TRANSCULTURAL NURSING CARE OF AN ARABIAN PATIENT
by Dolores Light, R.N. Department of
Nursing Easter New Mexico University (1999)
F.F. a twenty four year old
female, was admitted to the labor and delivery department of Eastern
New Mexico Medical Center. F.F. had labor pains five
minutes apart. F.F. was accompanied by her husband, M.A.
, and N.F. her sister. Mr. M.F. translated for F.F. because her
English was limited. Mrs. N.F. was able to communicate with the
health care providers on behalf of the couple (F.F. and M.F.).
It is customary to address people from Arabia and most Muslim
countries by Mr. or Mrs. followed by the first name (Andrews, Boyle,
1999 p 169).
The family is from Jiddah, a city
on the western coast of Saudi Arabia, and had been in the United
States for three years. Mr. M.F. was attending the Oil
Field Training School at Eastern New Mexico University in
Roswell. Their plan had been to return to Saudi Arabia for the
birth but it appears the family was unaware the time of birth
was so close. Mrs. F.F. expected her term to last for another month.
It is desirable for a baby of Saudi decent to be born in the homeland
(Fahd.1990). Mrs. F.F. has two children living, ages four and six,
and one spontaneous abortion two years ago. The two children
are male and are healthy except for the youngest that has frequent
ear infections since coming to the United States. Mr. M.F. stated
Mrs. F.F.'s siblings and parents had no medical problems. The
nurse should be aware, most Arabians do not believe disclosure of
family medical history is necessary. In fact, Arabian people
believe such disclosure is private. They expect physicians and other
healthcare providers, because of their expertise, to select necessary
treatments (Purnell, Paulanka, p. 155). Mrs. F.F.'s
sister, the family mid-wife, came from Saudi Arabia to be a companion
in the home while Mr. M.F. was in school.
Cultural Sanctions and Restrictions
The two women did not leave the
house without Mr. M.F. Muslim custom dictate that all females
do not go into public without a male member of the family as an
escort. It is the custom in Saudi Arabia that the sister or
mother tend to the needs of a pregnant woman and to continue
the care for forty days after the birth of the baby. The custom
assures the new mother will have time to recuperate.
Health-Related Beliefs and practices
It is customary for females to
care for females and males to care for males. A male who is not
the spouse is not allowed to see an Arabic woman uncovered in Saudi
Arabia. Mr. M.F. stated that his wife would prefer that
no male except for family be allowed in her room. F.F. wanted her
husband to remain in her room during her hospital stay in order to
host any visitor (Fahd, 1990).
The physician was able to convince
Mr. M.F. to allow the physician to perform physical exams at least
monthly on Mrs. F.F. The physician allowed Mrs. N.F. (Midwife)
to perform most of the physical examinations in his office. The
physician wanted to monitor Mrs. F.F.'s blood glucose levels because
diabetes mellitus is one of the major health problems in people from
Saudi Arabia. Other diseases prominent in the Arab countries
include glucose-6-phosphate dehydrogenase (G-6-PD), sickle cell
anemia, and the thalassemias a hereditary hemolytic anemia (Purnell,
Paulanka), cutaneous leishmaniasis, a variety of visceral and
superficial infections caused by protozoan parasites of the genus
Leishmania, and filariasis which is a n infection of a filiform
nematode which is a member of the superfamily Filarioidea.(Geissler p.240).
Mrs. F.F.'s prenatal term
had been unremarkable. F.F. had visited a local physician three
months ago. The physician was sensitive to the customs of the Arab
couple and agreed to allow Mrs. N.F. to follow through with the
parental course. F.F. and M.F. wanted a female to deliver
the baby. The physician agreed to stand by Mrs. N.F. when the
baby was born. The physician wanted to be close in case of
complications. The physician was careful not to go into detail
about possible complications. Communicating a grave diagnosis is
often viewed as cruel and tactless because it deprives the client of
hope (Purnell, Pulanka, p. 155).
The husband is the family leader
and decision maker. A woman cannot sign an operative consent form.
The man may answer questions directed to his spouse. He may decide
when the wife should eat and bathe, or the wife may decide basic care
patterns such as when to bathe, eat, and breast-feed. The nurse
will want to ask Mr. M.F. if he or Mrs. F.F. will decide when she
will eat and bathe. (Fahd, 1990).
