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Providing Culturally Sensitive Care for Islamic Patients and Families

Blankinship, Lisa, Ann

doi: 10.1097/CNJ.0000000000000418
Feature: practice/education

Nurses can expect to care for patients from different cultures and faith traditions and need to develop cultural competence. This article describes what is important in providing culturally and religiously sensitive care to Muslim and Middle Eastern patients. The Crescent of Care Model by Lovering is offered to aid understanding of five key areas of culturally competent care. Jesus' story of the Good Samaritan (Luke 10:25-37) offers guidance for Christian nurses caring for those in need.

Lisa Ann Blankinship, PhD, is an associate professor at the University of North Alabama in Florence, Alabama. She enjoys serving as a Spanish translator for missions and local clinics.

Accepted by peer-review 10/17/2016.

Published Ahead of Print on 6/7/2017.

The author declares no conflict of interest.





Nurses today will care for patients from multiple cultures and faith traditions. Islam is the fastest growing religion in the world, expected to exceed Christianity by the end of the century. There were an estimated 3.3 million Muslims living in the U.S. in 2010, and this number is expected to increase. A 2011 survey of U.S. Muslims found that 69% said religion is “very important,” whereas 96% believed in God, 65% prayed at least daily, and nearly half (47%) attended religious services at least weekly (Pew Research Center, 2017). Concern has been expressed that Western healthcare models fail to meet the needs of the Islamic and non-Islamic Arabs in the Middle East and worldwide, due to the lack of religious and cultural awareness (Rassool, 2015 ; Weatherhead & Daiches, 2015). This article discusses how Western nurses of Christian faith can provide culturally and religiously sensitive care to Muslim and Middle Eastern patients.

In the story of the Good Samaritan in Luke 10:25-37, Jesus clarified that his followers are to care for their neighbors, even going above and beyond to supply what someone needs. In the story of the Good Samaritan, where a Samaritan crossed cultural barriers to care for a Jewish man who had been beaten, Jesus confirmed that anyone in need is our neighbor. Nik Ripken, an American Christian missionary to Africa, relayed how he attempted to show Christ's love in a culturally sensitive way through provision of food, water, clothing, shelter, and medicines, and meet spiritual needs through the provision of burial cloth and listening to the Somali people tell their stories about living in a long-term war-torn area. Ripken's Muslim bodyguards were especially moved when Ripken and a team member provided a proper burial for a Somali villager who had starved to death (Ripken & Lewis, 2013).

Two models of culturally based care can help nurses in caring for Muslim patients. Leininger's Culture Care Theory recognizes the influence of culture on the health behaviors of individuals (Saca-Hazboun & Glennon, 2011), whereas the Crescent of Care Model (Lovering, 2012 , 2014) is specific to Arabic and Arabic-descent patients.

The Western biomedical model is the primary mode of instruction for healthcare providers in the Americas, Europe, Australia, and parts of Asia and Africa. Western medicine can create ethical dilemmas for Western-trained providers and Middle Eastern or Arabic-descent patients. For example, in the Islamic community, the spiritual element of healing, family involvement with patient care, religious requirements for prayer and fasting, and cultural laws that govern modesty and traditional healing practices are important (Hammoud, White, & Fetters, 2005 ; Lovering, 2012 ; Rassool, 2015). The culturally aware nurse develops a culturally sensitive plan of care, assessing the unique perspectives of each patient and family, and communicates patient and patient family needs to the healthcare team (Giger, 2017).

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As with any religious group, Muslim beliefs and practices vary, depending on myriad factors, such as place of residence (Western, Middle East, or Eastern) and upbringing. However, Muslims worldwide are almost universally united by a belief in one God and the Prophet Muhammad, and the practice of religious rituals, such as fasting during Ramadan. The teachings and law of Islam are derived from the Holy Qur'an and the Sunnah. Tawhid, meaning “the Oneness of Allah,” requires that Muslims live in unity of mind and body with Allah; there is no separation of the body from the spiritual dimension of health (Rassool, 2014). Devout Muslims have strict adherence to the Qur'an, submission to Allah, conservative cultural values, and emphasis on the good of others.

