Culturally Competent Group Paper:
Muslim Americans
Culturally Competent Paper: Muslim Americans American Muslims are a growing minority group that share a religious identity, but are ethnically and racially diverse. In the United States, the largest ethnic groups that identify as Muslim include US born African Americans, immigrants from South Asia, and immigrants from the Middle East (Padela & Curlin, 2013). Despite the ethnic diversity within Muslim Americans, Padela and Curlin (2013) state that empirical research shows that “religions shape their adherents’ understanding of disease and illness, their health-related behaviors, their interactions with and expectations of the healthcare system, and their adherence to medical recommendations” (p. 1334). Thus, in order to provide culturally competent care to patients that practice Islam, nurses must have an understanding of the Muslim patient’s religious practices and influences. Muslims believe in the integration of daily prayer, spiritual medicine practices, and reading of the Qur’an, the religious text of Islam, with modern medical treatment. Therefore, healthcare beliefs are informed by their religious views and practices. Health is essential to Muslims because their faith compels them to maintain optimal health by practicing everything in moderation such as praying, exercising, working, and eating. On the other hand, illness can be indicative of penance of sin or a test of a Muslim’s faith. When illness occurs, the patient seeks conventional medical treatment and prays to Allah for a cure. Prayer is also an important factor of Islam. As nurses, we can facilitate a Muslim patient’s prayer ritual by providing running water for the ritual cleansing and an area for them to pray (Townsend, 2014). In regards to Muslim folk medicine, the Qur’an states, “Allah did not create a disease for which he did not also create a cure.” In other words, Muslims seek both traditional and modern avenues of medicine, with faith that any cure is from Allah. Some traditional remedies that are part of the Islamic culture include, black seed, honey and olive oil. One of the prophets, Muhammad, stated that consuming black seed would cure any type of disease other than death. It is said that black seed helps with digestion and suppresses inflammation. Honey is known as a healing source based on the Qur’an. Lastly, olive oil contains vitamin E to promote healthy skin. Muhammad is quoted in saying that the olive is from a blessed tree, which in turn will give you a blessing of good health (“Medicine of the prophet,” 2015). According to the Qur’an, aging individuals in the Muslim community are valued and are viewed as having earned the care they will need as they age. Scriptures in the Qur’an clearly state that the younger generations are to serve their parents in old age. Since it is believed that it is the sole responsibility of the children to take care of their elderly parents, formal care services or community support for the elderly are often not sought. This poses a challenge for the elderly Muslim in that they may struggle with finding a way to ask for formal support services without implying that traditional family care and support is neglectful or inadequate. Nurses can address this dilemma by promoting formal community support for Muslims as an additional form of support or as an “advantage or blessing” for them (Ajrouch, 2008). Terminal and life threatening illnesses are expressed as tests from Allah. Moreover, Muslims view death as the beginning of everlasting life and a life of bliss with Allah. They also believe that Allah decides the time of death. Therefore, suicide and denial of nutrition and water is viewed as interfering with Allah’s will and is forbidden. On the other hand, discontinuation of certain life-supporting treatments is an exception. In this case, the eldest male, which is typically the father or eldest son, makes the decision of discontinuing life support (Ott, 2013). When a Muslim patient is dying, several things are implemented to promote comfort to the patient and the family. First, the patient is placed on their right side facing Mecca, the birthplace of Muhammad and the site of Muhammad's first revelation of the Qur’an. This is done to provide a sense of unity to their religion. Next, an atmosphere where the patient and family can recite the prayer of allegiance to Allah is provided. The patient’s loved ones pray that forgiveness, mercy and the blessing of Allah be given to the dying patient. Also, certain verses from the Qur’an are read to help the dying individual overcome the fear of death. When death finally occurs, Islamic practices are performed for the deceased. As the patient is placed in the direction of Mecca, the family members wash the body with water and with leaves of the Lote tree, which is believed to disinfect the body, at least three times. After that, camphor is used in the last washing, which perfumes the body and saves it from decay. The body is then wrapped in white sheets and is covered at all times. As this process is performed, family members or friends recite verses from the Qur’an and prayers are offered asking Allah to forgive all the sins and to envelop the person in Allah’s mercy (Ott, 2013). In death and throughout all major life events an imam is usually present to guide the family and offer spiritual support and direction. This becomes increasingly important when discussing the health care seeking behaviors of Muslim Americans.
