Oncology Nurses and Pain Management in Saudi Arabia Hospitals

Subject: Nursing
Pages: 22
Words: 6086
Reading time:
24 min
Study level: PhD

Overview of Pain

Pain can be described as an unpleasant sensation that regularly arises as a consequence of destructive stimuli. Simmons, McLeod, and Laird term pain as an “unpleasant sensory or emotional experience associated with actual or potential tissue damage, or described in terms of such damage” (2012, p. 332). A normal, healthy body rarely experiences pain. Therefore, it is right to conclude that pain comes from illnesses since it is the most common symptom of numerous life-threatening ailments such as cancer, musculoskeletal disorders, neuropathic complications, postsurgical pain, in addition to visceral pain (American Pharmacists Association, 2012). Pain has a damaging influence on the physical and psychosocial wellbeing of an individual. It also diminishes the quality of life due to its relationship with other indications such as despair and fatigue (Borda, Charnay-Sonnek, Fonteyne, & Papaioannou, 2013). For these reasons, people in pain seek medical attention to make life bearable. It is known that timely palliative care intervention that entails proper managing of symptoms may enhance the quality of life and significantly boost the chances of survival (Simmons, McLeod, and Laird, 2012).

Several attempts to classify pain have come up with two broad groups depending on the intensity and longevity of pain. These categories are acute and chronic pain. Acute pain has a short duration, and its onset is clear-cut. In addition, acute pain is usually a consequence of the excessive activity of the sympathetic nerves, which is a common happening in conditions such as heart attacks. Chronic pain, conversely, does not have an explicit onset and often occurs in persistent conditions such as cancer. Acute pain is experienced in conditions that only last a few hours or minutes while chronic pain may last for years. One of the most widespread causes of chronic pain is cancer. More often than not, pain arises because of various reasons. Therefore, a multidisciplinary approach in handling pain is essential for the effective management of all aspects of pain.

Global Management of Pain (WHO)

The World Health Organization (WHO) is devoted to the progress of proper management of pain by ensuring the lawful utilization of opioid analgesics. WHO has several programs aimed at facilitating this endeavor. One such program is the Access to Controlled Medications Programme, which supports member states to strike a point of balance between lawful administration of controlled substances because of medical reasons and their misuse. WHO offers assistance to institutions and healthcare professionals in its member states on policies, legislation, and practices that govern pain management through the formulation of specific guidelines.

One such guideline is the analgesic ladder, which is a plan that guides medical practitioners on the sequence of prescribing pain medications (analgesics) according to the intensity of the pain (Vargas-Schaffer, 2010). The first group of drugs to be administered is simple analgesics, which include drugs such as paracetamol and NSAIDs (non-steroidal anti-inflammatory drugs). When pain intensifies (moderate pain), the second category of weak opioids such as codeine is given. The third category comprises strong opioids, for example, morphine, pethidine, and fentanyl, which are given during severe pain (WHO analgesic ladder, 2010). The ultimate category consists of adjuvants, which are drugs meant for purposes other than pain management but are used in severe pain that fails to respond to other painkillers. In all these steps, simple analgesics are administered alongside the other analgesics. This elevates the efficacy of the treatment regimen while minimizing side effects (World Health Organization, 2012). WHO also encourages the administration of these drugs at regular time intervals of between three and six hours.

Pain Management in the United States

According to the Institute of Medicine of the National Academies, approximately 100 million adult Americans are affected by chronic pain (2011). This pain causes the government to lose around 600 billion U.S. dollars annually in terms of treatment costs and lost productivity. In 2010, the Patient Protection and Affordable Care Act recognized pain as a key public health concern and compelled the Department of Health and Human Services (HHS) to solicit the services of the Institute of Medicine (IOM) in investigating the issue of pain by carrying out extensive research on pain, handling of patients in pain and providing appropriate education on pain management.

