of any contributing components and the percent of variance explained by the each component. A total of eight components were retained because they had eigenvalues which exceeded 1, as shown in appendix 13.  After rotation, Component 1 accounted for only 12.39% of the total variance explained by the original variables, while Component 8 only accounted for 6.41%.

4.4.5         Communalities

Communalities show how much of the variance in the variables has been accounted for by the extracted factors. High communalities indicate a more reliable factor analysis.  Communalities results shown in appendix 14 revealed nurse’s information about medical test explained 82.7% of variance, followed by other staff helpfulness (80.6%), nurse’s information about care (79.5%) and doctor’s information about illness (79.4%). Only three variables (doctor’s knowledge of illness, nurse’s buzzer promptness, and doctor’s willingness to listen) fell below the recommended .60.

4.4.6 Factor Loadings

Factor loadings (see appendix 15) illustrates how variables were loaded into components after rotation based on their coefficient size. An assessment of component loadings was necessary in order to label each component. The variable with the highest loading was hospital cleanliness (.825), followed by doctor’s information about illness (.818) and nurse’s information about care (.795).

4.4.7         Extraction

Principal component analysis was conducted utilizing a varimax rotation. The analysis retained the eight components. Table 13 provides the assigned names given to each component based on the highest factor loadings. The first component comprises items 12, 13,17,21,22 named Nurse Skills.  Second component, includes items 18-20 named Nurse Information provision. Third component contains items 2, 4, 9 named Doctor Skills. The fourth component includes items 23, 24 named Staff helpfulness. The fifth component comprises items 27, 28 named Promptness of and accessibility to health care. The sixth component includes items 10 and 31 named doctor support and hospital environment. The seventh component contains items 7, 11 named doctor information provision and availability. The last eighth component comprises items 25, 26 named staff information provision.

Table 13 - Component Loadings and Eigenvalue by Varimax rotation

 4.5 Binary Logistic Regression

Using the resulting factor scores from the factor analysis and the socio-demographic variables, four binary logistic regressions were performed to evaluate the degree of association in these determinants on patients’ overall satisfaction.  The findings are presented in the subsequent sections.

4.5.1         Doctor’s Clinical Effectiveness and Patients’ Overall Satisfaction 

For this analysis, the independent variables were Doctor Skills (FAC3_2), and Doctor Information Provision (FAC7_2) and dependent variable was overall satisfaction. Model fit statistic shown in appendix 16 Table 1 indicates a fairly good-fitting model -2 Log Likelihood = 58.427. The two components, Doctor Skills and Doctor Information Provision and Availability, accounted for nearly 32% of the explained variance in patients’ overall satisfaction.

The final model did not significantly differ from the empty model (i.e., model without variables). The Chi-square value was 11.309 and its associated Sig. value was not statistically significant, p = .13. Appendix 16 Table 2   presented the classification results, which indicated the model correctly classified 89.0% of cases.

The summary of model variables displayed in Table 14 revealed the odds ratios; however, the Wald statistics for one component (Doctor technical and interpersonal Skills) was not significant, p = .16.  Therefore, the null hypothesis was retained for this component.

 Table 14 - Regression Coefficients

 The logistic regression coefficients give the change in log odds of the outcome based on a one unit increase in the variable. For every one unit change in Doctor Information Provision and Availability, the log odds of overall satisfaction increases by 0.312, as seen in Table 14 above. This was the only component that significantly contributed to the model, p<.001.  

4.5.2         Nurse’s Clinical Effectiveness and Patients’ Overall Satisfaction 

For this analysis, the independent variables were Nurse Interpersonal and Technical Skills (FAC1_2) and Nurse Information Provision (FAC2_2), and the dependent variable was overall satisfaction. Model fit statistic shown in appendix 17 Table1 indicates a fairly good-fitting model -2 Log Likelihood = 54.396. The two components, Nurse Interpersonal and Technical Skills, and Nurse Information Provision, accounted for 38% of the explained variance in patients’ overall satisfaction.

The final model did not significantly differ from the empty model (i.e., model without variables). The Chi-square value was 6.940 and its associated Sig. value was not statistically significant, p = .44. As shown in appendix 17 Table2, the results of the classification table revealed the model correctly classified 90% of cases.  

The summary of model variables displayed in Table 15 revealed the odds ratios; however, the Wald statistics for one component (Nurse Information Provision) was not significant, p = .54.  Therefore, the null hypothesis was retained.

Table 15 - Regression Coefficients

 The logistic regression coefficients give the change in the log odds of the outcome based on a one unit increase in the variable. For every one unit change in Nurse Interpersonal and Technical Skills, the log odds of overall satisfaction increases by 0.277, as seen in Table 15 above. This was the only component that significantly contributed to the model, p<.001.

4.5.3         Service and Care Organisation and Patients’ Overall Satisfaction 

For this analysis, the independent variables were Promptness of and Accessibility to Healthcare (FAC5_2), Staff Information Provision (FAC6_2), Staff Helpfulness (FAC4_2), and Hospital Environment and Doctor Support (FAC8_2), and the dependent variable was overall satisfaction. Model fit statistics shown in appendix 18 Table 1 indicates a fairly good-fit, -2 Log Likelihood = 68.020. The four components, Promptness of and Accessibility to Healthcare, Staff Helpfulness, Hospital Environment and Doctor Support, and Staff Information Provision, accounted for about 16% of the explained variance in patients’ overall satisfaction.

The final model did not significantly differ from the empty model (i.e., model without variables). The Chi-square value was 6.307 and its associated Sig. value was not statistically significant, p = .61. As shown in appendix 18 Table 2, the model correctly classified 87% of cases.

The summary of model variables displayed in Table 16 provided the odds ratios; however, the Wald statistics for three components (Staff Helpfulness, Promptness of and Accessibility to Healthcare, and Staff Information Provision) were not significant (p>.05).  Therefore, the null hypothesis was retained for these components.

Table 16 - Regression Coefficients

 The logistic regression coefficients give the change in the log odds of the outcome based on a one unit increase in the variable. For every one unit change in Hospital Environment and Doctor Support, the log odds of overall satisfaction increases by 0.574 as seen in Table 16 above. This was the only component that significantly contributed to the model, p=.03.

4.5.4         Socio-demographic Characteristics and Patients’ Overall Satisfaction

For this analysis, the independent variables were gender, age, marital status, residence, and education, and the dependent variable was overall satisfaction. Model fit statistic shown in appendix 19 Table1 indicates a poor fitting model, -2 Log Likelihood = 72.798. The five socio-demographic variables accounted for approximately 8% of the explained variance in patients’ overall satisfaction.

The final model did not significantly differ from the empty model (i.e., model without variables). The Chi-square value was 5.762 and its associated p value was not statistically significant, p = .67. Appendix 19 Table 2 presented the classification results, which indicated the model correctly classified 87.0% of cases. 

The summary of model variables displayed in Table 17 revealed the odds ratios; however, the Wald statistics for the socio-demographic variables (gender, age, marital status, education and residency) were not significant (p>.05).  Therefore, the null hypothesis was retained.

Table 17 - Regression Coefficients

4.6       Summary and Interpretation of the Results

 The quality of the data was important in assuring the reliability and validity of the results. The quality of the data was established by selecting a representative sample of participants. The data was collected from participants who were all patients in oncology wards. The data collected was through the adapted EORTC 32 INPATSAT validated, Arabic pilot test and questionnaire. The sample size was evaluated using a KMO test and found to be of an adequate size. The data analysis was carried out in such a way that no data was lost or distorted

Generally, most respondents’ satisfaction level with the services received was very high (87%). These results support previous findings mentioned in the literature review that high scores are usually reported in patient satisfaction surveys. The study showed that females (50%), married (58%), highly educated (60%), and resided outside of Riyadh (56%) were more satisfied with the services received during their stay in the Oncology wards.

The exploratory factor analysis was conducted to determine what, if any, underlying structures existed for 32-items of the EORTC IN-PAT32 questionnaire, and to describe and summarize the relationship between this given set of variables. Principal component analysis identified eight factors and they are as  follows: Nurse Interpersonal and Technical Skills (5 items), Nurse Information Provision (3 items), Doctor Skills  (3 items), Staff Helpfulness (2 items ), Promptness of and Accessibility to Healthcare (3 items) , Hospital Environment and Doctor Support (2 items) ,  Doctor Information Provision and Availability (2 items), and Staff Information Provision (2 items).   These components enabled relationships between responses of patients with regard to their satisfaction to be analysed and allowed for the measurement of the patient’s level of satisfaction. The identified components may assist future research on patient satisfaction in a KSA oncology ward settings.

Binary logistic regression analyses were performed to determine which component loadings and socio-demographic characteristics were significant contributors to patients’ satisfaction. Regression analysis indicated that the factors that were important for overall patient satisfaction were: 1) Doctor Information Provision and Availability, 2) Nurse’s Interpersonal and Technical Skills, 3) Hospital Environment and Doctor Support However, none of the socio-demographic variables were important for overall patient satisfaction

Further exploration into why patients seemed generally satisfied with the care and services provided was necessary. In order to gain deeper insight and understanding, semi-structured interview questions were developed based on the resulting component loadings from the factor analysis. The integration at this intersection of phase 1 quantitative analysis and phase 2 qualitative semi structured interviews was designed to collect high quality data on patient satisfaction.

A discussion of the findings presented here, along with those from Phase 2 (chapter 5), is then provided in chapter 6, where the complementarity of the quantitative and qualitative data is shown. The process of integrating the findings on patient satisfaction in oncology ward settings which was collected from both phases is thoroughly detailed in chapter 6. The implications of the findings and considerations for practice and future research are also considered in chapter 6.