Mr. M.F. did not want to be
present for the delivery. He remained at his wife's bedside until she
was ready to move to the delivery room. It has been traditional
for men to leave the matters of birthing to the women. Recently, the
younger generation of Muslims have chosen to remain with the wife
during labor. The choice is left to the father (Fahd, 1990).
Cultural Aspects of Disease Incidence
The Physician assisted Mrs.
N.F. in the delivery of a healthy six pound ten ounce male with an
apgar of nine. The newborn's abdomen was wrapped with a white cloth
to prevent cold or wind from entering the baby's body (Purnell,
Paulanka. p 151).
The Physician and the nurse
were careful not to say anything that would be interpreted as
praising or admiring the infant. The newborn was placed in a crib in
F.F.'s room. Newborns are particularly susceptible to the evil eye
and expressions of congratulations may be interpreted as envy.
It is believed those who envy the wealth, success or beauty of others
causes adversity by the gaze, which transmits malignant radiating
energy and upsets the victims natural balance. Protection from the
evil eye is afforded by wearing amulets such as blue beads or figures
involving the number five, reciting the Quar'an, or invoking the name
of Allah. (Purnell, Paulanka. p.156).
A nurse entered the room and found
Mr. M.F. on the floor bowing in prayer. She left the room bewildered
and asked if anyone understood the customs of the couple. I was
on the unit and was able to answer questions because I had spent time
with two Saudi families. I explained that I had leaned much about
their customs while visiting in the Saudi's homes. The Saudis
had been very generous in their instruction and answers to my
questions about the customs of Saudi Arabia.
Devout Muslims believe they
must pray to Mecca, the Holy Land, five times a day. Traditionally,
they pray on a prayer rug placed on the floor. If the nursing staff
had some understanding of Muslim customs, they could have arranged to
provide the patient some privacy during certain times of the day so
the couple could pray.
People from Saudi Arabia
are Muslims and are of the Islamic faith. Much of their life and
customs center around their religion. Islam is based on the teachings
of Mohammed, who is called the Prophet. The Arabic word Islam
literally means "one who submits," (Andrews, Boyle, 1999 p
421) but as a religious term in the Koran, it means "to
surrender to the will or law of Allah (God)." A Muslims
duty is that of five daily prayers. The first prayer is offered
before sunrise, the second in the very early afternoon, and the third
in the late afternoon, the fourth immediately after sunset, and the
fifth before retiring and before midnight (Fahd, 1990).
Ramadan is that time of year
when Muslims recharge their spiritual batteries. For a whole month
they fast from dawn to sunset, and offer additional prayers at night.
Eid, a day of thanksgiving begins after the end of Ramadan. On this
day Muslims thank God for His guidance and grace in helping them to
control their baser, et al. desires and fulfill their spiritual needs
The next day was the time of
Ramadan. Since it is the time of Ramadan, the offer should be made to
have food brought to the room after sunset and before sunrise each
day. It may be necessary for food trays to be prepared during
the day and left in a refrigerator. At night the supervisor would
have the trays brought to the floor. Extra snacks should be
made available to the couple during the night. This would be a proper
time to ask if Mrs. F.F. would like to have food and drink during the
day. The Quar'an says anyone who is ill may forgo the fasting.
The husband will most likely want his wife to eat for the health of
the baby, because she will be nursing the baby.
Mr. M.F. moved into the hospital
room with his wife immediately after she gave birth. Mr. M.F. kept
the door to the room shut, and questioned everyone who entered,
including the nurses. The nurses were not happy but felt they had no
choice but to comply. The nurses stated they knew they needed to
learn about the customs of this couple.
Although the patient could
speak some English, the only time she would speak directly to the
nurses was when her husband was out of the room. Otherwise, he
answered all questions addressed to her. Mrs. N.F. helped
with the translation for Mr. M..F. who would decided when
Mrs. F.F. would eat and bathe. As leader of the family, his role is
to act as intermediary between his wife and the world.
Cultural Aspects of Disease Incidence
Mrs. F.F. will not nurse the
infant until the third day after birth, as is the custom of
Islam. It is believed the colostrum is not healthy for the
infant. Supplemental feedings are given to the mother to feed to the
baby until mother's milk begins (Fahd, 1990).
The nurse assigned to Mrs.