The findings and proposals put forward by the IOM are what is currently used in pain management (American Pharmacists Association, 2012). The first step is encouraging a cultural transformation (Institute of Medicine of the National Academies, 2011). A thorough comprehension of all forms of pain is essential in proper prevention, assessment, and management of pain. This can only be attained with a cultural transformation that involves the active participation of state agencies, healthcare providers, and patient advocacy initiatives.

The U.S. implements a pain management and prevention stratagem at the population level. This strategy is aimed at reaching out to people with different forms of pain. In line with this strategy, HHS plans to formulate an all-inclusive scheme that has precise objectives, activities, and timeframes. The scheme is intended to increase the perception of pain and its related health implications and call attention to the preclusion of pain. It aims to enhance the evaluation of pain and its management during the delivery of health care services. In addition, the plan seeks to use public health communication strategies to educate the masses on pain management at the individual level.

Since America has several subgroups, the plan addresses the discrepancies in pain experiences among the various subgroups such as ethnic minorities, the economically challenged, the less educated, the elderly, women and children, military personnel as well as surgery and cancer patients. Therefore, state agencies such as the National Centre for Health Statistics and private organizations are working hard to hasten data collection on the occurrence and prevalence of pain from these groups of people.

In the United States, people experiencing pain may attend pain clinics or they may be helped deal with their pain individually. In health facilities, pain is managed by the administration of pain-relieving drugs, surgery, behavioral interventions, mental counseling, and physiotherapy among many others. New drugs such as Ketorolac tromethamine nasal spray for instant management of modest to moderately relentless pain and diclofenac sodium 1.5% topical solution for managing pain and signs of osteoarthritis of the knees have been approved to manage pain (American Pharmacists Association, 2012). Such drugs aim to minimize the gastrointestinal and cardiovascular side effects associated with some NSAIDs. Healthcare providers modify the care given to patients to match each patient’s experience in an attempt to improve the services offered (American Chronic Pain Association, 2013). Physicians are encouraged to work together with pain specialists in instances where the pain seems unbearable to patients. In addition, healthcare providers in collaboration with state agencies and other stakeholders have special programs that educate the public on the intricate biological and psychosocial facets of pain to bridge the gaps in the understanding of pain. Among the primary care providers, continuing education programs are in place, which improves their knowledge of pain and pain management through assessments and examinations.

This study intends to establish the management of pain in Saudi Arabia. It has been shown from the WHO guidelines and the scenario in the United States of America that nurses, who are the main caregivers among healthcare providers, play a vital role in the management and prevention of pain. Therefore, it is essential to understand their beliefs, attitudes, and knowledge regarding the issue of pain management since these values to a large extent determine how the nurses manage patients’ pain.

Overview of Saudi Arabia


Saudi Arabia is a country in Southwest Asia located on the Arabian Peninsula, in the Middle East. It is the biggest country in the Middle East and is neighboured by the Persian Gulf on the eastern side (King Abdullah University of Science and Technology, 2014). To the west of Saudi Arabia are the Gulf of Aqaba and the Red Sea. Saudi Arabia’s neighbors are countries such as Qatar, Iraq, Jordan, Yemen, and the United Arab Emirates. Although KSA is the largest country in the Middle East, the majority of its land is a desert with the most notable sand desert being the Rub Al-Khali desert. Saudi Arabia occupies approximately 2.149,690 square kilometers and has a population of approximately twenty-six million people (Central Intelligence Agency, 2014).


The original inhabitants of the Arabian Peninsula were hunters and gatherers who lived off wild fruits and animal meat. The melting of the European ice cap during the final Ice Age brought drastic climatic changes to the Arabian Peninsula. Therefore, agriculture developed as an alternative means of obtaining food. As time progressed, farming intensified, and the people made the valleys and oases their permanent homes.

The location of the Arabian Peninsula led to the development of ancient trade. Its proximity to Mesopotamia and the Nile River Valley made it a center of trade. Agricultural products such as almonds, dates, spices, and aromatics were exported to Mesopotamia and the surrounding regions. Consequently, trade flourished since the products from the Arabian Peninsula were in high demand.