Chapter 5 - Qualitative Findings

5.1    Introduction

In this chapter, the findings from Phase 2 are presented. The organisation of this chapter compiled in order to produce information that will help in answering the research question of the current study; what factors contribute to or hinders patient satisfaction with care in oncology wards in the SRCC? The chapter is organised thematically based on themes that emerged during the interviewing process of the participants. The chapter begins with a summary of socio-demographic characteristics of the respondents which provides insights into the demographic trends of the respondents from which data on patient satisfaction is drawn. The remaining sections of the chapter (5.3.1-5.3.4) categorise the findings of the interview data using themes based on the results obtained from the interviews. These themes are considered as factors which impact patient satisfaction.

Each of the subsections under section 5.3 provide an in-depth understanding of interpersonal aspects of care and accessibility of health care as influential factors that formulate adult oncology patients’ perception of their satisfaction. The findings within these subsections aided in fulfilling the aims of the current study.   

To further achieve the aims of the current study, each key theme is presented separately, with relevant examples from the translated interview extracts. These interview extracts were selected based on the coding process and also to represent the wide range of participants’ views. Commentary is provided to link these findings with the literature, where appropriate, and also to highlight any similarities and differences between participants’ responses. The chapter concludes with a summary of the key findings from this second phase of the study. 

5.2    Socio-demographic patient characteristics

In Table 1, the socio-demographic details of the participants, outlining their age, gender, education level, marital status and place of residence are presented. It should be noted that there were a high number of young people participating in the study. This high proportion of younger people (<45 years) was due to the largely self-selecting aspect of this part of the research, since the choice of interviews was based on those who volunteered. This may have made the sample unrepresentative of the general target population, since the average median age of the diagnosis of cancer for a man was 58 years of age and 51 for women, in 2010 ( Saudi  Cancer Registry 2010). While the current study portrays an age for a man as 46-55 years old or 66-75 years old and for women a median age of 36-45 years olds. The current study’s sample is not reflective of cancer incidence/prevalence in KSA but is a mere reflection of the participants that had volunteered to take part in the study. 

Table 1 - Patient socio-demographic characteristics

Based on Table 1, of the 22 participants only two were male. Both of whom were married and resided in Riyadh. However, of the two male participants, one aged between 66- 75 years had only attained primary education while the other male participant aged 45- 55 years old attained intermediate education. The remaining 20 participants were females of varied age, marital status, and education level. The median age of females within the sample was 36-45 years old. Of the female participants 13 were married, 3 were single, 2 were widowed and one was divorced. A majority of the female participants resided outside of Riyadh (11) while the remaining (7) resided in Riyadh. All the female participants except one had attained some level of education. A majority of the participants (7) had attained a high school level education, while the remaining were dispersed with 3, primary, 3 intermediate, and 5 university level education amongst the participating females.  

5.3      Key themes emerging from the interview data

The four primary themes identified from interview data are shown in Table 2 and are discussed in extent in the sub-sections.  

Table 2 - Themes and Subthemes that Emerged from the Interview Data

5.3.1 The doctor-patient relationship

The analysis of participants’ descriptions of their interactions with their doctors provides insights into the aspects of the doctor-patient relationship that are especially meaningful to the patient and influence their understanding of their experiences and the satisfaction with the care they receive.

The doctor-patient relationship in KSA is somewhat different to the western model. The family often needs to be consulted concerning the doctor’s disclosure of information to a patient. Doctors are often required to inform a patient’s family of their treatment and health. This means that the doctor-patient relationship is more complex and that a doctor needs to consider the family in their relationship with their patient. Many patients in the KSA are comfortable with this, because of cultural considerations. However, this particular take on non-disclosure has a significant impact on patient satisfaction and restrains the KSA healthcare delivery from becoming patient-centred. This in turn may have a significant impact on the findings of the study. It is possible that since females are not participant in the delivery of their healthcare they will be less satisfied than compared to male patients. However, although male patients are involved in their healthcare and treatment options, they may not be as satisfied as ultimately the decision for treatment and discussion of patient health status is discussed by the patient’s family. The issue of  non-disclosure causes patient dissatisfaction due to their experience with having their health information disclosed to people other than themselves and treatment decisions making be left to individuals other than themselves.     

Four main factors were identified that represent aspects of interpersonal communication between doctors and their patients:

• Listening: listening to and addressing the patients’ questions and concerns
• Information provision: providing adequate information about the patients’ conditions and treatments
• Motivation: being encouraging and motivating to the patients
• Care and compassion: being caring and compassionate, with attention to the patients’ psychological as well as medical needs.

These aspects are important to the relationship between patient and doctor despite the requirements for non-disclosure. Based on the analysis of the findings, doctors functioning within the KSA healthcare delivery environment are unable to appropriately deliver these interpersonal communications due to the distraught non-disclosure policy that is family centred. There have been attempts by doctors to do so as evident from the analysis of the findings. Non-disclosure in the KSA setting is influenced by cultural norms, religious beliefs, and attitudes of the doctors. For example, female patients need to have a male guardian who makes the ultimate decisions regarding their healthcare, this will include deciding between treatment options. Therefore, patient information is disclosed to the male guardian of the patient which is ultimately against the philosophical and legal context of non-disclosure. However, this necessary for the doctor to do as it conforms to cultural beliefs of KSA.         

The following section presents the participants’ general perceptions of the doctor- patient relationship in the oncology ward at the SRCC in Riyadh. In the subsequent sections the four sub-themes are examined in detail. 

5.3.1.1  General perceptions of the doctor-patient relationship

The current study produced varied views among participants regarding the doctor-patient relationship experience. Many built their relationship with their patient in a way that was satisfying, although they were dissatisfied with some aspects. 

Fourteen of the twenty-two research participants in the study were positive about their experiences of the doctor-patient relationship. They expressed appreciation and gratitude for their doctors’ personal qualities and interpersonal skills, which had clearly contributed to satisfaction with their hospital stay, despite the non-disclosure requirements that were implemented on all patients including the current study’s sample of 22. Those reporting positive experiences described their doctors in terms such as comforting, trustworthy, helpful, kind, co-operative and patient. For example, two participants stated the following:-

They are so patient and obliging, and dealing with them is easy and comfort(able). (Participant 2)

However, eight participants were critical of some aspect of the doctor-patient relationship. They commented that, although the doctors’ medical expertise was of a very high standard, they were lacking in interpersonal skills, including communication skills, kindness, empathy, and compassion. These views may have been in part influenced by the non-disclosure requirements of their families. Families were consulted by the doctor in regards to the patient treatment options and updates. The eight respondents were not involved in the decision making of their treatment. Crucial care options and information was not disclosed appropriately to patients but was left to the families. This lack of non-disclosure causes patients to feel that doctors are not communicating with them properly when it comes to disclosing information that aids the patient in decision making in regards to their health. The following extracts from participants’ narratives illustrate this:

They told me about chemotherapy and sent me to the health educator to explain the cycles and side effects, which was good. But the doctors here didn’t give the whole treatment plan or future plan to clarify things for me more. (Participant 3)

Because many families restrict information disclosure this prohibits doctors from disclosing information to some patients, especially females. Doctors often need to consult patients’ families on providing information or what should be revealed. This can lead many patients to not being fully informed of their treatment. In fact, many patients are not aware of this family request and the restrictions that it places upon doctors’ level of communication with their patient, especially with regard to the disclosure of treatment plans. This may cause some patients, especially females, to believe that their doctors are poor communicators, while in fact they are only conforming to the families’ wishes.

Indeed, there was no indication that doctors were avoiding contact with these patients. However, in some cases the doctors’ communications with their patients were not satisfying experiences. Females and males are treated differently under the non-disclosure arrangements. However, several males, expressed their opinion that doctors have ‘poor communication’ and this suggests that some patients perceive their communications with doctors as being unsatisfactory.

5.3.1.2  Listening skills

Participants reported that they often had questions and concerns about their illness or treatment, which, if not answered, caused great anxiety and stress. It was important to them to have adequate opportunities to ask their doctor questions or discuss their concerns, and to feel comfortable in doing so. The fourteen participants who mostly expressed satisfaction with the doctor-patient relationship all indicated that their doctors were frequently available to them, encouraged them to ask questions, and provided all the information needed to address their concerns, as the following extracts demonstrate:

They made me comfortable enough to share my concerns with them and patiently listened to me. They answered each of my queries and cleared my doubts. (Participant 15)

They have been very kind and patient. They listen to my concerns and give complete attention to what I say … They answer all my questions no matter how foolish my questions might sound. (Participant 9)

These data show that the majority of the participants were experiencing high levels of personal attention from their doctors, providing evidence of optimum listening skills in the hospital, and indicating that the doctors are addressing the concerns and psychological needs of their patients. This was the case with both males and females and suggested that doctors displayed good communication skills despite the limitations imposed upon them by the non-disclosing cultural attitude. Communication involves issues like ‘listening’ which would not be greatly influenced by any non-disclosure requirements.

In contrast, eight participants reported negative experiences of communicating with their doctors, which they perceived as mainly owing to the doctors’ busy routines and limited time for patient conversations. These participants commented that the doctors seemed unwilling to listen to their questions and concerns, or to provide the information being sought. The following extracts demonstrate this, and also highlight the power dynamics implicit in these doctor-patient relationships:

I … didn’t have the courage to stop them or ask them more as they look busy and just talk quickly during rounds. (Participant 5)

This participant’s concerns and emphasis on his/her own lack of courage convey a state of being afraid to engage doctors in conversation, which may or may not be related to the doctors’ actual listening capacity. However, the subsequent observations made by other participants indicate that this listening capacity may be limited, in some cases:

My talk with them is usually very brief and one sided in which all I had to say was ‘yes’ or ‘no’; they tell and I listen. (Participant 6)

The doctors asked me general questions but were never interested in my specific concerns. (Participant 21)

These comments suggest a power dynamic that is downwards directed from doctor to patient, where the doctor is the one in control of the knowledge that the patients need in order to allay their anxiety. The fact that this anxiety is not adequately listened to, and the knowledge is not shared, highlights an unequal balance of power and control in the patient-doctor relationship here. In particular, the repeated reference to ‘fear’ and ‘courage’ demonstrate the distress some participants felt at not being adequately listened to.

