Listening beyond words: cultural safety in nurse–patient communication with Bedouin patients in rural Saudi hospitals

Abstract

Background

Listening beyond words is central to culturally safe nursing care, particularly in rural hospital settings where communication with Bedouin patients is shaped by dialect, silence, gesture, and deeply embedded social and spiritual meanings. In rural Saudi hospitals, however, nurse–patient interactions are often conducted in standardized Arabic and organized around biomedical routines, creating cultural–linguistic gaps that may undermine trust, engagement, and perceived safety in care.

Aim

To explore how cultural safety is experienced, threatened, and co-constructed through spoken and unspoken language between Bedouin patients and nurses in rural hospitals in Al-Ahsa, Saudi Arabia, and to identify nurse-led strategies that make care feel culturally congruent.

Methods

An interpretive phenomenological design informed by critical cultural safety was used. Semi-structured interviews were conducted in Arabic with 20 participants (10 Bedouin patients and 10 registered nurses) from two rural hospitals in Al-Ahsa. Interviews were audio-recorded, transcribed verbatim, selectively translated for publication purposes, and analyzed using Braun and Clarke’s six-phase thematic analysis supported by NVivo.

Results

Four interrelated themes described the cultural–linguistic work of care: (1) Speaking without words—patients used silence, indirectness, and kin-based framing that nurses had to learn to “listen for”; (2) Clinical space as cultural distance—hospital rules, gendered assignments, and rapid tasking were experienced as unfamiliar and sometimes unsafe; (3) Trust is earned, not assumed—historic and institutional marginality meant nurses had to demonstrate respect through repeated relational encounters; and (4) Navigating toward connection—nurses used local dialects, religious invocations, and family mediators to repair distance and legitimise communication.

Conclusions

Cultural safety for Bedouin patients cannot be achieved through translation alone. It requires relational listening, time, and organizational permission to use culturally grounded communication. Rural services should embed dialectal and cultural resources, support gender-sensitive assignments, and normalize family-inclusive encounters. Nursing education and continuing professional development should strengthen linguistic humility.

Clinical trial number

Not applicable.

Background

Language is more than a tool for communication; it is a vehicle of culture, identity, and power. For Indigenous peoples globally, language carries ancestral knowledge, social protocols, and relational values that underpin health and wellbeing [1]. Yet within biomedical health systems, Indigenous patients often encounter healthcare encounters where their linguistic and cultural worldviews are marginalized, misunderstood, or ignored [2]. This misrecognition manifests not only in poor health outcomes but also in interpersonal experiences of harm, silence, and alienation [3]. The World Health Organization recognizes culturally safe healthcare as a cornerstone of equitable access and improved outcomes for Indigenous populations [4]. However, cultural safety remains under-implemented in clinical practice, particularly in rural hospital settings that are structurally under-resourced and culturally misaligned with Indigenous lifeways [5].

Cultural safety, originally conceptualized in Aotearoa/New Zealand by Māori nurse-scholar Irihapeti Ramsden, demands a critical examination of power, history, and relational accountability in healthcare interactions [6]. Unlike cultural competence, which tends to focus on provider knowledge of other cultures, cultural safety places the onus on healthcare systems and professionals to confront institutional racism, support Indigenous self-determination, and create spaces where patients themselves define what is safe [7]. In practice, this requires more than diversity training; it calls for a transformation of healthcare language, relational norms, and structural policies to reflect Indigenous knowledge systems. Yet despite this mandate, health professionals in many countries continue to lack education, confidence, and institutional support to enact culturally safe care [8]. Nurses, who are at the forefront of care delivery, play a critical role in navigating this terrain of intercultural interaction, especially in rural hospitals where sustained nurse–patient relationships offer both opportunity and risk [9].

In Saudi Arabia, Bedouin tribes have unique dialects, oral traditions, and family-centered health beliefs that are rarely reflected in hospital protocols [10]. Similarly, Aboriginal and Torres Strait Islander peoples in Australia face a legacy of colonial violence and medical paternalism, which continue to shape distrust toward formal healthcare systems [11]. For both groups, rural hospitals are more than clinical sites; they are culturally charged spaces where identity, history, and communication norms collide [12]. Language, in this context, is not only spoken, it is embodied, relational, and political. Miscommunication may lead not only to errors in care but to refusals of treatment, fear, and withdrawal from services entirely [13].

Communication challenges in intercultural care are well documented. However, they are often framed narrowly as linguistic translation problems, rather than as embedded features of colonial systems that devalue Indigenous epistemologies [14]. Studies have shown that Indigenous patients frequently rely on non-verbal cues, storytelling, silence, and metaphor, forms of communication that may be misread or dismissed in hospital settings focused on clinical efficiency [15]. Nurses, in turn, may feel ill-equipped to interpret these cues or may default to biomedical scripts that overlook the relational context of care [16]. While health systems often invest in interpreter services, these are rarely available in rural hospitals and seldom reflect the full depth of Indigenous language as lived experience [17]. There is a growing recognition that cultural safety must be relational, co-created, and sustained through meaningful dialogue, not merely information transmission [18].