In the year 610, Muhammad, an inhabitant of the ancient town of Makkah got a communication from God asking him to decree the oneness of God all over the world. As he acted on that calling, he had many people follow him. In 622, Muhammad got wind of a plot to have him killed. He then assembled his supporters and moved to the city of Madinah in a movement known as Hijrah. That was the beginning of the Islamic calendar and, therefore, the birth of Islam. Islam then spread tremendously to areas such as Spain, India, and China in less than a hundred years. The new converts from those regions made pilgrimages to the holy city of Makkah, which made the exchange of knowledge easy.

The current kingdom was founded by King Ibn Saud in the year 1901. Ibn forcefully held Riyadh and established himself as the head of the Arab nationalist movement. Five years later, he set Wahhabi as the dominant group in Nejd, which saw him defeat Hejaz between 1924 and 1925. In 1932, King Abdulaziz Al Saud established the Kingdom of Saudi Arabia by uniting Nejd and Hejaz. The kingdom was a complete monarchy that was governed by the Shariah laws and the Sunnah. Sixty years later, the reigning monarch introduced the first constitution to the Kingdom of Saudi Arabia. The constitution whose basis was the Islamic Shariah law was adopted and incorporated into the legal system.


It is essential to understand the culture of Saudi Arabia to get a better understanding of the beliefs and practices of oncology nurses on pain control in cancer patients, in Saudi Arabian hospitals. Culture may be described as the structure of shared attitudes, behaviors, values, customs, and symbols carried from one generation to the next (Almutairi & McCarthy, 2012). Culture is greatly influenced by several factors such as religious conviction, ethnicity, education levels, financial standing as well as environmental factors (Matsumoto & Juang, 2012). The Saudi culture is Arabic with an Islamic influence that has existed for more than a thousand years since the birth of Islam. The culture is a distinctive amalgamation of the Islamic faith and Arabic tribal traditions and customs. These values have a tremendous effect on the attitudes and conduct of the Saudi people in all aspects of their lives.

Health and Illness

Islam centers its attention on the safety of its people. The holy Quran, which is the guiding principle in Islam, contains principles that encourage healthy living. Prophet Muhammad’s habits and modes of conduct as explained in the Quran explicitly describe how to live a healthy life and how to keep diseases at bay. Islam advances participation in beneficial routines that uphold health. Such practices include meditation, bathing, and fasting (Almutairi & McCarthy, 2012).

Islam is keen on cleanliness and prohibits participation in activities that are deemed harmful to health. Such activities include consumption of alcohol, greed for food, and taking meals contaminated with blood. In addition, the abuse of substances, homosexuality, and sexual promiscuity are strictly forbidden. Muslims believe that sickness is not a punishment from Allah, but is retribution for one’s sins. Therefore, apart from seeking medical attention, sick individuals are expected to repent their sins and pray to Allah. Charity and reading the Quran are encouraged as ways of staying close to Allah. Therefore, Muslims are also encouraged to give to the poor apart from observing their prayer rituals.


Saudi Arabian culture uses verbal and non-verbal communication. In verbal communication, Arabic is the medium of communication although English is used in learning institutions and official situations (Saudi Arabia – Language, culture, customs and etiquette, 2014). During conversations, Saudis uphold group discussions and avert individual altercations. In some instances such as when addressing the elderly, it is imperative to use formal language and suitable titles. Only members of the same sex can greet each other through handshakes.

Nonverbal cues also play a significant role in communication and at times convey more information than verbal communication. The tone of voice, eye contact, and facial expressions are employed to express an individual’s opinion. Silence, which is treasured as time for personal meditations, may also be used to convey a message (Cultural Information, 2014). The left hand is deemed unclean and, therefore, should be used for performing personal cleanliness only. The right hand, conversely, is considered clean and ought to be used for greeting and passing items from one person to another.