Muslim American health-seeking behaviors are strongly influenced by imams, as well as, apprehension regarding lack of cultural competence related to religious beliefs. Muslims may fear their culture will be misunderstood and their way of life disrespected. Imams are spiritual leaders, much like a minister, rabbi, or priest that can act as a patient advocate and educator (Padela, Gunter, & Killawi, 2011). They lead Muslims in prayer, offer guidance, perform rituals and give sermons among many other roles in the community. Priests, rabbis, and chaplains are continuously incorporated into the healthcare setting but are unable to appropriately assist in making major healthcare decisions. Unfortunately, due to the lack of integration of imams into healthcare, Muslim Americans may be reluctant to seek out medical care. The necessity of an imam to bridge the gap between healthcare workers and Muslim Americans should not be underestimated.
There are three key ways imams influence healthcare seeking habits of Muslim Americans. First, they advocate for the patient by offering spiritual guidance and assisting in healthcare decisions. Imams play a major role in the decision making process related to life’s events and healthcare of Muslims (Padela et al., 2011). It is not unusual for a family to insist their imam be present during healthcare collaboration. This helps the family make decisions based on medical information, as well as, religious belief. Second, they play a large role in educating the healthcare community about Muslim beliefs and how to offer culturally competent care. By educating staff members, imams help develop understanding and respect for Muslim traditions and culture. This information enhances the nurse-client relationship through gaining trust and providing holistic patient-centered care. Finally, imams have the ability to educate Muslim communities at large on health related matters. They do this by incorporating health topics into their sermons through scripture messages (Padela et al., 2011). Imams’ incorporation into the healthcare setting is essential to health seeking behaviors of Muslim Americans. They are a critical part of the Muslim community and their guidance and support brings understanding, piece of mind and improves patient outcomes.
There are commonalities across cultures that all healthcare workers can use to provide competent care. The majority of people in any variety of culture experience pain. This is a human feeling that is hard to deny, regardless of your culture. Cultures may express pain in different manners, but it is a universal experience. It is important for the nurse to observe her patient for signs of pain. Some cultures verbalize their pain, while others may only have slight facial grimacing and are harder to observe. In the Islamic culture, the use of pain medication is different from person to person. The use of alcohol or any mind-altering drugs or any substance that may shorten one’s life is prohibited, however the use of medication in an emergency or to decrease pain is typically allowed (Van den Branden, Broeckaert, & Universiteit Leuven, 2010). It is the nurse’s job to monitor the patient for any signs of pain, whether it be subtle or not, and offer those medications to your patient, and this should be done regardless of culture. Another aspect that is common among most cultures is fear and anxiety. Many cultures believe that they go to a better place after death, and this may eliminate the fear of dying for some, but not everyone. That may not eliminate the fear of suffering or disease process or pain either. If a patient has cancer and is told that they may have to endure months of being sick and chemotherapy and such, fear and anxiety can certainly be present despite the culture they come from. This may be harder to observe because of a particular culture or language barrier, but it is up to the nurse to try to alleviate those fears as best we can. Some member of Islam do not allow the woman to be spoken to directly, so you may have to go through her husband to find out how she is feeling. As nurses we have to do our best to reach the patient and meet their needs, no matter how difficult the communication can be. As a whole, the only way to provide culturally competent care to all of our patients is to respect their cultural needs. We need to respect their rituals and requests and make their experience and positive as we can, and be understanding to the things that we may not understand or agree with in our own cultures. Communication within the Muslim community is very dependent on context and it often relies on unspoken cultural expectations, especially in relation to gender roles. Among Islamic teachings, the relationship between men and women is regulated. In other words, touching members of the opposite sex, when not related, is not allowed for Muslims as directed by the teachings of Islam. For example, Muslims often touch each other’s hands or shoulders and stand in close proximity when communicating, but this is only seen between members of the same gender. In fact, devout Muslim men may not shake hands with women. According to a prophet in the Qur’an, “It is better for you to be stabbed in the head with an iron needle than to touch the hand of a woman who is not permissible to you.” This implies that touching a woman may lead to temptation, becoming immoral, and whoever does this has sinned. Moreover, Muslim women value modesty and practice hijab, which is the covering of the body (except the hands and face) as a barrier or mode of protection in situations of gender mixing. These religious needs related to gender roles can be met by matching the gender of the healthcare provider with the Muslim patient, whenever possible. This is especially true for Muslim women undergoing sensitive genital or breast examinations (Charles & Daroszewski, 2012). In terms of language and speech, Muslim Americans may speak English as their second language. Their primary language will depend on