These findings indicate that at least some of the oncology doctors treating the participants in the current study did not give the impression that the participants’ concerns are  not of interest. Previous research by Jagosh et al. (2011) argues that physician listening has three very important functions: (1) clinical data gathering, (2) healing and therapeutic value, and (3) building the doctor-patient relationship. While it is uncertain from my findings whether or not the doctors were actually listening to the concerns of their patients, what the study does show is that some felt that they were not being heard. As Ansmann et al. (2013) found, a busy hospital work environment and heavy workload may hinder physicians’ ability to adequately support patients and they may feel constrained in communicating with patients because of any non-disclosure arrangements.

5.3.1.3  Information provision

Most participants reported positive experiences of receiving comprehensive information from their doctors, and noted the calming and reassuring effects that these had on them. The following extracts illustrate this:

The doctors listened to my queries and clarified my doubts in detail. They took every step to inform me well at the start of treatment and also provided me with relevant information during the course of treatment. (Participant 16)

I even had some misconceptions about radiology but they clarified the concepts and now I’m not scared of my treatment. (Participant 11)

These statements would indicate that despite any non-disclosure arrangements in many cases doctors are, in fact, listening to patients and offering them information on their treatment. They are able to clarify a patient’s treatments in a general way and in doing so keep patients somewhat informed. These participants’ statements provide a contrast to some of the more negative perceptions of doctors’ listening skills described in the previous section. Of note is the frequent referral of participants to their lack of clarity regarding their illness and treatments. The responses here, however, certainly suggest some doctors’ efforts to alleviate patients’ anxiety regarding the course of their disease and treatment (even if the prognosis itself may not be positive) through adequate information provision.

It did appear that information provision was problematic for some participants; some reported having to wait too long to receive the information they needed. This was at least partly due to the doctors’ busy schedules, and partly due to the hospital protocol arising from policies of the KSA health service, which prevents the nursing staff from providing certain information to patients.  As one participant said:

I am waiting longer to get information about results from doctors, while nurses can’t give me this information until the doctors do their round. I sometimes can’t tolerate the nurses saying that they are unsure about my treatment, as they have to wait for the results and for the doctor to read the results and inform me about progress. This process makes me feel more worried and anxious about my stay. (Participant 5)

Even though some data showed a positive trend toward taking patient satisfaction into account, participant responses such as these indicate that organisational factors such as hospital policies or procedures can sometimes adversely affect the experience of patients and have a negative impact on patient well-being (Aljubran, 2010). The following comments highlight this:

It’s worrisome and irritating to wait so long. Especially for cancer patients, it’s even more irritating to wait. I don’t like it when hospital management forget about the psychological state of their patients. (Participant 13)

I had even requested my oncology team twice to come quickly for the referral visit. They didn’t pay any attention and I’m still here waiting for my psychologist session. I feel so dissatisfied and depressed. (Participant 10)

The stark contrast between these perceptions and those of the participants who were satisfied with the quality and timing of the information they had received conveys high variability in the level of information provision among different doctors at the hospital.  What is apparent from these extracts is that long waiting times to receive information can substantially increase patients’ stress levels. Addressing this issue is important since studies have shown that psychological distress has an impact on cancer mortality (Hamer et al, 2008). For example those individuals who expressed dissatisfaction with the doctors’ communication skills could be at risk of poorer health outcomes. This would support the view that non-disclosure could be interfering with a patient’s health.

5.3.1.4 Motivation

The data from the interviews support the evidence that the nature, as well as the level of communication between doctor and patient has a significant influence on patient satisfaction and how it is perceived (Mobiereek et al. 1996; Ezubair 2002). It is clear from participants’ statements that doctors potentially play an essential role in raising and maintaining patient morale, by being encouraging and positive about their recovery:

They advise me to keep myself hopeful. They tell me that I can get healthy again and I’ll be able to live a normal life. I’m so determined to get rid of my breast cancer and I’m thankful to my doctors that they have been helping me so much. (Participant 9)

They were supportive in the success of the treatment. They were encouraging and kind. They sounded like they truly wanted me to get well. (Participant 3)

The key elements here are the nurturing of hope, encouragement, and the perception of genuine well-wishing on the doctors’ part. The doctors’ positive attitudes and the nature of patients’ communication with them may reflect, at least in part, the culture of the KSA, in which physicians are traditionally held in high regard and as figures of authority (Mobeireek et al.1996; Younge et al. 1997; Aljubran 2010). However, in contrast to the negative dynamic of power and control, the findings suggest that there were few doctors who were perceived as listening inadequately to their patients’ needs were not viewed favourably by patients. The doctor’s ability to listen is described as deeply appreciated and seen as responsibly used, i.e. for the psychological improvement of the patient. Being in the position of authority means that compared to other members of the health care team, doctors have a greater impact, either positive or negative, on the health and wellbeing of patients. There were mixed views that appeared in the investigated which included that some of the participants expressed being motivated and encouraged by their doctors which is evident from the quotes below, attesting that communication and relationship with doctors is a significant factor in enhancing patients’ psychological well-being;

I myself didn’t want to stay as I felt depressed, but their motivating words helped me and I started being hopeful. Now, I can proudly say that if my doctors hadn’t stayed positive and supportive, I wouldn’t have been able to come out of my illness ever. (Participant 19)

They have inspired me with their attitude and kindness. They are encouraging, it becomes easier to hope for successful treatment … Their supportive words became my strength and here I’m ready to go home with a healthy body and healthy mind. (Participant 13)

However, the current study had also found contrasting views to those above, these especially surfaced when patients were questioned specifically about their relationships with their doctors.

When doctors are encouraging and motivating, this can be perceived as having a positive impact on the progression of the patient’s recovery. As previous research has indicated, doctors’ communication in an oncology setting can affect the level of patient satisfaction and may also influence the patient’s wellbeing and quality of life (Ong et al., 2000; Wildes et al., 2011).

The practice of non-disclosure could, especially for females, lead to them to build their experiences in a negative way and this in turn could impact upon their health outcomes. The implication of the non-disclosure as a cultural attitude could therefore mean that females are more likely to suffer a negative health outcome than males in KSA oncology settings.

Some participants reported that communication with their doctors had been negative, in the sense that their experiences with doctors were not constructed as encouraging or motivating. This is demonstrated by two participants, who explicitly stated how this had disheartened them and weakened their resolve to recover from their illness:

As medical attendants their behaviour has never been motivating or heartening. (Participant 10)

They have a very casual attitude which I don’t appreciate much. They don’t fill the patient with motivation and determination to fight against their illness. (Participant 6)

These positive and negative examples show the impact that the physician’s manner may have on the psychological state and even on the physical well-being of the patient. These examples also reflect on the connection between a healthy body and a positive mind, as ‘hope’ was a key word emerging in positive descriptions of doctors who were seen as motivating. Previous research argues that a patient’s attitude may be positively correlated with doctor behaviours that are perceived as encouraging and motivating, often resulting in positive medical outcomes such as improved adherence to treatment and self-care (Street et al. 2009). By being motivating and encouraging to the patient, doctors’ communication may have a significant impact on the patient’s state of mind, such as lowering anxiety, and thus, may indirectly influence the overall outcome of the illness episode (Ommen et al. 2010). While it has been argued that an awareness of psychological distress is an essential aspect of patient care, oncology doctors are often unwilling to note the distress in patients, and ask questions regarding patients’ psychological health (Cull et al. 1995; Fallowfield et al. 2001).

The interviews provide insights into the overall impact of a trusting and motivational relationship between the doctor and patient on patient satisfaction and well-being, and particularly on the patients’ abilities to cope with and fight their illness. Participants’ comments tend to support the findings of previous studies that have highlighted the association between a trusting doctor-patient relationship and patients coping with their illness, which may result in improved patient outcomes (Epstein and Street 2007; Arora 2008).

In the beginning of all this I was scared to death and every step of my treatment used to frighten me ... But when I talked about this with my doctors, they listened and gave such kind advice and motivation that finally I started to feel calm. (Participant 4)

The doctors were very friendly and took time to build up my confidence. This provided me with the strength to fight (the) suffering caused by the disease and treatment. I felt comfortable in their presence and that brought a lot of positive energy to me to receive the treatment with great hope and confidence. (Participant 16)

The interview data show a strong link between hope and trust, reiterating the notion of a positive power dynamic between doctors and patients, where the doctors are respected figures of authority who are seen as crucial to reassuring and encouraging the patient with whom they have built up a good relationship. Other research similarly indicates that having a trusting relationship with one’s doctor can have a positive impact on the patient’s mind, generating a more hopeful attitude towards the condition and thus aiding the overall mental state and self-care, which ultimately improves the patient’s quality of life (Clever et al. 2008). Trust could become an issue as a result of the non-disclosure by doctors of issues related to the patient’s treatment. However, there are multiple factors involved in patients’ construction of satisfaction, such as listening and if a doctor concentrates on these then any arrangements between the family and doctor about non-disclosure would not impact too negatively upon patients trust.

Exploring further the connection of trust with patients feeling motivated and encouraged by their doctors, it was found that where there was insufficient trust in the doctor’s genuine interest in the patient’s well-being, feelings of hope and encouragement suffered to the detriment of the patient’s emotional state. For example:

Doctors’ change in behaviour or attitude can make the patient feel ‘unwanted’. Depression and hopelessness take over his mind and his hopes to get healthy fade away. Fear, frustration and sadness fill his mind. (Participant 3)

These findings support evidence from other studies regarding the lack of a trusting doctor-patient relationship, which can negatively influence patients’ levels of satisfaction (Stewart 1995; Parker et al. 2003). It is evident from my findings that, if doctors fail to communicate in appropriate ways with patients, the lack of trust and subsequent lack of motivating and encouraging behaviour may adversely impact on the psychological wellbeing of the patient, and potentially on the clinical outcome.