Gender is a very important constituent of culture. Gender roles and behavior in Saudi Arabia are guided by Islamic laws. Saudi society permits gender segregation, which is further enforced by the constitution of the national government. Different sexes have their areas in the public domain including workplaces (Al-Hudhaif & Nalband, 2012). Learning institutions are a good example of gender segregation. There are independent schools for males and females even though both schools offer the same curriculum. Certain activities and professions are also restricted to certain sexes. For example, women are forbidden to drive or cycle (Almutairi & McCarthy, 2012). The male is the head of the family and is responsible for bearing the financial burden of the family. The repercussions of gender segregation in the workplace are, therefore, felt by everyone. In the health setting, for instance, male nurses are only comfortable caring for male patients and vice versa.

Health System in the KSA

The organization of Health Services

The health system of Saudi Arabia receives considerable priority from the government in terms of planning and allocation of resources. This expands the quality of services that the healthcare system provides to Saudi nationals. The health system in Saudi Arabia is ranked among the best globally by the World Health Organization (Khaliq, 2012). All health services fall under the Ministry of Health, which runs over 200 public hospitals and more than 2000 primary healthcare centers (Almalki, Fitzgerald, & Clark, 2011).

Other government institutions manage a few other health facilities that offer services to specialized categories of people. Such health facilities include referral hospitals, hospitals managed by higher education institutions, and those under the military. About one hundred other hospitals are managed by the private sector. The Council of Health Services coordinates the activities of all hospitals to uphold the provision of reasonably priced state-of-the-art health services to the people of Saudi Arabia (Almalki, Fitzgerald & Clark, 2012). However, the ministry of health sees to it that the council’s undertakings satisfy its terms of service.

Nursing in Saudi Arabia

Nurses are deemed the most important part of a healthcare system because they contribute significantly to the care received by patients. Therefore, properly trained nurses with the proper attitudes and skills are essential for the effective delivery of healthcare services. The demand for nursing services in Saudi Arabia surpasses the supply of nurses due to the tendency of Saudi students to study for other careers apart from nursing. The reason for their choice of courses is that the other careers offer better monetary rewards and are regarded more prestigious than nursing (Almutairi & McCarthy, 2012). Consequently, the majority of health experts are expatriates from different parts of the world. These experts make up three-quarters of the total health workforce. As a result, barriers develop between patients and nurses due to the differences in the cultural backgrounds between the two parties (Al-Fozan, 2013). In addition, discrepancies in religion and social values further worsen these barriers (Karout et al., 2013). The nurses, being immigrants, have a relatively short-term commitment to their work compared to the natives of the country. This is also likely to impact their work as they may not be enthusiastic to learn and embrace the Saudi culture. Poor working conditions in some regions also affect the attitudes of nurses (Almaki, Fitzgerald & Clark, 2012).

The public tends to look at nursing as a career that is most suitable for women. However, the cultural values of Saudi Arabia and the restrictions placed against women taking up careers see that very few women participate in this profession. The care of women and children, which is an extremely sensitive area, is particularly affected by the state of nursing in Saudi Arabia. The number of expatriate nurses is not usually constant and tends to vary with the seasons. Recent reports reveal that the extensive nursing workforce is reduced (Khaliq, 2012). All these factors alongside the high demand for nurses make it necessary to make the nursing profession attractive to Saudi nationals. However, since this is a process that may take a long time for the impact to be felt, it is important to ensure that the few available nurses offer an acceptable quality of service. This is why it is necessary to examine the attitudes and beliefs of nurses about pain and pain management since pain is the most common symptom of illnesses that make people seek healthcare services.

Saudisation, which is the practice of having vacant job positions filled by Saudi natives, is in progress as one of the objectives of the Saudi Health System (Al-Mahmoud, Mullen, & Spurgeon, 2012). The process was initiated way back in 1992 when a royal diktat was made. The diktat required that Saudi nationals underwent training in all fields including nursing so that they could replace all immigrant workers. The process has taken off considerably well with the Ministry of Health of Saudi Arabia targeting the recruitment of nurses.