Existing qualitative studies have explored aspects of Indigenous patient experience in hospitals, including themes of mistrust, cultural disconnect, and resilience [19]. Other research has examined nurses’ attitudes toward cultural safety training, revealing gaps in confidence, institutional support, and reflective practice [20]. However, few studies have examined the interpersonal journey of both Indigenous patients and nurses within the same care encounter, particularly focusing on how language, spoken, unspoken, or silenced, shapes this relational space [21]. Even fewer have compared these dynamics across culturally distinct Indigenous groups within parallel rural contexts. Understanding these micro-level interactions is critical to advancing cultural safety from an aspirational policy goal to a lived clinical reality.

This study addresses that gap through an interpretive phenomenological approach, informed by culturally grounded principles, to explore how cultural safety is enacted or undermined through nurse–patient communication in rural hospitals. By listening closely to both Bedouin patients and the nurses who care for them, the study seeks to surface the relational, linguistic, and structural dimensions that shape culturally safe, or unsafe, care. In doing so, it aims to inform how nurses can be better supported to provide culturally responsive care, and how rural hospitals in Saudi Arabia can evolve into spaces where language and communication foster trust, respect, and healing.

Theoretical framework

This study is underpinned by the Critical Cultural Safety Framework, which draws on principles of postcolonial theory to examine how structural power, historical marginalization, and institutional norms shape healthcare experiences, particularly for Indigenous or nomadic populations such as the Bedouin [22]. Cultural safety extends beyond cultural awareness or competence by shifting the focus from provider intentions to patient-defined experiences of respect, recognition, and trust [23].

Originally developed in Aotearoa/New Zealand in response to the health inequities experienced by Māori, cultural safety critiques how dominant healthcare systems may unintentionally reproduce cultural exclusion through language, routines, and hierarchical communication [24]. The critical turn in cultural safety emphasizes the role of institutional structures and colonial legacies in shaping provider–patient interactions, making it particularly relevant for understanding the dynamics between hospital-based nurses and Bedouin patients in Saudi Arabia.

In rural Saudi settings, Bedouin patients often speak distinct dialects and hold oral, family-based traditions of healing that are not well integrated into formal healthcare environments [25]. This mismatch between institutional norms and patient worldviews can lead to miscommunication, mistrust, or care refusal, especially when care is delivered without cultural mediation. Critical cultural safety allows us to analyze how linguistic dominance, clinical hierarchies, and culturally neutral policies can alienate patients whose identities fall outside the assumed mainstream.

Method

Design

This study adopted a qualitative interpretive phenomenological design to explore how cultural safety is experienced and enacted in nurse–patient communication among Bedouin patients in rural hospitals. Phenomenology was selected for its capacity to illuminate lived, embodied experiences and contextual meanings, particularly relevant to the interpersonal and sociocultural dimensions of care [26]. Given the study’s focus on relational dynamics and culturally mediated understandings of safety, the design prioritized rich, first-person narratives from both nurses and patients. The study adhered to the Standards for Reporting Qualitative Research (SRQR) to ensure methodological transparency, reflexivity, and rigor in data collection and interpretation [27].

Study setting and recruitment

The research was conducted in the Al-Ahsa region of eastern Saudi Arabia, an area known for its diverse tribal communities and significant Bedouin population. Data were collected in two Ministry of Health-operated rural hospitals located in semi-nomadic and peripheral areas of Al-Ahsa. These hospitals serve a predominantly Arabic-speaking population with a wide range of dialects, traditional healing beliefs, and family-centered cultural norms.

Participants were recruited using purposive sampling to ensure the inclusion of individuals with relevant lived experience. Recruitment materials were distributed by nursing supervisors and ward staff, who referred eligible individuals to the research team. Nurses were selected based on their active clinical engagement with Bedouin patients, and patients were approached based on their recent admission to hospital wards. Recruitment and data collection occurred concurrently. Thematic saturation was determined when no new patterns or insights emerged during subsequent interviews. Saturation was reached after 20 interviews: 10 Bedouin patients and 10 registered nurses.

Inclusion and exclusion criteria

Inclusion Criteria:

• Bedouin patients:

  • Adults aged 18 years or older.
  • Self-identifying as Bedouin and fluent in a regional dialect of Arabic.
  • Admitted to one of the two study hospitals within the past 2 weeks.
  • Cognitively able to engage in a reflective interview.
  • Willing to provide informed consent.