My findings are similar to those of Fogarty et al. (1999) and Ommen et al. (2010), but additionally provide a deeper, more meaningful contribution to the hitherto poorly researched field of patient satisfaction from the perspective of the KSA context. It would also indicate that more disclosure of health information is important to enhance the doctor-patient relationship and this in turn – based on the evidence that good communications improve patients’ well-being (Aljubran, 2010) – would lead to better health outcomes for those being treated in an oncology setting. 

5.3.1.5  Care and compassion  

The analysis revealed that a further communication aspect that can have a significant influence on patient satisfaction is when doctors show compassion and care. The compassionate behaviour of physicians is defined by Carmel and Glick as ‘strong devotion to the welfare of the patient on two crucial dimensions of patient care: technical and socio-emotional’ (1996, p. 1253). Doctors perceived as caring and compassionate with patients may provide an element of emotional healing, which could be viewed as a determinant of patient satisfaction (Fogarty et al. 1999; Bertakis et al. 1999). 

Many of the participants frequently reported experiences associated with compassion and caring exhibited by their doctors, using terms such as tender, understanding, patient, concerned, and reassuring, and indicating a broader definition of care and compassion. For example:

Doctors have been so tender and (re)assuring. (Participant 13)

The doctors were concerned about me and wanted me recover soon. (Participant 15)

Many also directly alluded to the concepts of compassion, or lack of compassion, when discussing the care they had received from doctors. The absence or presence of compassion clearly had an impact on patients’ overall level of satisfaction with their care. These findings evoke the understanding that an important dimension of patient satisfaction is the ability of the doctor to relate to and engage with the patient as an individual or, as highlighted in the 2001 IOM definition of the patient centred approach, to be concerned with the ‘needs, and values [of the patient], and ensure that patient values guide all clinical decisions’ (IOM 2001, p. 40). 

The perceived lack of compassion may have been attributable to doctors’ avoiding close engagement with some patients due to the practice of disclosure of certain health information to families rather than patients. Another possible explanation is that expatriate doctors for whom Arabic is a second language experience difficulty verbally expressing care and compassion to Saudi patients. These expatriate doctors may feel in particular constrained about communicating with patients in the context of the requirements regarding the non-disclosure of information to patients.

The findings indicated that some participants had experienced compassion and care from their doctors according to these terms, which in turn helped them to feel more comfortable in discussing their concerns with the doctor; this also made them feel the doctor was truly interested in their recovery. The following extracts illustrate this:

The doctors were understanding about my need for a sitter^[1]  and sent me a social worker to facilitate that during my stay. (Participant 20)

The doctors were compassionate enough to give me a few minutes (out of) their busy routine and listen to my concerns. (Participant 10)

These extracts convey that compassion and care was shown towards these patients by showing that the doctors understood and responded well to their personal circumstances, paying attention to their concerns and preferences.

In contrast, other participants commented that the doctors showed inadequate compassion in their communication with them and appeared uninterested in their personal well-being. Thus, these patients felt discouraged from asking questions, and this constraint reportedly made it more difficult for them to cope with their illness:

They don’t have time to talk to patients and everything is so routine to them that they don’t have compassion towards the patient. They just ask routine questions and provide general reassurance. I am suffering so much of it without any psychological support from doctors. It is really difficult for me to cope.  (Participant 19)

The doctors are not compassionate at all. They just asked a few questions about our illness but never appeared concerned with our psychological state. (Participant 21)

Two main findings emerge in relation to compassion and the doctor-patient relationship. First, there is a link made between compassion and coping (psychologically), with the implication being that an absence of compassion impacts negatively on the ability to cope. Second, the appearance of a lack of concern on the doctors’ part is recurrent within the participants’ narrative. ‘Concern’ is here distinguished from basic communication, the implication being that it is more than just asking questions, rather it requires a ‘patient-centred’ attitude that achieves a balance between meeting the patient’s clinical and psychological needs.

Expatriate doctors for whom Arabic is a second language may be hindered in expressing care and compassion by the language barrier between themselves and Saudi patients. The language barrier may mean that they appear detached from their patients and not appear as empathic, especially as they may also lack cultural sensitivity.  The current study’s findings agree with previous research that indicates the positive impact of doctors’ compassion on decreasing the level of anxiety in cancer patients, which in turn increases the level of patient satisfaction and results in improved medical outcomes (Fogarty et al. 1999).

Patients’ satisfaction in an oncology setting was related to the important role that the doctor plays in all aspects of their recovery, and highlighted the need for excellent interpersonal skills in order for them to fulfil this role effectively:

To me, doctors aren’t diagnosticians only but also the ray of hope. Their behaviour, words and facial expressions are important to me, and the means by which I judge the chances of getting well. (Participant 3)

By interpersonal skills I mean the communication skills and compassion. They need to have more kindness and empathy. Here doctors are good — I don’t say they are bad — but in the situation of these skills and characteristics there is a lot lacking. (Participant 18)

A comment from one of the participants summed up the importance of the interpersonal aspects of the doctor-patient role, which appear at times to be disregarded by the medical profession, but which are often the standards by which doctors are judged by patients:

The patients classify doctors on an additional criterion that is ‘behaviour’. The doctor who’s good at his job but isn’t so supportive or caring is designated as a bad doctor, while the doctors are selected by hospitals on the basis of their abilities and experience. (Participant 3)

These findings suggest that it is not only doctors’ medical expertise that is valued but, also their interpersonal communication skills and the level of trust, compassion and ‘felt’ concern that they bring to their relationships with patients. It also suggests a disagreement between what patients value in a doctor and those attributes and values considered by doctors and important to the organisation. Non-disclosure, and language barriers may all interfere with doctor’s expression of care and may make them appear as remote figures, who show ‘detached concern’, rather than empathy. This may be a factor in patients constructing their experiences when interacting with doctors in a negative way.

5.3.2   The nurse-patient relationship

Findings in this theme can broadly be divided into two elements, which interplay to varying degrees, and show varying experiences of the nurse-patient relationship. The first of these is the sub-theme technical competence, relating to nurses’ professional skills at administering medication and other treatment. The second sub-theme is nurses’ perceived level of interpersonal skills, which are defined as encompassing a caring attitude, showing compassion, and being available to respond to patients’ needs. Beginning with an overview of participants’ overall impressions and general perception of the nurse-patient relationship, the following sections outline each of these key areas in turn, analysing their interplay.

5.3.2.1    General perceptions of the nurse-patient relationship

The majority of participants recognised the importance of the nurses’ roles and were appreciative of their help and attitudes. Those reporting positive experiences when describing their relationship with nurses used words such as ‘kindness’, ‘supportiveness’, ‘accuracy’, ‘responsiveness’, ‘trustworthiness’, and ‘understanding’, as the following extracts show:

They are always willing to help us. It’s so inspiring that despite their busy routine they like to wear a kind and reassuring smile on their faces. (Participant 13)

The nursing staff was very dedicated. They provided a great deal of help and support. They attended to each patient with a smile and performed their work diligently. They made my stay comfortable.   (Participant 16)

These comments convey the impact of the nurses’ positive interpersonal attitudes (i.e. being kind and reassuring), as well as their professional qualities and competencies (performing their work diligently), on patient satisfaction.

In contrast, a few participants reported that nurses did not have supportive attitudes, and were sometimes too busy for positive communication. The most noteworthy aspects of dissatisfaction related to issues such as inadequate attention to individual patients’ needs and a lack of psychological support:

Generally, nurses are good but need to recognise the psychological status of the patient by allowing more time to spend with cancer patients when asking questions. (Participant 5) 

The nursing staff is good but there’s a lot of need for further development. They are not able to adapt to patients of different mind-sets, having a generalised attitude which isn’t sufficient at all. And that’s the reason I’m not really satisfied. (Participant 7)

The findings also indicate that, in order to deliver improvements regarding the nurse-patient relationship, there is a need to address organisational constraints. These include the low number of trained nurses at the hospital, which places a strain on their capacity and/or capability. It seems that there is a need to increase the number of nurses and enhance their efficiency so that they can devote more time to effective communication with their patients, as illustrated by the responses of two participants:- 

They are good but they are very busy and there is a real staff shortage. (Participant 1)

The number of nurses is a drawback, as they are limited. Therefore, sometimes I don’t want to bother them to get assistance for the bathroom, so I asked them to teach me how to disconnect the IV plug, and then it was easier for me to help myself. But of course, when I need them they are around and respond well to my calls. (Participant 18)

The last excerpt highlights the awareness that, while nurses’ capacity may be limited, this is not owing to any technical incompetency or lack of care, but is rather an issue of resources. The positive opinions towards the end of the extract indicate that, despite constraints, nurses do make themselves available to help patients with urgent needs.  However, some of participants mentioned a lack of psychological support rather than technical assistance as being the key feature that defined their relationship with nurses:

Nurses need to be specifically trained to deal with cancer patients. They should be aware of our psychological state and their attitude should provide confidence to patients as we sometimes have many questions or are worried about the next appointment or discharge. They should welcome questions and comfort us with patience and kindness.  (Participant 21)

This extract gives the impression that the nurses did not fulfil their role appropriately and failed to offer psychological support, which is important for a patient-centred approach to nursing. Moreover this participant felt that nurses should focus more on communication and relationship building. Overall, it was apparent that a nurse not having sufficient time to interact and communicate with patients was a determinant of patient satisfaction with the nurse/patient relationship. These findings concur with those of Shattell (2004) and Rachiadia (2009), who indicate that patients want nurses who are approachable, available, empathic and willing to talk with them, as well as nurses who are not rushed because of their workload and responsibilities.