their ethnic origin (Townsend, 2014). Thus, nurses must use appropriate interpreters to effectively communicate with Muslim patients. A person who is Muslim and is practicing the religion of Islam follows the teachings of the Five Pillars of Islam. Salat, the second pillar of Islam dictates that the Muslim must pray five times a day while facing the direction of Mecca, which is towards the east in the United States. The prayers are performed in kneeling positions on a prayer mat or carpet. When hospitalized, the need to perform these prayer rituals and express their faith must be supported and respected by nurses and other healthcare professionals. For example, a room that faces the east can be offered to the Muslim patient. Another consideration for nursing practice related to religion is the scheduling of medications during Ramadan. Ramadan occurs once a year and is a fast from sunrise to sunset, which lasts one month. Thus, medications should be scheduled during the hours in which they are not fasting, when possible (Charles & Daroszewski, 2012). Muslims are required to follow a diet that is “halal”, meaning lawful or allowed. Food items that are unlawful or prohibited are called “haram”. All foods are considered halal except for: pork and all of its byproducts, carnivorous animals (birds of prey and land animals without external ears), animals that were dead before they were slaughtered, and alcohol. Foods containing animal shortening, lard, or gelatin should be avoided because these can be derived from pigs ("Provider's Guide to Quality & Culture - Muslims," n.d.). Foods made from vanilla extract may also be prohibited because vanilla extract typically contains alcohol. Another issue that may be related to a Muslim patient’s diet is the use of their hands. Muslims believe that the left hand is the unclean hand; therefore they will eat with the right hand (Division of the Chief Health Officer, 2010, p. xx). Since Muslim means “member of Islam,” which is a religion, it is difficult to pinpoint any specific physical or psychological conditions that are common in this culture. A Muslim can be from diverse countries or ethnicities. Muslims, however, do have certain beliefs about specific healthcare practices. Genetic research using embryos is acceptable in Islam under certain conditions, but they are against human cloning. Islam also permits the use of temporary contraception, and only permits sterilization if pregnancy was to physically harm the mother. Islam believes that a fetus is alive after 120 days of gestation, and abortion after that is not allowed unless it is a serious threat to the mother’s health. Abortion prior to 120 days is permitted under certain circumstances, such as if the fetus has abnormalities, or the mother was raped. Transplants and organ donation vary from person to person. Some Muslims believe it is ok, but some do not. Muslims believe in “God’s will,” which prevents some Muslims from allowing transplants to take place. A person who suffers from cognitive impairment or mental illness is not responsible for following the requirements of Islam. For example, these people are not required to participate in the prayer that takes place five times a day. These people are usually cared for by their family members (Division of the Chief Health Officer, 2010, p. xx). Nursing implications for the Muslim patient’s dietary needs would be things like avoiding using utensils that have been used on pork products. These items would contaminate the patient’s food and go against their belief. Since Muslims are prohibited from using pork products, certain medications that might contain gelatin or pork products should also be avoided as well. As the nurse you can notify the physician of this so that you can collaborate on giving culturally competent care to your patient. Since Muslims do not eat with their left hand, it would be important as a nurse to understand that and be sensitive to that if you have a patient who is unable to use their right side or who may need hand over hand assistance. If you were providing assistance with feeding, you would not want to place utensils in the patient’s left hand. If a patient was not able to use their right side, you might not understand why they would want to be fed if their left side is working. It is important to be sensitive and understanding to that patient’s needs.
In summary, healthcare workers must be well educated in many aspects of cultural practices related to the care of Muslim Americans in the healthcare setting. A firm understanding of cultural background, beliefs, rituals, influence on health seeking behavior, as well as, nursing implications related to communication and life style is extremely important. With holistic care in mind it is the job of the nurse to be aware of all needs: physical, emotional and religious. By raising awareness to the barriers related to cultural competence nurses can build trusting relationships, increase patient outcomes and give better quality care. References
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Padela, A., & Curlin, F. (2013). Religion and disparities: Considering the influences of Islam on the health of American Muslims. Journal Of Religion & Health, 52(4), 1333-1345. doi:10.1007/s10943-012-9620-y
Padela, A, Gunter, K., Killawi, A. (2011). Meeting the healthcare needs of American Muslims: Challenges and strategies for healthcare settings. Institute for Social Policy and Understanding. Retrieved from www.ispu.org.
The Provider's Guide to Quality & Culture - Muslims. (n.d.). Retrieved April 11, 2015, from http://erc.msh.org/mainpage.cfm?file=5.4.6h.htm&module=provider&language=English Townsend, M. C. (2014). Psychiatric mental health nursing: Concepts of care. Philadelphia: F.A. Davis. Van den Branden, S., Broeckaert, B., & Universiteit Leuven, K. (2010). Necessary interventions: Muslim views on pain and symptom control in English Sunni e-Fatwas. Retrieved from http://www.ethical-perspectives.be/viewpic.php?TABLE=EP&ID=1281