• Nurses:

  • Registered nurses with ≥ 2 years of clinical experience in the study hospitals.
  • Involved in the direct care of Bedouin patients within the past month.
  • Fluent in Arabic.
  • Willing to participate and share perspectives on communication and cultural interaction.

Exclusion Criteria:

• Participants with cognitive impairment or language barriers that would preclude in-depth dialogue.

• Patients in acute medical distress or requiring continuous monitoring.

• Nurses in temporary or administrative roles not directly engaged in bedside care.

Data collection

Data were gathered through semi-structured, in-depth interviews, designed to elicit experiential narratives surrounding communication, trust, and culturally safe or unsafe interactions. This method was chosen for its effectiveness in exploring relational phenomena and culturally sensitive topics. Interviews were conducted in private consultation rooms within hospital premises, or, for patient participants who preferred it, in quiet areas near their inpatient bedsides.

All interviews were conducted in Arabic by the lead researcher, a bilingual academic nurse trained in qualitative methods and external to the hospital’s staff hierarchy, to minimize social desirability bias and perceived authority dynamics. Interviews were audio-recorded with consent and supplemented by field notes capturing nonverbal cues, environmental context, and reflective observations.

Interview guide

The interview guide was iteratively developed and piloted with two participants (not included in analysis). Open-ended prompts were used, including:

• “Can you describe a time during your hospital stay when you felt understood, or misunderstood?”

• “What does feeling safe or respected during care mean to you?”

• “How do you usually express needs or concerns to nurses?”

• “In your opinion, what helps or hinders trust between nurses and Bedouin patients?”

• “How do nurses adapt their communication when caring for Bedouin patients?”

Interviews ranged from 42 to 85 min (mean duration: 63 min). Each session was followed by immediate memo-writing to document context, emotional tone, and analytical reflections.

Transcription and translation

All interviews were digitally recorded and transcribed verbatim in Arabic by a professional transcriptionist familiar with local dialects. For quality assurance, bilingual members of the research team reviewed transcripts and matched them against recordings to ensure cultural and linguistic accuracy. Selected segments were translated into English for cross-disciplinary collaboration and publication, maintaining fidelity to original expressions and idiomatic nuance.

Data analysis

Data were analyzed thematically using Braun and Clarke’s six-phase process [28], supported by NVivo 14 (QSR International). Analysis proceeded as follows (Fig. 1):

1. Familiarisation: Transcripts were read repeatedly and annotated with analytic and reflexive memos.

2. Initial Coding: Meaningful units were coded inductively to capture concepts such as “coded silence,” “dialect mismatch,” “nurse avoidance,” and “emotional alignment.”

3. Theme Development: Codes were clustered into broader interpretive categories and discussed within the research team.

4. Searching for Themes: Patterns were grouped into candidate themes reflecting both patient and nurse experiences.

5. Reviewing and Refining Themes: Themes were cross-validated against transcripts, field notes, and across participant groups for conceptual coherence.

6. Finalisation: Four final themes and eight subthemes were identified, supported by thick narrative excerpts that preserve participant voice.

Fig. 1.

Braun and Clarke’s six-phase process

Ethical considerations

The study was approved by the Institutional Review Board of XXX. Written informed consent was obtained from all participants, who were informed of their right to withdraw at any time. Pseudonyms were assigned (e.g., N01, P03) to protect confidentiality, and all identifiers were removed or altered. Data were stored on encrypted university servers, accessible only to the research team.

Rigour and reflexivity

To ensure trustworthiness, the study followed [29] criteria:

• Credibility: Member checking was conducted with five participants who reviewed summary interpretations and confirmed thematic relevance.

• Dependability: An audit trail of coding decisions, memos, and data logs was maintained.

• Confirmability: External peer reviewers examined a subset of transcripts and analytic themes.

• Transferability: Rich, contextual descriptions of Al-Ahsa’s cultural landscape and Bedouin social norms were provided to facilitate application to similar settings.

The lead researcher kept a reflexive journal throughout the study to examine positionality and mitigate bias related to language use, clinical authority, and cultural assumptions about Bedouin identity.

Results

Characteristics of participants

Twenty individuals participated in the study, including 10 Bedouin patients and 10 registered nurses working in two rural hospitals in the Al-Ahsa region of eastern Saudi Arabia (Table 1). All patient participants identified as Bedouin, were currently hospitalized or had recently been discharged (within two weeks), and ranged in age from 30 to 71 years (M = 51.2, SD = 11.7). Most were married (n = 8), and the majority had completed only primary or intermediate education. Their occupational backgrounds reflected a traditional rural lifestyle, including camel herding (n = 3), farming (n = 2), small trade (n = 2), and manual labor (n = 3). Several participants reported limited prior interaction with formal healthcare systems, relying historically on family-based or tribal healers.

Table 1.