F.F. brought tea to the room for the couple and herself to
develop rapport with the couple. It is important to make the couple
feel comfortable with the nurse. The conversation was kept to a
discussion of the weather locally and what the weather must be like
in Saudi Arabia at the moment. This is the time to show a relaxed
cordial side being careful not to give non-verbal cues of being in a
hurry. At this time, the nurse may ask Mr. M.F. what time of day he
would like food trays delivered to the room.
A Saudi husband will show
hospitality to visitors by serving them refreshments or coffee and
chocolate. Friends and relatives will be frequent visitors.
When a woman has a new baby, her relatives, friends, and neighbors
visit her to congratulate her and to present her with gifts.
Relatives, friends and neighbors visit the father of the new baby to
congratulate him. The mother of the new baby will usually spend the
first 40 days after the delivery in her family home, where she will
be taken care of by her mother and/or sisters. When a visitor
comes to visit the following will usually be said by him.
"Yetrabba Be Ezzekum, Waa Allah Yajaluhoh Min El Thorriah Al
Salehah": May he/she (the new baby) be raised in your goodness
and may Allah (God) make him/her be a good son/daughter (Al-Sabt).
Alteration in self concept
related to American Nurses lack of understanding of the cultural
diversity of the Saudi Arabian people.
Mr. M.F. refused to allow a male
lab technician to enter his wife's room to draw blood. The
staff finally convinced the husband of the need. He reluctantly
allowed the technician in the room. However, he took the precaution,
of making sure his wife was completely covered. Only her arm stuck
out from beneath the covers. For Arabian families, honor is one of
the highest values. Since family honor is dependent on female purity,
extreme modesty and sexual segregation must be maintained at all
times. Male nurses should not be assigned to female Arabic
patients. Female purity and modesty are major values, in many parts
of the Islamic world.
Mrs. F.F. had several gold chains in her luggage. The nursing staff
attempted to persuade the F.F. and M.F. to take the gold home or, for
safety, place it in the hospital safe. Mr. M.F. insisted the gold
would be safe while he remained in the room. Gold is a Saudi woman's
insurance. It is the only possession she owns. Separation from her
gold would have been very stressful for Mrs. F.F. (Fahd, 1990). In
recent years women of Saudi Arabia have been know to own property and business.
When you explicitly admire a
possession of an Arabian, he/she might feel obligated to offer it to
you even if it is of special value. Admiring something should not be
prolonged. When Arabians receive gifts, it is a custom not to open it
in front of the giver. The same is expected when they give someone
else a gift (Fahd, 1990). At this point it is wise to drop the
subject. The nurses were wise to forgo their judgment of the situation.
The Arabian culture is a
non-confrontational one, which seeks the least conflict possible. A
concept called "save face" is a way to solve conflicts and
avoid embarrassing or discomforting the parties involved. Saving
someone's face or dignity involves using maneuvers or holding one's
reactions to give the other party a way to exit the situation with
minimal discomfort or harm to their dignity. It involves compromise,
patience, and sometimes looking the other way to allow things
to get back to normal. The "save face" concept is looked at
as a behavior of high quality ethics and manners. The Arabian culture
encourages people to act humbly and with sensitivity to a person's
dignity, especially when that person's dignity and self respect is
endangered (Abalati, 1998)
Nutrition Aspects Related to
In Arabian and Islamic countries
alcohol and pork is forbidden (Andrews, Boyle, 1999 p 423). Clients
in hospitals and other health care settings may need assistance in
identifying foods that have been prepared using animal shortening or
pork seasonings. They should avoid regular gelatin made with pork,
marshmallow and other confections made with pork. Avoid
medicines containing alcohol such as some cough suppressants. Avoid
extracts such as vanilla and/or lemon that contain alcohol (Andrews,
Boyle, 1999 p 351).
One does not compliment an Arabian
man about the beauty of his wife, sister or daughter (it is not a
compliment). In Arabic culture, it is not proper to compliment women.
Only Allah is admired. A female Saudi Arabian is held in high
esteem and her virtue is most important but must not be placed
above Allah. Only Allah can be complimented on beauty.
Mr. M.F. frequently
summoned the nursing staff using the call light. He requested a ?pain
shot? for his wife or requested extra blankets or asked that the
bathroom be cleaned. The nursing staff asked Mrs. Fatima if she was
in pain. Her answer was that she had only a little pain. Mr. Mohammad
insisted that his wife be given the medication.
Family members indulge the
individual and assume the ill person's responsibilities. The patient
will usually down play her pain with the knowledge that her husband
will assure that she will receive pain medication when she needs it.