5.3.2.2    Nurses’ technical skills

Having confidence in professionals’ technical competence represents one of the most important underlying indicators of patient satisfaction or dissatisfaction with nursing care (Dowling 2008; Wagner and Bear 2009; Zhao et al. 2009). The findings indicate that patients generally have positive attitudes towards nurses’ technical skills. Most of the participants highlighted the proficiency of nurses’ professional and technical competence, also asserting that such competence helped to build trust between them and the nurses. A recurrent notion that was also seen to be important in the doctor-patient relationship, was “trust” built on patients’ perception of nurses’ expertise:

Nurses are with us all day round. Their technical expertise in preparing accurate drugs, administering them properly at the right pace and constantly watching for any alarming symptoms, are vital for any patient. I am happy that the nursing staff attending to me were all expert in their profession and I did not face any trouble during my stay.  (Participant 16)

Their time management and team work impressed me a lot. They were overburdened yet they managed to deliver the correct drug at the correct time to all the patients. They were well organised and very professional in their job. (Participant 17)

The nurses were very professional and have good experience. They took enough care to be accurate with indicated treatment. Whenever they had a doubt they consulted the doctor to be accurate. I am impressed with their competence.   (Participant 15)

These comments reveal a high level of satisfaction with the attendant nurses, which in turn had a positive influence on patients’ constructions of their interactions with nurses.

In contrast, some participants had less positive experiences, in particular voicing uncertainty or concerns over the technical expertise of some nurses. There was often an apparent lack of understanding regarding the nature of the chemotherapy treatment being administered and anxiety over the accuracy of its administration. Such concerns could stem from the fact that the ultimate objective of these patients was to cure their cancer and survive the illness, which depends directly upon the technical skills of the nurses supporting them. The following are examples of these experiences; that is, of problems arising from a deficit in nurses’ skills or knowledge:

In my first visit a nurse had almost given me the very strong tablets intended for my neighbouring patient. But fortunately she realised her mistake in time and I threw up the medicine. Since then I keep a keen eye on my medication. (Participant 6)

Medication administration seems the most important technical skill to me. Nurses should consider the medications they control for patients. They work so closely with patients that they are for the most part the ones who capture drug slips made either by the pharmacist or prescribing doctor. Drug handling is important as well. (Participant 6)

Some participants made several constructive suggestions regarding what could be done to improve the relationship between patient and nurse and implying that more could be done to make their experiences more satisfying in an oncology setting.  Examples of possible improvements in the patient-nurse include better time management, better explanation of medication administration and, in particular, enhanced skills at inserting intravenous lines. It was also emphasised that nurses should be better trained to ensure the optimal skills in intravenous therapy, as one participant states:

Hate anaesthesia, it makes me feel very uncomfortable. And it feels even worse if the nurses have to try 2 or 3 times to insert the medication. I wish that nurses could learn to do it and get well trained at it so they would be able to do it with one attempt. (Participant 13)

Researchers argue that patients often view optimum nursing care as a combination of practical skills and professional knowledge, which are agreed as fundamental to all nursing practice (Halldorsdottir and Hamrin 1997; Calman 2006; Duff 2013). From a nursing perspective, competence has been defined by ICN (2005, p. 6) as ‘the effective application of a combination of knowledge, skill and judgment demonstrated by an individual in daily practice or job performance’. Specifically, in terms of nursing definitions, competence reflects the following: knowledge, understanding, and judgment; a range of skills, including cognitive, technical, or psychomotor and interpersonal; and a range of interpersonal attributes and attitudes (ICN 2005). This definition describes a fundamental requirement which influences the quality of care of the participants. The findings of the current studythe current study suggest that there is a need to address nursing competencies, especially in relation to medication administration and the insertion of intravenous lines for chemotherapy.

5.3.2.3    Nurses’ interpersonal skills

Participants mentioned several aspect of nurses’ interpersonal skills as significant: 1) being caring, supportive and compassionate; 2) paying attention to the patients’ psychological as well as medical needs; 3) responding appropriately and taking time to listen and understand the patients’ needs; and 4) ensuring they are available whenever patients need them, even when overloaded with work. By embracing all of these, the nurse-patient relationship was seen to have the potential to evolve into a trusting relationship.

5.3.2.4 Care and compassion

Participants generally felt that nurses should be able to understand patients’ needs. Some vital interpersonal skills that were highlighted related to the level of nurses’ supportiveness, care and compassion. A connection was apparent between the levels of care and compassion shown by nurses and the motivation of patients to get better, which, in turn, related to patients’ level of satisfaction with their care:

They spent time talking with me. I found it so lovely and caring and sensitive to my needs, I really appreciate them and their way of dealing and sharing with patients. I see this as very important to cancer patients, to be surrounded by good nurses who are willing to accept and talk and dedicate their time to us.  (Participant 8)

They were caring towards me... Their kindness and sympathetic attitude were always encouraging and helped me to cope during my stay, thank God… They always asked me if I had any complaints or if I needed pain medication. Even if I rang them they were quick to respond and provide me with comfort and help during either their day or night shift. (Participant 20)

In contrast, other participants reported negative aspects of their interpersonal relationship with the nurses, including inadequate attention to the individual patient’s needs and a perceived lack of understanding and failure to supply support. There are several possible reasons for this, including the work load of the nurses. The non-disclosure issue may influence nurses’ attitudes to communicating with patients. They may interpret the non-disclosure requirements of some families as meaning that they must avoid their communications with all patients or they may seek to minimise communication to avoid patients, especially female patients from asking questions, which the nurses are prohibited from answering. This will mean that patients build their interactions with nurses as being unsatisfactory. 

Some participants also noted that nurses did not always have enough time to give patients adequate attention. This was complicated by the fact that some of the nurses were non-Saudi nationals, for whom Arabic was a second language:

Generally, the nurses are good but need to recognise the patient’s psychological state by allowing more time to spend with cancer patients when asking questions. They should also ask for a translator if the patient can’t understand some points in conversations, such as helping with room transfer from a shared to a single room. (Participant 5)

This again raises the issue of resources of time and cost for translation, specifically, the challenge of expatriate nurses, who potentially do not have adequate capacity to develop trust and good communication with patients. This may also be due to a lack of proper language training, specifically Arabic. Previous research indicates that, without a shared culture and language, it is difficult for expatriate nurses to deliver effective nursing care to Saudis (Al-Shahri 2002; Al-Dossary 2008). The language barrier may lead nurses to appear as detached and remote to the patients. This is contrary to the patients’ expectations of how a nurse should behave and act (Rchaidia et al. 2009). Such barriers will lead to patients construing their experiences with some nurses, as being unsatisfactory.

The finding discussed in this section have shown the importance of nurses being perceived as compassionate and caring by patients, features that have been highlighted in cross-cultural studies. For example, a review by Rchaidia et al. (2009), who investigated cancer patients’ perceptions of the ‘good nurse’, indicates that the personal characteristics of being caring, showing compassion and relating to the patient as a person are fundamental traits, which pertain to both western and eastern cultures. My findings would suggest (as in the case of the doctors) that cultural attitudes and the language barrier may interfere with nurses’ ability to express empathy and care that is expected of them by patients. If nurses are perceived as not acting compassionately and expressing care then they are not acting in ways that a patient can construe as appropriate or satisfying.

5.3.2.5    Availability: ‘Being present’

The findings demonstrate that several participants had a positive attitude towards nurses’ availability and their time management during care provision:

Their time management is commendable. They attended each patient with great competence. They performed their duties… dedicated enough time to each patient. (Participant 15)

However, other participants noted that nurses were sometimes too busy to give patients the attention they needed:

They just need more time to spend with patients as they have a staff shortage and the nurse couldn’t spend time with me when I asked or called in the afternoon... Then they do attend…  but they just need to be faster… one nurse who was caring for me had two beds in the room to look after so I always felt too shy to ask her for help with walking or the bathroom as I could see she was busy and couldn’t help me. (Participant 5)

The emphasis was on nurses being present and devoting the appropriate amount of attention predominantly to patients’ physical needs, but also to psychological needs, since the right attitude can make patients feel more comfortable. According to Rchaidia et al. (2009), this state of ‘being present’ both physically and mentally in terms of their openness to patients’ psychological needs, is an important indicator of a good nurse, based on the perceptions of cancer patients.

5.3.3     Contextual factors relevant to cancer in the KSA

 The third theme which is contextual factors seen as specific to the context of cancer in the KSA, also emerged as important to patients’ perceptions of treatment and the level of care being provided. The subthemes of the contextual factors that found are: the patient perception of cancer, culturally endorsed power dynamics regarding the doctor-patient relationship, the influence of religion, the role of family, and the effects of a multi-cultural hospital environment. The next section presents findings from the   analysis of interview data regarding these subthemes that emerged from the current study.     This facilitates identification of key factors relating to the KSA cancer context.

5.3.3.1    Patients’ perceptions of cancer

Patients within the KSA view certain illnesses, such as cancer, as being of greater medical priority than other forms of disease or illness. Therefore, oncology patients believe they are deserving of greater attention from medical staff and require better treatment conditions. The following quotes illustrate this:

Yes, oncology patients must have priority in appointments for labs or x-ray. (Participant 8)

Organisations should learn to treat cancer patients differently to other patients. They should understand that time is of utmost importance in our treatment. Any delay on their part could have a devastating impact. They could help us a lot by improving the pace of functioning. (Participant 1)

These extracts convey some participants’ perceptions that oncology patients should be given priority in accordance with their special requirements. The second extract, in particular, emphasises the urgency with which the need for treatment is perceived, with words such as ‘priority’, ‘delay’, and ‘pace’ in both extracts denoting the importance of timeliness.