Demographic characteristics of participants (n = 20)

Participant ID	Role	Age (yrs)	Gender	Marital Status	Occupation (Current/Former)	Years of Experience / Hospitalization	Notes on Cultural/Clinical Context
P01	Patient	60	Male	Married	Camel herder	Hospitalized (5 days)	Prefers oral storytelling
P02	Patient	53	Male	Married	Farmer	Discharged (7 days ago)	Avoids eye contact with nurses
P03	Patient	45	Male	Married	Small trader	Hospitalized (2 days)	Expresses via metaphors
P04	Patient	66	Male	Married	Retired laborer	Discharged (1 day ago)	Cites trust in tribal healers
P05	Patient	39	Male	Single	Camel market worker	Hospitalized (3 days)	Reluctant to ask questions
P06	Patient	71	Male	Widowed	Former shepherd	Discharged (5 days ago)	Minimal formal education
P07	Patient	47	Male	Married	Local grocer	Hospitalized (1 day)	Values politeness over clarity
P08	Patient	30	Male	Single	Agricultural laborer	Discharged (3 days ago)	Limited hospital experience
P09	Patient	58	Male	Married	Retired security guard	Hospitalized (4 days)	Questions nurse authority
P10	Patient	50	Male	Divorced	Construction worker	Discharged (6 days ago)	Values male-to-male communication
N01	Nurse	32	Female	Single	Staff Nurse (Surgical Ward)	7 years	Seeks training in dialects
N02	Nurse	41	Male	Married	Charge Nurse (ICU)	18 years	Confident, prefers direct speech
N03	Nurse	37	Female	Married	Staff Nurse (Medical Ward)	12 years	Understands cultural codes
N04	Nurse	29	Female	Single	ER Nurse	5 years	Reports challenges with dialect
N05	Nurse	45	Male	Married	Head Nurse (Inpatient Care)	22 years	Mediates between staff/patients
N06	Nurse	34	Female	Divorced	Night Shift Nurse	9 years	Describes tension in silence
N07	Nurse	26	Male	Single	Junior Nurse (Surgical)	4 years	Unsure how to adapt communication
N08	Nurse	49	Female	Married	Senior Nurse (Medical)	21 years	Advocates for family involvement
N09	Nurse	38	Male	Married	Clinical Educator	14 years	Teaches empathy training
N10	Nurse	33	Female	Married	Staff Nurse (Emergency)	8 years

The 10 nurse participants (6 female, 4 male) ranged in age from 26 to 49 years (M = 36.8, SD = 6.9), with nursing experience ranging from 4 to 22 years. All held bachelor’s degrees in nursing and had been working in rural hospital settings for at least two years. Three nurses were of Bedouin origin themselves, while the rest were Saudi nationals from urban regions. All reported regular interactions with Bedouin patients and had varying levels of comfort and training in culturally responsive communication.

While all participants were medically or professionally stable at the time of interview, their perspectives varied widely based on age, gender, tribal affiliation, and prior experiences of cultural safety or misunderstanding. Data collection continued until thematic saturation was reached after the 20th interview. The sample’s cultural and professional diversity provided a rich basis for exploring how communication practices and relational dynamics contribute to or hinder culturally safe care in rural hospital settings.

Thematic findings

Thematic analysis yielded four interrelated themes that capture how Bedouin patients and nurses in rural Saudi hospitals perceive, negotiate, and enact cultural safety through communication. These themes illuminate the tension between institutional norms and Indigenous identity, the unspoken rules of engagement, and the strategies both parties use to bridge cultural and linguistic divides. Table 2 summarizes the themes, sub-themes, and their descriptive meanings.

Table 2.

Themes, sub-themes, and descriptions

Theme	Sub-theme	Description
1. Speaking Without Words	1.1 The Weight of Silence	Patients often rely on silence, body language, or indirect speech to communicate needs, especially when feeling misunderstood or disrespected.
	1.2 Reading Between the Lines	Nurses describe learning to interpret gestures, pauses, and tone as culturally significant cues in the absence of explicit verbalization.
2. Cultural Distance in Clinical Space	2.1 Feeling Like an Outsider	Patients expressed feeling culturally misplaced within the hospital setting, often describing care as impersonal, rushed, or indifferent to tribal customs.
	2.2 Systemic Invisibility	Nurses acknowledged that institutional policies, documentation practices, and language protocols rarely accommodate Bedouin dialects or cultural norms.
3. Trust Is Earned Slowly	3.1 Proving Respect Over Time	Building trust required consistent relational gestures, such as tone, patience, and cultural deference, often developed over repeated encounters.
	3.2 Suspicion Rooted in History	Historical mistrust of formal institutions and previous experiences of discrimination influenced patient perceptions of safety and sincerity.
4. Navigating Toward Connection	4.1 Adaptive Communication Strategies	Nurses described adopting storytelling, humor, religious references, or local phrases to foster understanding and rapport.
	4.2 Shared Humanity as a Bridge	Patients and nurses both highlighted moments of mutual vulnerability, such as prayer, illness, or personal disclosure, as catalysts for authentic connection.