Several factors play a role in the shortage of nurses in Saudi Arabia. The growth of the Saudi health system and the subsequent launch of advanced technology in the 1980s was one reason. Few Saudi natives could adjust to the advanced techniques. Therefore, it was necessary to outsource labor from other countries. The Saudi people’s attitude towards nursing also played a significant role in the shortage of nurses. During the days of Prophet Mohammed, nursing was a respectable profession. However, this profession is no longer considered respectable especially for women in Saudi Arabia (Al-Fozan, 2013). It is thought that Saudi women do not take up nursing as a profession because it is likely to ruin their reputation. Saudi nationals believe that working as nurses encourages women to mix with men. It also allows females to care for male patients. Such contact between people of the opposite sex is not permissible according to Saudi laws and is likely to cause moral corruption among women (Mahran & Al Nagshabandi, 2012). In addition, society looks down upon male nurses such that male nurses sometimes have to lie to their family and friends that they are doctors. Nurses are seen as untrained manual workers who carry out the unwanted work of medical care. They believe that foreigners ought to do such ‘dirty work.’ Such unreceptive mindsets are indications of how nursing is perceived in the country and how Saudi natives view non-Saudis.


Education in General

The Ministry of Education, which is under the Kingdom of Saudi Arabia, oversees the education system. The inception of the Ministry of Education occurred in 1954. Three years later, the first public university began operating. However, only male students were allowed to study until the year 1960. Initially, only Saudi natives were allowed to attend institutions of higher education. However, those restrictions were lifted allowing international students to join Saudi Arabian Universities. The current education system consists of three main levels namely elementary, secondary, and college. Pupils in elementary school receive free funding from the Saudi Kingdom. The kingdom boasts of a high literacy level of 70.8% (Central Intelligence Agency, 2011).

Nursing Education in Saudi Arabia

The process of Saudisation of Saudi Arabia’s workforce has seen the increased training of healthcare professionals especially nurses and physician assistants (Nondo, Jebakumar & Fernandez, 2013). However, the number of nurses undergoing training is currently limited by the capacity of Saudi Arabia’s nursing colleges and institutions. In addition, several candidates aspiring to pursue nursing as a career fail to secure admission due to low high school GPA gave the high requirements for one to secure admission to an institution that offers training in nursing. This has seen an escalation in the number of private institutions that train nurses implying that many students are willing to pursue nursing as a career (Al-Mahmoud, 2013).

Presently, the Kingdom of Saudi Arabia has three types of institutes that train nurses. These are “Health institutes, Health Science Colleges and Nursing Colleges in Universities” (Al-Mahmoud, Mullen, & Spurgeon, 2012, p. 370). The Ministry of Health (MOH) manages a large number of these institutions. Some institutes are managed by the Ministry of Higher Education (MOHE) while others are managed by the military. Only a few institutions are managed by private institutions. There are three categories of nurses in KSA. These categories are designed to satisfy the different needs in healthcare facilities. The initial level is ‘Technical Nursing,’ which is carried out after graduating from a health institute. A Diploma qualification is awarded following two and a half years of training. This period includes clinical practice. The next level is referred to as ‘Qualified Nursing’ and is performed after graduating from advanced health colleges. A Higher Diploma certificate is granted following three and a half years of nursing training including clinical practice. The final level is the ‘Nurse Specialist’ that comprises graduates of universities or colleges. A Baccalaureate Science award in Nursing (BSN) degree is bestowed upon the graduate following five years of education. This period entails nursing training and an internship of one year in a university hospital.