Illness, particularly cancer, is perceived in various ways depending on national or regional cultural factors. In the context of the current study, participants’ perceptions that cancer should have priority status in terms of treatment may be drawn from the cultural beliefs of the KSA that cancer is likely to be an imminent death sentence. For example, one participant commented:

I never knew about cancer and its treatment. In my mind it was just one fatal disease and I knew nothing else about it. But when I came here and the tests confirmed that I had cancer, I started believing that I would be dead in few days. (Participant 12)

Similarly, cancer has been found to carry a social stigma worldwide (Goffman 1963; Albrecht et al. 1982; Chapple et al. 2004; Rosman 2004). However, Joffe (2002) has argued that fear of cancer has decreased markedly as medical knowledge and success rates have increased. Nevertheless, the my findings indicate that cancer within the KSA is perceived in ways that go beyond stigma alone; that is, as a fatal disease which can evoke a strong fear of death.

Another factor that has been found in other studies to impact on oncology patients’ satisfaction is the treatment environment (Gotlieb 2000; Ulrich et al. 2004; Rowlands and Noble 2008). Related evidence has emerged in the current study, where patients’ main concern was not being able to have privacy. The following participants emphasised the importance of having a single room, as being in a shared arrangement adversely affected them physically and psychologically:

I feel so shy when I have nausea in a shared room as I can’t tolerate the smells of food during lunch time. That’s why I am so irritated at sharing a room with someone. But if I am in a single room, I feel comfortable and free to request from the nurse that no food should be supplied to my room due to my severe nausea. (Participant 3)

Having a single room is important for me because I feel comfortable when I can sleep and rest with no noise, and can have a quiet place to rest and read the Quran. I prefer to be alone and not to socialise with people during my stay as staying with people increases my worries and fear as other patient have different treatment and stages, which is not always encouraging to me. (Participant 5)

For example, high-quality environments with high levels of support seem to be associated with higher levels of patient satisfaction, especially for the most severely compromised patients (Timko and Moos 1998a). The findings of the current study also demonstrate the importance of a treatment environment that is sensitive to oncology patients’ needs, particularly the need to be able to express the physical symptoms of their illness without fear of shame or embarrassment. Being unable to do so has a negative psychological effect and may even make patients feel uncared for and despondent over whether they will get better, as the extracts illustrate. A central desire was for a private space if they were very ill. These findings indicate that patient preferences are deemed to be an important element in providing patient-centred care, thus influencing the level of cancer patient satisfaction.

As these findings have shown, patients’ perceptions of cancer specifically in the KSA context, and their experience of the treatment environment both contribute to their perception of the treatment they should be receiving, and the quality of actual care they feel they are receiving. The following sections elaborate on the other key contextual factors affecting this perception.

5.3.3.2         The influence of doctor-patient power dynamics

As shown in section 2.5.2.4 in chapter 2 and section 5.3.1 of chapter 5, the doctor-patient relationship in the KSA context is typically mediated by the perception of doctors being powerful figures of authority whose word should be trusted, rather than encouraging dialogue or discussion between doctor and patient for purposes of shared decision-making.

Patients’ perceptions of doctors in the KSA, and the power imbalance that occurs, can be seen as closely related to the conventional role of physicians in KSA culture. Whether or not they are native to the KSA, doctors are considered to be highly respected figures of authority (Elzubier 2002). As one respondent commented:-

The relationship with doctors is important to every patient. We actually give them, after God, the authority over our body and illness, so having a good trusting relationship with my doctors keeps me calm and satisfied. (Participant 9)

Doctors are positioned as the ultimate human authority on health, who, by implication, have the necessary knowledge and skills to administer whatever treatment is best for the patient, and therefore should not be questioned. This view, in turn, lends itself to a top-down power relationship between some patients and their doctors, as the following extracts illustrate:

The doctors were not interested in patients’ mental condition. They took care of treatment and that’s it. We could not feel comfortable enough to express our concerns to them. This has adversely affected the whole situation by making us feel unmotivated. (Participant 19)

In the beginning, I had endless fears and doubts but I wasn’t able to talk about it with my doctors. I had once tried to tell them about it but they shooed me away and since then I never gathered enough courage to communicate openly with them. (Participant 7)

Both of these extracts imply a sense of being intimidated or ‘not comfortable’ with doctors. In particular, the fact that the second participant’s anxiety is not adequately listened to and the necessary knowledge is not shared highlights an unequal balance of power and control in the patient-doctor relationship. Participant seven’s emphasis on (lack of) ‘courage’ suggests a state of feeling intimidated by those who have the power to allay the fears and doubts associated with the illness. The participant’s feelings may stem from the fact that families wish to restrict information, a cultural attitude. This means that patients can feel anxious because they have little or no information on their treatment keeping them in the dark and questioning the treatment options chosen for them. The anxious feeling and the feeling of being shut out of making decisions of their own body leads to their dissatisfaction of the healthcare provided to them. Patients such as participant seven desire to overcome the family restrictions that are placed on them terms of their treatment and giving them the sole right to decide about their healthcare. 

In contrast, several patients mentioned feeling very well-informed by doctors, to the extent of feeling they knew whether their illness would be cured or not. Given the strong cultural context at work, this effect can be seen as part of the high regard in which doctors are held in the KSA. As one respondent stated:

The doctors in oncology were so respectful and helpful, they tell me everything about my condition and options for treatment such as surgery, chemo and radiation, also they were honest about prognosis and this was so important for me to know (whether my disease is) curable or not. (Participant 8)

This finding also reflects a cultural shift in doctors’ information provision to patients in the KSA as evident from the experience of the participants in the current study, indicating that they are increasingly providing patients with full details about their condition, such as the prognosis.

As discussed in chapter 2, studies conducted in the KSA and internationally (Al-Ahwal 1998; Tanaka et al. 1999; Al-Amri 2010) provide evidence that patients prefer to have full disclosure of information about their illnesses. In contrast, surveys of physicians in the KSA (Bedikian et al. 1985; Mobeireek et al. 1996) have revealed their preference for discussing patients’ condition and treatment with patients’ close relatives rather than with the patients themselves. More recently, however, there has been growing public awareness of medical issues, as well as ethical pressures, in the KSA that are reportedly driving a change in doctors’ attitudes and behaviour, with full disclosure of diagnosis to the patient rather than their relatives becoming more common (Sokol 2006; Mobeireek et al. 2008; Al-Amri 2010; Aljubran 2010). The current study’s findings support that doctors in the KSA today provide full disclosure of information to oncology patients which implies that it has become a norm, however, if the family has expressly stated that a patient is not to be informed of about their health or treatment doctors do not do so.   

Considering these cultural factors, it becomes evident that the perceived power imbalance between doctors and patients can affect patient satisfaction with care either positively or negatively, depending largely on the interpersonal dimension, that is, the capacity and the way in which doctors deliver the relevant information. Some of the participants indicated the ideal power balance they would like to have with doctors, including a preference for an open and trusting relationship in which they could feel comfortable discussing any of their concerns in a sensitive manner. The following extracts illustrate these expectations:

A patient should trust and be able to depend on his doctor. This relationship develops with understanding and interaction. Doctors shouldn’t be the medicine/treatment prescribers but also a counsellor. (Participant 21)

The personal skills of the doctors here need much improvement as they should consider the psychological state of the cancer patient. I want them to deal with me in a kind way and consider that their attitude will affect the patient, like if they didn’t listen or just try to be in hurry during visits. (Participant 7)

This apparent change of attitude where patients wish to build relationships of trust with their doctors and openly verbalise their concerns is surprising in a KSA context. This preference for patient empowerment and advocacy is arguably at variance with cultural norms in the KSA. These patients’ attitudes, and their emphasis on doctors’ ‘kindness’, represent a shift towards the need for a more western and patient-centred approach involving active patient participation in care.

5.3.3.4    The influence of religion

In the current study, a major point to consider was that the religion of Islam is the main aspect shaping the culture of the KSA. Many of the participants indicated that their faith affected their perceptions not only of their disease, but also of the care they received. These findings add to other studies conducted in KSA which have drawn the importance of faith in receiving healthcare, particularly the study conducted by Halligan (2006) who argues that Islam is a contributing influence on patient satisfaction. He highlights the way in which the influence of Islam can be felt in every aspect of patient care. All of the participants in Halligan’s study, who were expatriate nurses, recounted that everything people do is centred on religion, and it is the main way of life. Consequently, Halligan (2006) correlates patients’ attitudes towards their illness with their religion, which is identified as ‘central to the provision of caring’ (Halligan 2006 p1565). The current study adds to the discussion produced by Halligan (2006) as it brings to surface the impact of religion on patient’s assessment of healthcare delivery while Halligan (2006) focused on experiences of nurses.  

In the current study, participants indicated that their belief in God was more powerful than medicine. In addition, some of the participants stated that it is their faith and connection with God through prayer that helps to keep their spirits up, as one person stated:

  I believe that my disease has been gifted from God as a test to see how I will be patient and deal with this fact; therefore, I accept my destiny of cancer and I will be working hard to deal with recovery by praying first to God to help me and then also to help my doctors to cure my disease in the near future, Inshallah. (Participant 8)

These finding are in line with other research which conveys the positive influence of religion on coping with cancer; specifically, some have argued that cancer patients in Islamic countries have better coping mechanisms than those in other countries (Ezzat et al. 1995; Young et al. 1997; Silbermann and Hassan 2011). The current study uses patients directly as participants and adds to other research which used doctors or nurses to assess the impact on faith as a coping mechanism when dealing with cancer.