Speaking without words

The weight of silence

Across interviews, Bedouin patients frequently described relying on silence, non-verbal cues, and indirect expression to communicate their discomfort, needs, or dissatisfaction during hospitalization. Many viewed direct confrontation or open questioning, especially in formal settings, as culturally inappropriate or disrespectful. P06, a 71-year-old retired shepherd, explained, “When I don’t like something, I stay quiet… if they understand, they understand.” Several patients noted that silence served as a way to preserve dignity and avoid conflict. As P03 put it, “We are taught not to complain too much, it’s better to keep things inside and wait.”

This form of communication, however, often led to misunderstandings. Nurses described situations where patients declined medication, withdrew socially, or delayed requesting help, yet never explicitly voiced concern. As Nurse N03, who shares Bedouin heritage, noted, “Many of my patients will not say what’s wrong, but you can tell something is off by their eyes, their body, or even the way they greet you.” These insights reveal that silence was not a lack of communication, but a culturally embedded strategy for managing vulnerability within hierarchical systems of care.

Reading between the lines

Nurses who had experience working with Bedouin communities described developing a heightened sensitivity to subtle behavioral changes, tone of voice, and symbolic gestures. Nurse N05 explained, “Sometimes it’s not what they say, it’s how they look at you, how long they pause, or if they say ‘it’s fine’ in a very quiet tone. That means something is not fine.” This interpretive labor, often unrecognized by formal training or policy, emerged as a key adaptive skill in creating culturally safe care.

One nurse recounted how a patient’s persistent refusal to make eye contact or accept assistance was initially misunderstood as noncompliance. “Only after asking a male relative did we learn he felt ashamed being cared for by a young female nurse,” said N04. In response, the team adjusted care routines, and rapport improved. These moments highlighted how nurses learned to “read between the lines” and adapt their responses, not by asking more questions, but by observing more attentively and responding with cultural humility.

While many nurses acknowledged the difficulty of interpreting indirect communication, they also described it as a source of professional growth. As Nurse N08 put it, “Working here has made me more patient, not just with time, but in how I listen. You can learn a lot when you slow down and stop expecting direct answers.”

Together, these subthemes illustrate that in Bedouin cultural contexts, communication often occurs beyond spoken words. Silence, posture, intonation, and respectful restraint carry meaning, and when nurses recognize these cues, the clinical relationship becomes less transactional and more relational. In such moments, language is not only spoken but embodied, creating space for culturally safe and emotionally resonant care.

Cultural distance in clinical space

Feeling like an outsider

Many Bedouin patients described the hospital as a foreign environment, where their values, language, and expectations did not align with the clinical routines or interpersonal style of healthcare providers. P01, a 60-year-old camel herder, stated, “When I come here, I feel like I am in another world… the way people talk, the rules, everything is different.” For several participants, this sense of cultural displacement began at the point of admission, when medical forms, standard greetings, and unfamiliar jargon created confusion or discomfort. Some reported feeling hesitant to ask questions or clarify instructions, fearing they would appear uneducated or burdensome.

The absence of culturally recognizable rituals or practices also contributed to this distance. P08 shared, “In my tribe, when someone is sick, we gather, we read Qur’an, we sit close. Here it’s quiet, and I’m alone with machines.” Such comments pointed not just to physical isolation, but to the erosion of communal care traditions and the discomfort of receiving care in a system designed around speed, privacy, and biomedical efficiency, values that often contrast with Bedouin norms of collectivism and relational presence.

Systemic invisibility

From the perspective of nurses, many acknowledged that the hospital system itself lacked mechanisms to adequately respond to the cultural needs of Bedouin patients. As Nurse N01 noted, “We don’t have clear guidelines on how to care for tribal patients differently. The policies are the same for everyone, but everyone is not the same.” Several nurses commented on the absence of interpreter services for regional dialects and the lack of culturally adapted materials for patient education. As a result, staff often relied on informal strategies, such as asking a family member to interpret or simplifying instructions to basic terms.

Nurses also reported that institutional documentation practices and time constraints discouraged culturally sensitive interactions. Nurse N07 explained, “We are expected to follow the checklist, complete tasks quickly. There’s no time to sit and really talk with a patient unless there’s a problem.” In this rushed environment, opportunities to build rapport or address deeper cultural misunderstandings were often lost.

Moreover, some nurses noted that cultural assumptions embedded in hospital routines, such as assigning opposite-gender caregivers without asking, or emphasizing individual decision-making, unintentionally clashed with Bedouin social norms. Nurse N10 shared, “We sometimes think a patient is being difficult, but really they are just following their values. They want to consult the family first or speak to a male nurse.”