Five pillars or foundations of Islam must be upheld by Muslims: 1) profession of belief that there is no other God to worship but Allah, and Muhammad is the Messenger or Prophet of God (Iman); 2) prayer performed five times a day (Salat); 3) giving alms, a religious tax of 2.5% of wealth given to the needy (Zakat); 4) fasting from food, fluids, sexual practices, and worldly comfort from sunrise to sundown during the holy month of Ramadan (Siyam); and 5) pilgrimage to Mecca in Saudi Arabia at least once for all who are able (Hajj) (Giger, 2017 ; Rassool, 2014).

Although monotheistic like Christianity, Islam denies the deity of Jesus Christ—that he was God incarnate, who came to die for sin and save the world, and denies the existence of the Holy Spirit. The Qur'an (19:30) states that Jesus, referred to as Isa, was a prophet of Allah, along with other prophets, beginning with Adam (Adem) and ending with Muhammad (Rassool, 2015).

Islamic and Arabic cultures are centered around religious and cultural traditions (Rassool, 2015). Although the spread of Western society is causing some cultural shifts to occur within Arabic nations and people groups, most Muslims retain traditional views with respect to family, faith, and healthcare. Family remains the central building block of society and takes precedence over the needs of the individual (Giger, 2017 ; Goldblatt, Cohen, Azaiza, & Manassa, 2013 ; Lovering, 2014). For nuclear families (husband, wife, children) that are geographically separated from the extended family (parents, grandparents, siblings), culture and religious traditions may be modified out of necessity, fostering a more independent or Western approach to family life.

For Muslims, culture and faith are tightly intertwined and cannot be separated. Islam dictates every aspect of life, including healthcare relationships (Bester, Lovering, & Arafat, 2013 ; Rassool, 2015). Health, a state of physical, psychological, social, and spiritual well-being, is considered the greatest gift God has given to humankind. Illness is a test from Allah for sin or failure to follow the tenets of Islam, or is a reminder to improve personal health, and should be received with patience and prayer. Through illness, sins are atoned, and one experiences spiritual renewal and opportunity for spiritual reward (Rassool, 2014).

Some cultural beliefs explain the cause of illness in Arab Muslim society. The evil eye, a cause of disease, predates Islam and is referenced in the Qur'an (113:1-5). The evil eye is cast intentionally or accidentally by someone who is jealous or admiring of another or their possessions. Pregnant women, children, and newborns are especially vulnerable to harm from the evil eye, so rather than saying admiring words, one uses the word Masha'allah (what God has willed) to offer a compliment. Jinn, good or bad spirits, can cause abnormal physical or mental behavior. Healing for illness from evil eye or jinn is obtained by reading and citing the Qur'an and saying prayers (Giger, 2017 ; Lovering, 2012 ; Rassool, 2015).

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The Crescent of Care Model (COCM) accounts for meeting the spiritual and cultural needs of Islamic patients and their families in a culturally sensitive way (Lovering, 2012 , 2014). The primary difference between the COCM and Leininger's Culture Care Theory is that the spiritual aspects of Islamic culture are considered, which helps build trust between the patient and the healthcare team, and the family and the healthcare team. Because the family, rather than the individual, is the key unit in Islamic society, this model focuses on meeting the needs of both. The five basic principles of the COCM are: spiritual care, cultural care, psychosocial care, interpersonal care, and clinical care.

Spiritual care is paramount. It is offered through support of patient prayers, and in some cases praying with, or for, the patient, if requested. Spiritual care can involve providing adequate notice of or delaying procedures while the patient finishes Qur'an readings or prayers, help with kneeling for prayers, indicating the direction of Mecca, providing access to the Qur'an, and facilitating use of holy water (ZamZam water) or religious phrases before starting intravenous fluids, giving injections, or cleaning wounds. Only those of Islamic faith may touch the Qur'an. In some cases, nurses may be asked to assist with end-of-life rituals, even though they are not of the Islamic faith (Lovering, 2014).

Cultural care includes nursing actions that support the values, beliefs, and traditions of the patient and family. Most patients appreciate the opportunity to share their culture, and this action helps build trust between the healthcare team, patient, and family (Saca-Hazboun & