Preferred terms. Identified by region, such as Arab Americans, Middle Eastern Americans - or by country of origin, such as Egyptian Americans or Palestinian Americans. Ask about country or origin; some may identify city (e.g. Ramallah).
Nonverbal communication. Expressive, warm, other-oriented, shy and modest. May have flat affect to protect others from accessing their inner feelings. More traditional women may be reserved and non-expressive. Why they trust and feel accepted, tend to be more expressive. Arabs respect elders and professionals and are reluctant to take up their time. Are comfortable in touching within gender but not between genders. Traditional women may avoid eye contact with non-acquaintances and men.
Prefer closeness in space and with same sex. When comfortable with others, prefer to be in close proximity to build trusting relationship.
Very polite. Therefore, may not disagree outwardly and may respond in ways that they think others want them to respond.
Use of interpreters. After assessing language skills, inform them of availability of interpreters and give them the option of interpretation. Use same sex interpreters whenever possible. Use family members but only same sex family member for translation of sensitive topics related to sex, elimination, marital problems, reproductions, or such highly sensitive diseases as cancer, HIV/AIDS, tuberculosis, or venereal diseases. Note that sometimes family members may edit messages to protect patient.
Privacy. Value modesty and privacy, particularly with strangers. Respect for professionals allows disclosure and loss of privacy. Segregate genders when procedure calls for undressing. Disclosure enhanced for gender matching.
Serious or terminal illness. Family members buffer sick person from knowing whole truth about situation. Confide first in spokesperson of family and consult on best way to approach patient with news. Family prefers to disclose information but may request presence of health professional. If information given in Arabic by family member, no guarantee that seriousness of situation os conveyed. Accommodate family needs for gradual and prolonged disclosure of information.
Activities of Daily Living
Modesty Very modest. Most need long gown and robe. Drape patient appropriately and carefully, particularly in presence of opposite gender health professionals.
Skin care. Variation by country. Some prefer daily shower, some reluctant to use foreign bathrooms and need careful orientation and support. Some may refuse showers postnatally or during menstruation, believing them to be harmful. Others may not want to shower because of belief that it will undermine their recovery. Orient, explain rationale, and support process. Hospital and its routine intimidating. Careful orientation to all routine will enhance self-care. Some women may wish to use make-up in hospital.
Hair-care. Prefer to wash hair weekly. Concerned about catching cold, interference with recovery or management of hair after washing.
Nail care. No particular routines for nail care.
Toileting. Toilet paper not purifying enough. Most prefer to wash after every urination and bowel movement. May insist on using a bidet to wash up after urination and bowel movement. Respect privacy.
Special clothing/amulets. Depends on country of origin. For many women, scarves are important and essential. They like their Koran or Bible handy and may have blue beads or other amulets to ward off evil eye. Even highly educated non-traditional Arabs may believe in evil eye and may keep special amulets during illness.
Self-care. Maintain belief in complete rest and abdication of all responsibilities during illness. Expect family and hospital personnel to take care of them. Energy should be reserved for healing, not expended on self-care. Ask family members to assist. Explain rationale for self-care and its role in patient's recovery and progress.
Usual meal pattern. Three meals per day, largest usually preferred about 2:00 p.m. Do not mix milk and fish, sweet and sour, hot and cold or sweet with meals. Like fruits and desserts. Need to be oriented to meal routines in U.S. and in hospital, particularly if new to this country.
Food beliefs and rituals. Eating important for recovers. Do not give ice with drinks. Hot soup helps recovers.
Usual diet. Vegetables cooked with tomato sauces, chicken, lamb, beef and fish, rice, bread, and pickles. Prefer own food.
Fluids. Water, orange juice as well as other juices, strong black tea with or without milk. Sugar with beverages. Alcohol prohibited among Moslems.
Food prohibitions. Most Moslems do not eat pork, ham, or food cooked in alcohol. Most Christian Arabs eat pork, and ham and may consume alcohol. No cold beverages in the morning, no icy beverages when sick. Do not offer hot and cold food simultaneously. Will not eat raw fish, rare or medium rate cooked meat; prefer well done meat.
Food prescriptions. Mint teas for abdominal discomfort. Chicken and chicken soups help in recovery. Offering food is associated with nurturing, caring for, accepting and trusting. Sharing of tea, coffee, and chocolates indicates reaching out, trusting, and caring for. Receiving and accepting offers of tea, coffee, or sweets demonstrates acceptance and trust. Take time to share a cup of tea or a sweet offering. Ask kitchen for availability of Middle Eastern food; include all wheat pita bread or Syrian bread.