This theme highlights how structural and institutional practices, though seemingly neutral, may render certain cultural identities invisible or incompatible with the expectations of care. When patients feel alienated by the clinical space and nurses are unsupported in bridging these gaps, the result is often miscommunication, disengagement, or care refusal. Addressing these challenges requires a shift from equality to equity in care, recognizing that treating all patients the same does not necessarily result in safety or inclusion.

Trust is earned slowly

Proving respect over time

Both nurses and Bedouin patients emphasized that trust is not assumed in clinical relationships, it must be demonstrated consistently through culturally appropriate behavior. Many patients shared that their initial instinct was to remain cautious or reserved, particularly in unfamiliar hospital environments. P05, a 39-year-old market worker, noted, “At first, I speak little and observe. If the nurse is respectful, not just polite but really listening, then I can start to speak.” Patients often described trust as a gradual process, built through nonverbal signs of sincerity, patience, and tone of voice.

Nurses echoed this sentiment, recognizing that respect had to be shown through action rather than titles or authority. As Nurse N02 stated, “For many patients here, especially the elders, trust comes from how you treat them day by day. It’s not about what you say, but how you behave.” Nurses described small, relational gestures, offering water, using kinship terms, waiting silently rather than interrupting, as meaningful ways to convey dignity and build rapport.

These interactions were not seen as separate from clinical care but as integral to it. As Nurse N03 explained, “If the patient feels respected, they are more likely to speak, follow advice, and trust your judgment. Without that, even the best medical plan can fail.” In this context, trust functioned not just as emotional comfort but as a clinical facilitator.

Suspicion rooted in history

Many Bedouin patients described a lingering sense of distrust toward formal healthcare systems, shaped by previous experiences of neglect, stereotyping, or disrespect. Several referenced stories passed down from relatives or communities about being treated “like a number” or feeling dismissed due to their dialect, appearance, or tribal origin. P09 shared, “Some doctors speak fast, don’t look at you, write and leave. You feel like you don’t matter, like you are too simple for them.”

These perceptions were not limited to individual providers but were often directed at the system as a whole, which some patients viewed as distant, bureaucratic, or misaligned with their values. Nurse N06 remarked, “There’s a history here… many Bedouin patients come with a protective shell. If they had a bad experience before, it’s hard to break that.”

Several nurses noted that even well-intentioned care could be misread without adequate cultural framing. One example shared by N08 involved a patient who declined medication after overhearing clinical jargon he didn’t understand, assuming the treatment was unsafe. “He thought we were experimenting,” the nurse explained, “because no one took the time to explain it clearly in a way he trusted.”

This subtheme underscores that mistrust is not always personal, it often reflects a collective memory of marginalization, where patients expect to be misunderstood unless proven otherwise. Nurses who understood this legacy were more likely to approach communication with humility and persistence, recognizing that trust is a process, not a default.

Together, these subthemes illustrate that cultural safety cannot exist without trust, and trust is not instantaneous. It is built slowly through repeated, respectful engagement, and can be easily disrupted if cultural dynamics are not acknowledged. In rural hospital settings, where care encounters are brief but high-stakes, relational continuity and cultural attunement are critical for fostering trust.

Navigating toward connection

Adaptive communication strategies

Nurses working in rural Al-Ahsa hospitals described learning to adapt their communication styles over time, developing informal, culturally grounded techniques to enhance understanding and connection with Bedouin patients. Rather than relying solely on scripted clinical language or formal education materials, nurses often incorporated storytelling, religious references, humor, and familiar analogies to build rapport. Nurse N05 explained, “I noticed that when I relate instructions to their daily life, like comparing a treatment to how they care for camels or farms, they understand and smile. It feels more like a conversation, not a lecture.”

Other nurses shared that invoking faith-based language often helped reduce patient anxiety and encourage engagement. As Nurse N08 recounted, “If I say, ‘This treatment is a trust from Allah and we are just the means,’ it helps them see care as part of their faith, not something imposed.” This spiritual framing made the clinical process more culturally congruent, especially for older patients.

Patients also responded positively to these adaptive strategies. P04 shared, “When the nurse speaks to me in our dialect, or makes a joke like we do in the village, I feel more relaxed. I can ask questions without shame.” These moments of cultural familiarity often served as entry points to deeper conversations about symptoms, fears, or decisions, conversations that might otherwise remain unspoken.

Shared humanity as a bridge

Beyond techniques, both nurses and patients emphasized the power of mutual vulnerability and shared emotional experience in creating moments of authentic connection. Several participants described how non-clinical topics, such as grief, family, or shared life struggles, helped transcend cultural divides and fostered a sense of common humanity. P07 shared, “When I saw the nurse cry with another patient who died, I knew she had a heart. That changed how I saw her, more like a person than a worker.”