The emphasis on the spiritual dimension of coping in illness was also evident through the fact that SRCCs have visiting religious scholars, who are on hand to lend patients moral support and spiritual guidance through their situation, and some of the participants commented on this aspect of their care:

The weekly official visit of a religious scholar was very helpful and motivating for me and other patients. I felt so great during religious scholar visits and really need the hospital to consider his visits to be daily for patients, as this reassured me and helped me a lot in my spiritual condition during the treatment. When I felt lost I wished to see someone who could connect my heart with God so I could find some peace. (Participant 7)

Religious lectures on Islamic affairs are needed to bring positive changes for us as cancer patients. (Participant 12)

These extracts demonstrate the importance placed on spiritual health by these oncology patients, and highlights how a visit by a religious counsellor or a lecturer on religious themes can fulfil the spiritual needs of the patients. This fulfilment is also shown to improve their mood and confidence about their situation, as conveyed through language such as attaining ‘peace’ and ‘positive changes’.

However, other participants presented contrasting views by emphasising their belief that the doctors and nurses were the only ones who could help them:

I believe that they are the only ones who could clear my mind about my situation. (Participant 10)

This extract echoes the other dominant cultural context that is relevant here, that is, the conventional perception of physicians in the KSA, who are seen as highly respected figures of authority (Elzubier 2002).

5.3.3.5    The influence of family

The principal idea of family is fundamental to the provision of care within the KSA. This is further supported by Halligan (2006) and Younge et al. (1997), who argue that the importance of family has a direct impact on the perceived level of care by the patient. This is especially the case with the family’s ability to influence doctors’ disclosure of information to a patient. These researchers describe family involvement as pivotal to the experience of the care being delivered and as a significant factor affecting the emotional, social, and psychological well-being of the patient.

In the context of the current study, family members were viewed as the principal decision-makers who often dictate the care that patients receive, including the extent of the care to be given. For example, participants in the current study recounted both how families help to direct their treatment and also offer vital moral support:

Thank God my family are with me; this helps me bear the after effects of the treatment. (Participant 21)

However, while the patient’s family has significant influence on the care to be provided, patients still look to the medical staff, such as their doctor, for ultimate guidance and explanation of treatment prior to making any decisions. In the following extracts, participants underline the doctors’ involvement in the process of informing family members as well as the patient him/herself:

But my mother wasn’t able to understand and she was very afraid. The doctors calmed her down and assured her that they wouldn’t be doing anything wrong to me. (Participant 13)

They explained all about the treatment to my husband. (Participant 22)

These extracts underline the critical role of the family, in that they are physically present at key diagnostic stages; the implication here is that they are then expected to be involved in subsequent decision-making about treatment. This is in line with other findings that, in developed countries, patients often demand more resources, i.e. medical staff attention, to be available to their family (Given et al. 2001). However, these extracts also emphasise the continuing importance of medical staff not only for informing and reassuring the patient, but also for reassuring all members of the family. Thus, while the family can be a determining factor in terms of care, patients are also aware that professionally trained medical staff are essential in providing clarification and ultimately informing treatment decisions (Given et al. 2001; Ezubair 2002).

However, the influence of family, although fundamental is still bias towards females. As noted before, female patients in KSA need the presence of male guardians which can be their father, husband, or son depending on their marital status. The treatment decisions of female patients fall on the father or brother if she is unmarried, on the husband if married, or on the son if widowed or divorced with children. This contrasts to the role that women have when the patient is male. The treatment decision making, disclosure of information, and advise given by a doctor or nurse in the case of male patient is restricted to the male members of the family. In the case of a male patient, the wife is not the sole decision maker for her husband, the male family members of the patient are the ones who are handed the responsibility of decision making and being the main point of contact for information. This is due to the societal hierarchy framed from cultural beliefs within KSA which is male-centric and male dominated. 

5.3.3.6    The influence of the multi-cultural health care environment

The health care environment and its own cultural context play a vital role in patient satisfaction (Rafii et al., 2008). A major cultural factor in terms of the KSA hospital environment, and prevalent in the specific SRCC examined in the current study, is the presence of largely expatriate nursing and medical staff from all over the world (in particular South Africa, India and the Philippines) who are unlikely to speak Arabic (Luna 1998; Al-Dossary 2008). In particular, the expatriate nursing staff were found to affect patient satisfaction in that their difficulties with the Arabic language created some tension in communicating with patients. Many participants noted that they could only express their emotions and needs clearly in Arabic languages, which these nurses were not always able to understand fully. As several participants commented:

Their language is a bit of problem; it would be easier to communicate with them if they were capable of speaking Arabic.  (Participant 10)

Communication skills are the most important, for example, being able to talk freely and ask about treatment, but in my opinion the nurses need to understand more of the Arabic language to be able to deal with patients easily. (Participant 5)

Inadequate communication arising from language barriers can be seen as a determinant of these patients’ satisfaction level, frequently causing a loss of rapport with nurses. Accordingly, Arabic-speaking nurses were deemed more likely to provide the optimum psychological support and to be able to meet patients’ medical needs than non-Arabic speakers. Evidence of language barriers in communication between the patient and their nurses has been reported by a number of studies in the KSA owing to these nurses frequently being non-KSA nationals (Al-Shahri 2002; Attalah et al. 2013). As previously mentioned, there is, however, currently a drive towards employing greater numbers of Saudi Arabian nurses or Arabic national nurses as part of the Saudisation process (Al-Malki et al. 2011). 

Because of the multi-national mix of personnel, including many non-Saudi doctors, English was the default language being spoken among professionals in the presence of the patient, and this could create a feeling of anxiety in the patients. The following extract illustrates this:

For example, the doctor saw me and requested some tests or radiology; then I asked the nurse, but she said there was no instruction written by doctors, so I felt lost between doctors and nurses because doctors speak English with them in front of me, which is difficult for me to understand – is he requesting something or just talking? That’s why I felt worried and asked a lot if doctors were requesting tests or x-rays. (Participant 5) 

In this patient’s case, the language barrier negatively affected the way patient constructed their experiences. The use of English rather than Arabic by the medical staff led the patient to feel excluded from discussions about his/her own health, and created a sense of dissatisfaction with the care they were receiving. The issue of the language barrier here overlapped with the requirement of non-disclosure to the patient, thus compounding the potential problems with establishing a personal relationship between expatriate nurses and Saudi patients.

Personal relationships can only be established when communications are possible. The fact that a nurse and patient only have limited communications mean that a nurse can appear as not engaging with a patient or may appear as being inattentive. The ability of a nurse to establish a relationship is further impacted by the fact that they often have to ensure that they don’t disclose information to a patient at the request of the family which is considered a norm of non-disclosure in the KSA healthcare setting. This may make nurses unwilling to spend time and interact with a patient. The language barrier and non-disclosure means that often the nurse-patient relationship is not a satisfying one for both parties.

Language barriers must be addressed in order to ensure quality trans-cultural nursing, given the high proportion of expatriate, non-Arabic speakers in the KSA (Luna 1998; Al-Shahri 2002). It can be argued that the gap, identified here and in previous studies, between patient needs and the language barriers of expatriate nurses may adversely affect the degree of care provided, thus lowering patient satisfaction levels (Al-Shahri 2002; Ezubair 2002; Al-Dossary 2008).

This section has highlighted the importance of nurses and other medical staff in oncology wards tailoring their care to patients’ needs and providing a more patient-centred approach, as this can significantly affect patient satisfaction levels.

5.3.4   Organisational factors impacting patient care

This section presents the findings from the study that highlights the organisational factors influencing patients’ satisfaction or dissatisfaction. Based on the participants’ responses, three main factors were identified as important aspects of the service organisation which influenced their overall satisfaction levels: (1) accessibility to healthcare (i.e. having full access to the hospital and permission to use all the necessary facilities); (2) general service organisation and (3) waiting times (i.e. that they should be reasonable and that the staff should be supportive of patients while they were awaiting treatment).

Prior to a more detailed examination of each of these factors, patients’ perceptions of the general service organisation are detailed in the next section. This is followed by a presentation of the findings relating to each of the three key organisational factors.

5.3.4.1    Perceptions of general service organisation

Overall, there was a mix of views among the research participants regarding their experiences of the service organisation, with many indicating that, while they were generally happy, there was some dissatisfaction with the operational structure of the facility. 

The majority of participants who reported positive feedback on the general service organisation talked about both the medical services and overall service organisation:

The referral system is good here.  Labs and other testing services are very good and prompt. I don’t have any problem with them. (Participant 9)

My overall experience with the service organisation during my stay is good. (Participant 4)

In particular, some of the participants emphasised the high level of effectiveness of cancer support services with regard to the non-medical support they received, including that provided by the social workers:

I wish them all the best as this main referral hospital deals with a large number of patients and still manages to have great services available to us, such as a social worker and Saudi cancer society officer, who always support me. (Participant 16)

I have the ability to connect freely to the Internet during my stay, as well as social worker services that let me feel happy and rest assured. Also the way they approach me is friendly and helps me feel supported and satisfied during my hospital stay. (Participant 8)

However, some of the participants reported negative experiences of the organisation of medical services. The following extract illustrates this factor:

I had to wait for a long time to obtain the approval of referrals.  My treatment was delayed because of a delay at the lab. Sometimes it was really troublesome to get things done with them. (Participant 19)

The previous extract highlights one of the most problematic issues, as several participants reported long waiting times for referrals, admission and for labs. The waiting time for psychiatric services was also seen as problematic:

Other services like referral took a long time, it took a long time to get   appointments and it was very uncomfortable to be seen by psychiatric services after 1 month. Generally, I don’t like this waiting time because I feel more worried and less assured, which sometimes makes me feel unstable and anxious during my stay. (Participant 3)

These findings demonstrate that, while there are positive findings regarding the healthcare services, there may be a need to improve certain aspects of service provision for oncology patients, particularly with regard to waiting times and doctor availability. The following interview excerpts emphasise this point:

It’s worrisome and irritating to wait so long. Especially for cancer patients, it’s even more irritating to wait. I don’t like it when hospital management forget about the psychological state of their patients. (Participant 13)

What is needed is making more doctors available to oncology patients. (Participant 3)

The opinions arising from these excerpts and discussed throughout this section show that there are several organisational policy factors that may be at odds with patients’ preferences for the treatment setting or logistics of care such as referrals that are not seen as fast enough and a shortage of medical staff on oncology wards.