Pain. (Wagaa or Allam) Very expressive about pain, particularly in presence of family members with whom they feel comfortable. Focus is on present pain experience. Pain feared and causes panic when it occurs. Pain to be avoided at all expense. Some may have low pain threshold. Better able to cope with pain if source and prognosis of pain is understood. Tolerance for pain procedures also high when benefits understood. Differentiate between pain they believe inflicted because staff does not care about protecting them and pain that is inevitable due to procedure or to course of recovery. Express pain metaphorically, using symbols such as fire, iron, knives and rocks. Important for health professional to find out symbols and their meaning. Some patients can respond to numerical pain scale; others cannot. Their response may not reflect reality of pain. Believe injections more effective than pills. Some may perceive intravenous fluids as indication of severity of situation. Explain meaning. Some may be able to manage self medicating. Provide detailed information about differences and advantages and disadvantages. Be prepared to offer advice.
Dyspnea. (Deeket nafas) Panic attached to being unable to breathe. Tend to hyperventilate. Need careful coaching about meaning of oxygenation, associated with severity and urgency of situation. May panic more.
Nausea/vomiting. Many will be embarrassed with they vomit. Most do not differentiate between nausea and vomiting; they say "I will vomit" but not "I am nauseated." Some may say "nefsi ghama aleya" meaning nausea, but may not translate it as nausea. Vomiting is serious for them because of loss of nutrients. Need to be assured that vomiting not as devastating as seems. Coaching can help them utilize strategies to prevent nausea and vomiting. Tend to trust that medications may help them but not as much as other non-invasive strategies.
Constipation/diarrhea. Expect routine BM, and become very distressed if does not occur at specified time. May not volunteer information due to modesty, but will be uncomfortable and distressed. Ask about BM and follow with teaching about lack of significance of routine and time with BM. Constipation prevalent due to low fluid intake (except tea), lack of mobility, and low roughage in American diet. Some may use laxatives for regularity; ask about their use. Will accept medication for diarrhea.
Fatigue. (Taab, taaban, andy doukha, habtaan) "Tired, fatigued, dizzy, cannot open my eyes, my blood pressure is low" are all expressions of fatigue. Encourage afternoon nap, ask family members to allow patient to rest. Give them permission to be away from patient so everyone can rest.
Depression. Fatigue, sadness, restlessness, oversleeping, and flat affect are all expressions of depression. Will not acknowledge because emotional well being is believed to be family matter. Encourage patient to discuss; give permission to feel depressed.
Self-care for symptom management. Prefer Western medicine for treatment of symptoms and may use home remedies simultaneously.
Birth Rituals/Care of the New Mother/Baby
Pregnancy care. Some may delay seeing health care provider because they believe normal pregnancies do not need medical attention, or because of expense. Tend to enter health care system late in pregnancy. Much attention given to pregnant woman; encouraged to rest, do minimal work, and eat well. Pregnant women should be given anything they crave. Preparation for birth or for baby not part of most Arab subcultures. Arabs very present-oriented during this process; when it happens, it is dealt with. Need to be encouraged to receive health care, be active, and eat will balanced diet. Need to be assured they can maintain normal routine.
Labor practices. Many myths about labor pains for Arab women. Labor pains greatly feared. Very expressive during labor with loud noise, moans and groans; some may scream. Father not expected to be present by female family members expected to be present and available. Prefer medications to control pain. Husbands need support as they feel overwhelmed and powerless.
Role of laboring women during birth process. Active participation in labor a foreign concept to most Arab American women. Tend to tense their muscles and wait for delivery to take place. Hold her hand, fan her, and dry her perspiration. Talk with laboring woman, remind her of her other labor experiences, and that it will soon be over.
Role of father and other family members during birth process. Father not expected to participate in delivery. Mother, sister, or mother-in-law expected to be present and provide support.
Vaginal vs. cesarean section. Vaginal delivery preferred; cesarean greatly feared.
Breastfeeding. Modernization means giving up breastfeeding. Help mother make decisions and explain the advantages of breastfeeding. Will need help with first baby. May not offer breast because colostrums believed to be harmful to baby. May not request assistance for fear of imposing on staff. Health professional needs to offer assistance.