Saudi Arabian Economy

Oil mining is the main economic activity in Saudi Arabia. The kingdom has vast oil fields, especially in the eastern region. The majority of the workers in the oil fields are foreigners who mainly come from South Asia and the neighboring Arab states. Saudi Arabian laws restrict the employment of Saudi Arabian women hence the need to outsource labor from other countries. Saudi Arabia sells the largest quantities of oil and oil products to other countries and holds a quarter of the global oil reserves (Khaliq, 2012). Manufacturing industries also contribute to the economy of Saudi Arabia and diversify the economy by preventing overreliance on oil exports. In addition, the country uses the limited underground water resources to carry out irrigated farming that yields products such as tomatoes, wheat, barley, and watermelons. In addition, sheep are kept for mutton. The kingdom’s GDP is currently at 7.6% (Saudi Arabia Economic Report, 2013) making it one of the best economies in the G-20 (The Kingdom of Saudi Arabia: Economic insight, 2013).

Background to Pain and Pain Management

Pain is described as an unpleasant sensation due to injury. Individuals respond differently to pain in various situations. Extensive research on the origin and diagnosis of pain enhances novel and superior methods of managing pain. However, research shows that the nursing practice does not adequately implement the procedures that ensure adequate pain management for patients (Russell, Madsen, Flesner, & Rantz, 2010; Czarnecki, et al., 2011). Inadequate knowledge among nurses is the main cause of the inadequacy that causes them to aim at reducing pain rather than eliminating it (Butt, Tarar, Amin, & Butt, 2013). Nurses’ attitudes and beliefs that the constant use of painkillers causes addiction influences their decisions to refuse to administer strong painkillers to patients in cases of severe pain.

Nurses’ experiences during training also influence their beliefs. According to Butt et al., the training does not sufficiently prepare nurses to tackle pain (2013). Culture influences people to believe that complete liberation from pain is unattainable and that constant use of analgesics causes addiction. These beliefs coupled with insufficient training of health workers especially nurses see that patients do not get total pain relief.

Challenges in Pain Management

One of the key challenges in pain management is the belief held by the population that one cannot be ill without experiencing pain. Certain difficulties such as chronic pain may arise from the failure to manage pain adequately (Michelle et al., 2011; Johnson, Collett, & Castro-Lopes, 2013). Unrelenting pain may also cause mental complications, for instance, hopelessness, sleeplessness, and suicidal tendencies. In addition, an individual in pain may fail to perform the usual day-to-day activities.

Over-the-counter medications are among the drugs that individuals can use to manage pain without having to visit health facilities. However, the main challenge encountered from these medications is the issue of patients overdosing themselves in a bid to alleviate pain. Prescription drugs are also misused by the patients (National Institute on Drug Abuse, 2011). Drug allergies may also arise from certain drugs such as aspirin (American Chronic Pain Association, 2013). In some instances, it is difficult to manage pain in critically ill patients without compromising other clinical attributes such as cardiopulmonary stability (Barr et al., 2013).

Pain management also has financial implications for the economy. The world expends billions of dollars annually in the management of pain. A large sum of money is also lost in terms of loss of productivity from pain patients. Eventually, inferior methods of pain management cause patients to extend their hospital stays unnecessarily thereby causing them to incur the expenses of huge hospital bills.

Pain Management

The entire process of pain management starts with obtaining a prescription from a prescribing authority, who in most cases is a physician. Thereafter, it is the nurse’s responsibility to ensure that the prescription is taken as required. During the administration of the pain medication, a nurse ought to monitor the extent of the patient’s pain regularly to decide whether the prescribed drug is sufficient or whether the prescription requires adjustments (National Institute of Clinical Studies, 2011). In instances where the patient responds well, the dosage of the drug may be reduced as the pain reduces. However, in pain that tends to get worse, the dosage may be increased. The nurse may report these observations to the physician, who may prescribe a more potent analgesic than the previous prescription.

The ability of nurses to perform their pain management roles effectively is largely determined by their beliefs, knowledge, and experiences. The escalating instances of cancer lead to an increase in the number of patients who need permanent chronic pain management. Therefore, there is the need to assess whether the knowledge and beliefs held by nursing staff are adequate to ensure effective pain management.