Although the patient may seem overly dependent and the family over
protective by American standards, family members? vigilance and
?demanding behavior? should be interpreted as a measure of concern.
It is a custom for Muslims to care for the ill (Purnelll,
Paulanka). Giving birth is considered an illness.
Saudi Arabians believe that
intrusive procedures such as injections and intravenous fluids are
more effective that are those procedures that are not intrusive
(Geissler, 1998). The nursing staff contacted the physician for
orders for intramuscular pain medication. The physician ordered
Ketorolac (Toradol) 30 - 60 mg I.M. with half the original dose in 6
hours. Toradol is a non-steroidal Anti-inflammatory drug
(N.S.A.I.D.) and it has analgesic, anti-inflammatory and antipyretic
effects. Unlike narcotics, which act on the central nervous system
(C.N.S.), Ketorolac is primarily considered a peripherally
acting analgesic. It does not have the sedative properties of
narcotic analgesics. Relief has a rapid onset when given
intravenously and peak plasma concentrations occur 50 minutes after
intramuscular administration. Side effects to watch for are edema,
hypertension, rash, itching, nausea, headache, dyspepsia,
constipation, diarrhea, drowsiness and dizziness. Contraindications
are hypersensitivity to aspirin (A.S.A.) and to other non-steroidal
Anti-inflammatory drugs (N.S.A.I.D.). Precautions to watch for are:
inhibits platelet aggregation and may prolong bleeding:
gastrointestinal irritation and hemorrhage can occur, though probably
not common in short-term pre-hospital use: use cautiously for
patients with hepatic or renal disease.
It may be necessary
to adjust dosages of medication because of a potential
Arabian's response to drugs such as: lower dosages of
antiarrhythmics, antihypertensives, psychotropics and neuroleptics,
or increase dosages of opioids due to diminished ability to
metabolize codeine to morphine (Andrews, Boyle, p. 62).
In an Arabian family, gender
and age plays a big role in specifying responsibilities. The father
is usually the head of the family and the provider for its needs,
while the mother plays a major role in raising children and taking
care of the house. This structure is not always the norm; in recent
years, both the father and the mother provide for family needs, while
household chores are taken care of by maids and servants. In the past
the father made major family decisions, but now they make many
decisions jointly (Al-Sabt, 1999).
The Nursing Diagnosis of
Alteration in self-concept related to American Nurses lack of
understanding of the cultural diversity of the Saudi Arabian people
indicates that nurses cannot always look for ways to change
behavior of people. It may be necessary to simply honor the
culture and customs of a person's country. One example
is, when the nurse entered the room and found Mr. M.F. on the floor
praying. If the nursing staff had some understanding of Muslim
customs, they could have arranged to provide the patient some privacy
during certain times of the day so the couple could pray.
Before taking this course, I had a
concept that people of other cultures need to be honored and held in
esteem. I have learned that understanding my own self-concept
is important in order to get myself out of the way and to allow
myself to learn about other cultures. Learning about cultures
and customs is refreshing and rewarding.
The most important thing I have
learned is: Cultural Competency is the ability of individuals and
systems to respond respectfully and effectively to people of all
cultures, classes, races, ethnic backgrounds and religions in a
manner that recognizes, affirms, and values the cultural differences
and similarities and the worth of individuals, families, and
communities and protects and preserves the dignity of each. This
concept is not new. This concept is bases on the results of research
by Dr. Madeleine Leininger who published Cultural Care Diversity and
Universality: A Theory of Nursing. In 1991.
I can never stop learning about
other cultures. I have learned that I have a lot to learn about
people. This can only mean I will continue to be surprised and
refreshed with the new concepts I will learn in the future.
Abalati, Hammudah. (1998). Islam in Focus. A Guide To
Al-Sabt, Mohammad. ( 1999). Arabian Business &
Andrews, Margaret M., Boyle, Joyceen S. (1999).
Transcultural Concepts in Nursing Care. (3rd ed.). Philadelphia, New
York, Baltimore: Lippincott.
Fahd, Mohammad Abu. (1990). Interview. A Native of
Geissler, Elaine M. ( 1998). Cultural Assessment,
Mosby's Pocket Guide Series. (2nd ed.). Mosby, Inc., St. Louis, Mo.
Purnell, Larry D., Paulanka, Betty J. (1998).
Transcultural Health Care: A Culturally Competent Approach,
Arab-Americans 6, 137-159.