5.4.4.2    Accessibility to health care

Participants in the current study reported positive experiences regarding access:

It was good and I didn’t face any problems with it as it was well arranged. There were always supportive services, for example from the social worker or from the cancer support society. (Participant 20)

The admission process was good, well ordered. I didn’t have problem in waiting for admission or referral; it was perfect during my stay.  (Participant 8)

In contrast to these positive experiences, some reported several problems with accessing the hospital and its facilities; the following is an example:

I remember the trouble I had to bear at my first CT scan. Firstly, it was crowded all the time and the personnel didn’t bother to do things quickly. I had to wait for two hours to get it done. According to them, it was a busy day, but I think if it’s better organised or there is a separate clinic for oncology it would benefit us more and improve our experiences. Also, referrals and labs have been working at a poor pace. My referral to an orthopaedist took three months; I was already on pain medication but still looking to see a specialist as soon as possible to get a clearer idea about the knee pain. (Participant 18)

Sometimes I got correct information but most of the time it was very confusing. There is lack of coordination between departments and nobody is in a position to provide all the information. The people here were also unconcerned with the trouble of the patient.  (Participant 19)

These negative experiences relate mainly to the slow pace at which care was given, and the lack of coordination in information giving or confusion regarding the information actually provided. Timeliness was closely linked with efficient access to services, and impacted adversely on patients’ satisfaction if it was not present. In addition, patients’ criticism of crowded circumstances also denotes the importance of the hospital environment when accessing it, which the following section explores in further detail.

5.4.4.3    Waiting times for services

Waiting times are one of the indicators that have been found to influence patients’ perceptions of the health care service and lead them to construct their experiences with it as satisfactory. In the current study, the waiting times for services were mainly positively assessed by the participants, as these extracts show:

I had a very good experience with the service of the organisation during my stay. There was well organised admission in a timely manner, and that was excellent. (Participant 16)

I feel so comfortable and like the earlier arrangement, such as getting my blood test earlier before going to the admissions office, which means that I can process my admission after the oncology staff confirmation, so that is very well arranged and organised and then I will just be waiting for doctors to be seen directly and treatment to be started. (Participant 8)

In contrast to these positive experiences, some reported that usually admission took longer and they had to spend time waiting in the emergency room for oncology doctors to decide and agree about admission. If patients book ahead for the admission process, it becomes easier and means that they can reach the doctor easily without a further waiting period. The following extracts demonstrate several patients’ dissatisfaction with admission and referral times:

I have been referred to two different doctors – a psychologist and neurologist – and neither of them have any available appointments; it has been almost a month now. It has been really hard for me to wait for so long. (Participant 11)  

My admission had been delayed for 8 days. Isn’t this unfair and troubling? And the reason behind it is the unavailability of beds in oncology wards. I couldn’t be admitted to any other wards in hospital to receive my scheduled treatment. (Participant 6)

By using language such as ‘unfair’, ‘really hard’, and ‘troubling’, these participants display a feeling of neglect that is experienced by patients being left to wait for long periods of time for medical attention and referrals, in some cases to the extent that they need to seek private care. This feeling of neglect can also be seen as connected to patients’ views that cancer is a priority disorder. Similarly, other professionals have argued that inadequate access to KSA cancer services such as the long waiting times negatively affects the level of patient satisfaction with the care provided (Al-Muziani 1998; Al-Sirafy 2009).

In light of this, another important element to assess is the perceived level of supportiveness of the health care personnel during these waiting times. Participants mainly reported positive experiences, emphasising the staff’s supportiveness, helpfulness and willingness to help:

Whomever I interacted with, they were well informed, nice and patient. They always provided us with the correct information about the services.  (Participant 17)

They are cooperative and helpful in guiding me if I need help such as fixing an appointment or changing the time of an appointment; they have been very cooperative with this. (Participant 8)

However, others noted less positive impressions of their communication with the medical staff during the time they were waiting to receive medical help:

They are good but CT staff need to be more kind and patient, especially with oncology patients. Lab services are usually crowded and need more organisation to make sure they have enough space to accommodate all the patients and not have them always waiting in corridors for a lab call as it's not helpful for patients to be in crowds with their pain. (Participant 3)

Another thing is the lack of psychological understanding among medical staff. They don’t try to understand the patient’s individual psyche. (Participant 6)

These criticisms indicate that medical staff need to act kinder and provide more supportive care, especially towards oncology patients, and that they sometimes demonstrate an inadequate psychological understanding of their patients’ needs.

As the following extracts also show, reference to crowded space and a lack of proper organisation indicates that participants felt that having adequate coordination within the health care system was important, yet was perceived as currently problematic and impacting on waiting times. This is illustrated by one who stated:

There is lack of coordination between departments and nobody is in a position to provide all the information. For example, my next readmission date was not provided until after discharge as the clerk was unavailable that day, so we had to follow this up with them after discharge and my son had to go back to get it confirmed. (Participant 21)

Another connected the problem of long waiting times with the shortage of nurses and the approachability of available staff noting that:

Here the situation is dependent upon the individual personnel; some of them are willing to help and some aren’t. No, I can’t reach out to all personnel if I need, they don’t seem easy going. (Participant 10)

The issues of capacity and problems with staff shortages have been highlighted by some researchers attempting to elucidate the impact of the staffing levels of nurses and the mix of nursing personnel in hospitals on patient satisfaction. For example, one study argues that hospital administrators, accrediting agencies, insurers, and regulators should take action to ensure that adequate nursing staff are available to protect patients and to improve the quality of care (Needleman and Buerhaus 2002). The current study found that good accessibility to health care – in terms of waiting times and availability of oncology ward staff (doctors, nurses) – are important factors influencing patient satisfaction in the KSA.

• Non-disclosure in the KSA setting

5.5      Summary of key qualitative findings

The qualitative phase of the current study has explored the ways in which interpersonal aspects of care and accessibility to health care influence patient satisfaction in an oncology ward setting at the SRCC in Riyadh. It has considered the role of cultural and organisational factors relevant to the health care context, as well as within the wider KSA society, in influencing these satisfaction levels. Four key themes have been identified and explored: (1) the doctor-patient relationship, (2) the nurse-patient relationship, (3) contextual factors relevant to cancer in the KSA, and (4) organisational factors.

A strong emphasis on the psychological as well as physical elements of care was evident; with many patients highlighting that doctor should understand and respond well to psychological state. Nurses’ interpersonal skills were deemed important and impacts on the quality of their experience. Largely, nurses were seen as supportive and understanding. However, some patients perceived the nurses as lacking in compassion and responsiveness, although this was also linked with nursing shortages and the observed lack of time that nurses had to interact with patients. In addition, it is attributable to the non-disclosure policies variability that instructs some nurses not to communicate certain health information to patients.

In relation to KSA contextual factors, it is evident that cultural perceptions of the doctor as a figure of authority and power in relation to one’s health often engendered a top-down power dynamic, where patients felt constrained about asking questions or interacting with doctors. However, other patients recognised the need for a more balanced dynamic of trust and rapport. In addition, there was evidence to suggest doctors are increasingly sharing information with patients themselves rather than with their families, as has historically been the norm in KSA. This departure from longstanding non-disclosure policies appears to promote patient satisfaction.

The multicultural care environment, comprising mainly expatriate nurses, had an impact on patient satisfaction levels. The language barrier with nurses who did not speak Arabic presented challenges to some patients and lowered their satisfaction with nursing care. In addition, the default English-speaking between doctors and nurses engendered a feeling of exclusion and anxiety among some patients.

The findings were mixed relating to patients’ perceptions of the SRCC’s operational efficiency and its impact on their satisfaction with care. While some participants praised the SRCC for its efficiency, environment and admission processes, many voiced strong views in their criticism of two main organisational factors: accessibility to health care and waiting times. These two factors were closely linked. Many patients noted having had to wait for long periods of time to be admitted to hospital, whether for a referral, or to gain access to a laboratory test or results. This, in turn, compromised their access to the treatment they needed and greatly lowered their levels of satisfaction with the services offered. 

The norm of non-disclosure was considered a common factor that influenced patient satisfaction as seen through the analysis of the all the four themes and their subsequent subthemes. Non-disclosure is complex issue in KSA which contrasts to the general perception of non-disclosure in the Western context. In the Western context, the patient is the key individual who is responsible for the decision making in terms of treatment, interaction with doctors and nurses, and acquires crucial information about their health which they deem sensitive. This Western form of non-disclosure links very closely to doctor-patient confidentiality. However, in the KSA setting non-disclosure is the total opposite as analysed from the findings. Non-disclosure in the KSA setting means that information regarding the health of the patient is disclosed to the family of the patient, and the family decides which information is disseminated to the patient.   

The current study’s qualitative findings add to the plethora of knowledge of interpersonal aspects that was focused on healthcare professionals exclusively. However, the current study expands to the knowledge of how interpersonal aspects of care coupled with service organisation influenced the level of patient satisfaction in the KSA oncology ward settings. Through the evidence extracted from the findings it can be concluded that patient satisfaction is closely linked to specific contextual factors that are related to the themes which have been discussed in this chapter. 

^[1] Sitters are commonly relatives of the patients who, at the patients’ request accompany them during their hospitalisation, offering moral and practical support. Typically, patients are required to ask for their doctor’s permission to have a sitter stay with them overnight.