Statement of the Problem

Pain causes intense discomfort to patients and reduces their quality of life. In addition, pain costs governments substantial amounts of money in terms of labor loss and health care services. When taking care of patients, pain management is one of the areas that are given priority. For oncology nurses, this is particularly important as pain is one of the key symptoms in cancer patients. In the Kingdom of Saudi Arabia, oncology nurses perform this role inadequately. Studies in other parts of the world show that there is insufficient knowledge in the proper management of pain for oncology patients (Johnson, Collett, & Castro-Lopes, 2013). Factors such as poor training of nursing practitioners and embracing wrong beliefs and attitudes on pain and pain management are thought to contribute significantly to this problem.

Earlier studies concentrated on improving techniques of assessing and managing pain (Keefe, Porter, Somers, Shelby, & Wren, 2013; Luckett et al., 2013). Those studies paid attention to other nursing areas with little attention being paid to oncology nursing. In addition, a few studies on oncology nursing were performed in countries with cultures that are different from those in Saudi Arabia. Therefore, there is a need to address critically the issue of pain and pain management among oncology nurses in Saudi Arabia and how the attitudes and beliefs of oncology nurses influence how they care for their patients.

Research Questions

In assessing the attitudes and beliefs of oncology nurses about pain and pain management in Saudi Arabia, it is important to have certain questions in mind. These questions are going to guide the objectivity of the study. Answers to these questions are expected to be useful in describing the attitudes and beliefs of oncology nurses regarding pain management. In addition, these answers are supposed to fill the gap in the literature on oncology nurses’ knowledge, attitudes, beliefs, and pain management within the cultural context of Saudi Arabia. The following questions are useful in attaining the objectives of this study.

  1. Do oncology nurses in Saudi Arabia know pain and pain management?
  2. What is the relationship between the Saudi Arabian culture and pain?
  3. What is the attitude of oncology nurses in Saudi Arabia regarding the management of pain?
  4. What are the beliefs of oncology nurses in Saudi Arabia concerning the management of pain?
  5. What challenges do oncology nurses in Saudi Arabia face in the management of pain for their patients?

Significance of Study/ Purpose

Numerous studies have been performed to evaluate the attitudes and beliefs regarding pain and pain management in many parts of the world (Narayan, 2010). However, the majority of these studies concentrate on Western countries with few of them targeting the Middle East. This study seeks to tackle the beliefs, attitudes, and knowledge of pain and pain management in Saudi Arabia, especially among oncology nurses. The study also seeks to determine the influence of the rich cultural practices and attitudes of Saudi nationals on pain and how they affect the way nurses administer health care services to their patients. This study is unique since no such study has ever been performed in KSA.

Conceptual Framework

The conceptual framework for this work is built on the theory of reasoned action (TRA), which was developed by Fishbein and Ajzen. The theory suggests that individuals’ actions are governed by the individuals’ beliefs and attitudes, their cultural standpoints, and their conduct, which ultimately decides whether valid actions are performed. This theory, therefore, can be used to forecast a person’s intent, which is seen as behavior, based on the individual’s beliefs and attitudes (Fishbein & Azjen, 2011).

Intention, which is the cognitive portrayal of the willingness to execute a certain action, is the best judge of behavior. As explained by the TRA, the intention is influenced by the attitude towards behavior, personal norms, and the apparent behavioral control (what is considered right by society). Certain behaviors can only be predicted by precise attitudes surrounding those particular behaviors (Orr, Thrush, & Plaut, 2013). Therefore, it is important to know these beliefs before attempting to predict the intentions. In addition, intentions are influenced by the professed behavioral control (a person’s opinion on his ability to execute a given task). Generally, a given behavior is performed when the attitude, subjective norm, and perceived control are favorable towards that behavior.