Nurses likewise reflected on moments when emotional presence, rather than expertise, built trust. N02 noted, “One day, I sat with a patient and just listened while he talked about his father’s death. No medical questions. After that, he started telling me everything, even things he hid before.”

These experiences underscore that cultural safety is not only technical or linguistic, it is relational. When nurses allowed themselves to be emotionally present and responsive, outside of rigid professional roles, patients became more willing to engage, disclose, and participate in their own care. Such moments did not always occur predictably, but when they did, they created transformative spaces of care that felt respectful, reciprocal, and human.

Discussion

This study explored the lived experiences of Bedouin patients and nurses in rural hospitals in the Al-Ahsa region of Saudi Arabia, focusing on how cultural safety is understood, experienced, and enacted through communication practices. Four key themes emerged: Speaking Without Words, Cultural Distance in Clinical Space, Trust is Earned Slowly, and Navigating Toward Connection. Together, these findings reveal how structural, linguistic, and relational dynamics shape the quality of nurse–patient interactions in ways that either promote or undermine culturally safe care.

This study contributes new insight to the literature on culturally responsive healthcare in Arab settings by centering the voices of Indigenous Bedouin patients, who are frequently rendered invisible in dominant hospital discourses. While past research has addressed health disparities among tribal or rural populations in the Middle East [30, 31], few studies have explicitly examined cultural safety from the lens of both patients and nurses or grounded the analysis in postcolonial frameworks that acknowledge how state-centered health systems may replicate exclusionary practices toward nomadic and semi-nomadic communities [23, 32].

Reproducing cultural silence in biomedical systems

Participants’ narratives of disconnection, miscommunication, and emotional withholding illustrate how mainstream healthcare institutions often reproduce a model of care that privileges technical efficiency over relational presence, particularly in high-paced hospital settings. Echoing earlier work in settler-colonial contexts [33, 34], this study affirms that when healthcare is practiced without deep cultural awareness, the clinical space becomes alienating. Bedouin patients described feeling like outsiders, unfamiliar with the protocols, overwhelmed by language barriers, and uncomfortable with the individualistic, formal tone of provider interactions. Such perceptions resonate with [35] argument that systems that fail to adapt to Indigenous worldviews create “cultural load,” which burdens patients and inhibits their participation in care.

Importantly, these dynamics are not merely interpersonal, they are institutional. Several nurses in our study recognized the absence of culturally tailored policies, interpreter services, and training as factors that restricted their ability to provide culturally congruent care. Without formal acknowledgment of Bedouin linguistic and cultural specificity in clinical protocols, nurses relied on intuition and informal strategies to navigate difference, often without organizational support or validation. These gaps suggest a form of structural invisibility, whereby the needs of Indigenous populations are overlooked in both policy and practice.

Trust as a relational process rooted in history

Our findings further underscore that trust between Indigenous patients and providers is not a given, it must be earned, often in the context of historical distrust and perceived marginalization. Participants’ cautious approach to disclosure, reliance on family intermediaries, and emotional restraint reflect deep-seated protective mechanisms shaped by previous experiences of disrespect or dehumanization within medical institutions. As observed in studies of Aboriginal and First Nations patients in other contexts [36], such guardedness is not rooted in ignorance but in accumulated knowledge of how their identities are routinely misunderstood or stereotyped.

This study builds on postcolonial theory, which posits that historical inequities do not simply disappear in post-tribal nation-states, they are refracted through new systems of governance and care [37]. In the case of Bedouin populations, the shift from tribal self-determination to assimilation within state healthcare systems has often been accompanied by a loss of cultural autonomy. Hospitals, with their standardized protocols, scientific lexicons, and urban-centric designs, are not neutral spaces, they reflect dominant values that may silence Indigenous voices [38].

Language as a site of power and possibility

At the heart of many participants’ accounts was the role of language as both a barrier and a bridge. Nurses and patients alike described moments of miscommunication, discomfort with dialectal differences, and the erosion of patient agency when language failed. Yet, they also shared stories of healing when language was reclaimed as a shared tool, whether through humor, religious idioms, or metaphors rooted in Bedouin life. These findings mirror critiques by cultural safety theorists who argue that healthcare must extend beyond linguistic translation to include epistemological translation, the ability to communicate care in a way that resonates with a patient’s worldview [18, 39].

In that sense, our findings complicate the assumption that cultural safety is purely about provider sensitivity or diversity training. Instead, it is an ongoing, negotiated process that requires nurses to listen actively, relinquish some clinical authority, and co-construct meaning with their patients [40]. As such, language is not merely a medium, it is a relational practice shaped by power, trust, and reciprocity.