Birth recuperation. New mother expected to be on complete bed rest after delivery. Mother or sister expected to be in charge of household and family. New mother should eat enriching proteins such as chicken and drink rich fluids made with milk and other ingredients. May take new mother some time to bathe and shower for fear of hurting incisions or introducing infection into uterus. Explain disadvantages of not washing. Very difficult time for first time mother without extended family; needs more understanding, support, and networking.
Problems with baby. Include both mother, father, and aunts or grandparents when discussing baby. They will be taking care of baby.
Male and female circumcision. Male circumcision expected. Some prefer it when son is about six years old. Others prefer it done in hospital before discharge. Explain rationale for hospital custom. Female circumcision never discussed at birth. If subject comes up, and it does for some, usually arises when a daughter is school age or adolescent. Not based on religious beliefs, but passed on culturally. Arab Americans usually do not attempt to have daughters circumcised. Some may have been circumcised in their home country.
Preparation. Arabs do not openly anticipate or grieve for dying person before death. Inform designated head of family privately of death or impending death of patient; allow him to decide how to inform rest of family. Prepare private room for family members to meet and grieve together. In some families, young women barred from being with dying or dead member. Respect wishes of family. Will find it difficult to decide on DNR (Do Not Resuscitate). Family may lose trust in health care system if this option offered.
Home vs. hospital. Patient who is critically or terminally ill will prefer to die in hospital with family surrounding. Hope that Western medicine may delay death prompts family's preference to die in hospital.
Special needs. Arab Christians may request minister's visit. Left family initiate visit; provide support. Moslems do not need an Imam to be present. An Imam reads the Koran after death, not before or during the process of dying. Family's grief is open, loud, and uncontrollable.
Care of body. Special rituals followed after death, such as washing the body and all its orifices.
Attitudes toward organ donation. May not allow organ donation due to respect for burying the body whole and meeting creator with integrity.
Attitudes toward autopsy. For reasons cited above, autopsy problematic and should be presented with care, allowing family the option of refusing.
Decision making. Families make collective decisions. Extended families also participate in decision making. Father, eldest son, or elderly uncle usually family spokesperson.
Gender issues. Men in immediate family expected to be responsible for logistics of patient transportation, financial arrangements, and funeral plans. Caring for daily needs of patients in or out of hospital usually delegated to women in family.
Caring role. Mothers, grandmothers, sisters, sisters-in-law, or daughters assume caring functions in families. Caring for patients may include preventing self-care and avoiding ambulation, believing that energy needs to be preserved for healing.
Primary religious/spiritual affiliation. Early immigrants were Christians, mostly Protestants or Greek Orthodox. Recent immigrants are Moslems and almost exclusively Sunni branch.
Usually religious/spiritual practices. Prayers usually done in silence. Strict Moslems pray five times a day, and may have to wash before every prayer. When person becomes sick, families may want to pray for him/her. May pray in silence or may prefer another room for privacy. Some patients like to have the Koran or the Ingeel (Bible) next to bed or under pillow. Parents may want to pin a blue stone, an evil eye protector, or a hand with five fingers spread onto their children's clothing; These are believed to keep away evil eye.
Causes of physical illness. Physical illness caused by evil eye, bad luck, stress in family, loss of person or objects, germs, winds and drafts, imbalance in hot and dry and cold and moist, and sudden fears. Among children, deprivations considered cause of illness.
Causes of mental illness. Mental illness caused by sudden fears, pretending to be ill to manipulate family, wrath of God, or God's will. Causes individually focused, not family focused. Could also be caused be loss of country, family, and friends. Mental health care sought only in advanced stages of illness and only after all family and community resources are exhausted.
Causes of genetic defects. Wrath of God, God's will, test of endurance. Religious beliefs call for acceptance by social expectations force isolation from distance family and friends. Disclosure an issue; prefer to "hide" genetically defective family members. Genetic counseling may be refused as believed to defy God's will. Tend to care for children with genetic defects at home and shun institutionalized care.
Sick role. Physically sick individuals treated well. Mentally ill individuals believed to be able to control their illness; therefore may not be treated well by family. Patients expected to assume passive roles in any decisions related to them or others. Patients expect to be pampered.
Home and folk remedies. Western medicine respected and sought after. Home remedies include amulets, sweating, rituals, religious verse, prayers, and well-balanced diets. Folk remedies include herbal teas, camphor ointment, hot chicken soups, and enemas.
Source: Lipson, Juliene G., Dibble, Suzanne L., Minarik, Pamela A. Culture & Nursing Care: A Pocket Guide. The Regents. 1996