The theory of reasoned action has been used in numerous studies to determine the attitudes and beliefs of people in different circumstances, for example, in the use of exercise as punishment (Burak, Rosenthal & Richardson, 2013), the behavior of consumers in the market (Zhang, Guo, Lai, Guo, & Li, 2014) among many others. In this research, TRA is employed as the primary tool for evaluating the attitudes and behavior of oncology nurses during pain management. The relevance of this theory to the study is based on the relationship between behavior and cultural norms because culture determines what is deemed right by society. The study seeks to establish how the attitudes and beliefs of oncology nurses on pain (as shaped by culture) influence the way these nurses manage the pain of patients under their care.

Definition of Terms

  • Attitude: Refers to a learned disposition to respond positively or negatively towards a person, participant, or object.
  • Analgesics: A category of medications that are administered to alleviate pain. They are commonly called ‘painkillers.’
  • Belief: The state of mind in which a person trusts the truth and accuracy of a statement or idea.
  • Knowledge: Familiarity, perception, or understanding that is obtained from experience or other things that are learned.
  • Oncology Nurse: A medical specialist who cares for patients suffering from malignancies (cancers).
  • Pain: An unpleasant sensation that arises as a consequence of destructive stimuli.


This chapter introduces the research on the knowledge, attitudes, and beliefs of oncology nurses in the management of pain. The chapter begins by giving an introduction to pain and pain management in the world. It uses the United States as an example of a country that has stipulated procedures of pain management. It also focuses on the guidelines and recommendations of the World Health Organization regarding pain management. The chapter also introduces the Kingdom of Saudi Arabia, which is the area of interest in the study. It sets the basis for the study by describing Saudi Arabia in terms of geography, culture, health sector, economy, and education. This subsection reveals that Saudi Arabia, which is the largest country in the Middle East, is entirely Islamic. It is established that this religion influences all spheres of life for people in Saudi Arabia. The Kingdom of Saudi Arabia cares about the health of its subjects and ensures that its people get the best possible healthcare services that they can afford. The kingdom employs the services of expatriates to satisfy the high demand for nurses. The education system is also well-developed, and the country has a high level of literacy.

The other areas tackled in the paper include the purpose and significance of the study, the research questions, the conceptual framework, and the definition of key terms. The available literature implies that global management of pain is well-structured. However, pain management, which is the sole responsibility of nurses because of long contact hours with patients during their hospital stay, is not addressed satisfactorily in health facilities. The attitudes and beliefs of nurses concerning pain and its management are thought to play a major role in how nurses handle patients’ pain. The cultural values and societal norms in Saudi Arabia are some of the factors that are thought to affect the process of pain management in the kingdom. The chapter sets a framework for the thesis by developing five research questions whose answers explain the attitudes and beliefs of oncology nurses in KSA on pain and pain management.

Structure of the Thesis

This thesis will be organized into five main chapters namely the introduction, literature review, methodology, results, and a chapter on the discussion of the results. The introduction will cover the introductory statement including the statement of objectives, research questions, the significance of the study, theoretical framework, and the definition of terms.

The literature review chapter will look at materials that are relevant to the study. It will expound on the area of interest and look at previous studies that are related to the main topic. It will then identify knowledge gaps that need to be filled by the findings of the study.

The methodology section will contain four subsections and will give the entire process that the researcher will use to obtain and analyze data. It will examine the area under investigation, method of sampling, data collection, and analysis of data. The procedure that will be followed during data collection will be explained under this subsection. The data that will be collected will be subjected to statistical analysis using suitable statistical methods and software. The outcomes of data analyses will be presented as graphs, charts, and figures for ease of interpretation.

The results obtained in the methodology chapter will be discussed under the discussion chapter. The researcher will interpret and elaborate the findings as well as account for the observed results.

The final chapter will give the conclusions and recommendations of the study. The information obtained from the discussion chapter will be used to come up with recommendations and implications of the study to the nursing practice.


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