Moving from recognition to reform

While nurses in this study expressed genuine efforts to bridge cultural gaps, their narratives also revealed frustration with institutional constraints, lack of time, insufficient cultural orientation, and rigid protocols. These challenges point to a pressing need for system-level interventions that embed cultural safety into the infrastructure of healthcare delivery. Drawing from international models such as New Zealand’s Treaty-based approaches or Canada’s Truth and Reconciliation Calls to Action [41], Saudi institutions must begin to move beyond inclusion rhetoric toward transformative policy reform that acknowledges the unique positionality of Bedouin and other Indigenous populations.

Cultural safety must become an organizational ethic, not an individual effort. This includes integrating Bedouin voices into healthcare planning, developing dialect-specific materials, investing in long-term nurse training in culturally responsive communication, and establishing mechanisms for feedback and accountability from marginalized patient groups [42].

Implications for nursing and health policy

The findings of this study hold important implications for nursing education, clinical practice, and healthcare policy in Saudi Arabia and other culturally diverse settings. First, they underscore the urgent need to embed cultural safety, not just cultural competence, within nursing curricula and continuing professional development. While many Saudi nurses are trained in technical care, few receive structured education on navigating linguistic diversity, social hierarchies, or Indigenous worldviews, particularly when working with Bedouin patients. Nursing education programs must adopt pedagogies that promote critical reflexivity, enable students to examine their own positionality, and encourage listening as a relational, ethical act.

At the clinical level, hospitals serving rural or Bedouin populations should develop policies that recognize dialectal and cultural variation as clinical considerations. This includes investing in Bedouin dialect translators or cultural brokers, adapting patient education materials to local linguistic and religious norms, and allocating time for relationship-building in routine care. These changes require institutional commitment to decolonizing the healthcare environment, challenging the dominance of standardized, biomedical frameworks that often alienate patients from non-mainstream backgrounds.

At a policy level, national strategies for health equity must include structural reforms that foreground Indigenous participation. This could involve establishing advisory councils inclusive of Bedouin elders, incorporating cultural safety metrics into hospital accreditation, and allocating research funding toward Indigenous health priorities. In line with global equity movements, culturally safe healthcare cannot be achieved through training alone, it must be co-designed with the communities it aims to serve.

Limitations

This study has several limitations. First, it was conducted in a single region, Al-Ahsa, which, while home to a significant Bedouin population, may not reflect the diversity of experiences across other tribal or Indigenous groups in Saudi Arabia. Second, participants were recruited from hospital settings, which may have excluded individuals who avoid formal healthcare due to mistrust or cultural incongruence. Third, while interviews were conducted in Arabic and accounted for dialectal nuances, some subtleties may have been lost in translation during the analytic process. Finally, the positionality of the research team, as academic and healthcare-affiliated individuals, may have influenced how participants shared their experiences. Reflexive journaling and peer debriefing were employed to mitigate this, but researcher bias cannot be fully eliminated.

Conclusion

This study illuminates the complex interplay between language, identity, and cultural safety in nurse–patient communication in rural Saudi hospitals. Bedouin patients and nurses alike described how institutional norms, linguistic disconnects, and historical mistrust shape their clinical encounters. Yet, they also offered stories of resilience, connection, and healing, demonstrating that cultural safety is possible when care is rooted in relationality, respect, and humility.

To advance health equity, cultural safety must be understood not as a checklist but as an ongoing, reflective practice, one that acknowledges past harms, listens deeply in the present, and commits to structurally just futures. In the Saudi context, this means listening not only for language, but for history, silence, and story, recognizing that every clinical encounter is also a cultural one. The transformation of hospitals into culturally safe spaces for Indigenous patients will require not only reform from above but courage and compassion from within the healthcare workforce.

Author contributions

MNAl and MYAl contributed to the study conception and design. MAA led data collection, data analysis, and interpretation of findings. All authors contributed to drafting the manuscript, critically revising it for important intellectual content, and approving the final version for submission. All authors agree to be accountable for all aspects of the work.

Funding

This study was funded by the Deanship of Scientific Research, Vice Presidency For Graduate Studies and Scientific Research, King Faisal University, Al-Ahsa, Saudi Arabia (Grant: KFU260436).

Data availability

The datasets generated and/or analysed during the current study are not publicly available due to the qualitative nature of the data and the need to protect participant confidentiality, but are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

Ethical approval for this study was obtained from the Institutional Review Board of King Faisal University, Al-Ahsa, Saudi Arabia. All participants received verbal and written information about the study, and written informed consent was obtained before participation. Participants were informed of their right to withdraw at any time without consequence. The study was conducted in accordance with the principles of the Declaration of Helsinki.

Consent for publication

Not applicable. No individual-level identifying data are included in this manuscript.

Competing interests

The authors declare no competing interests.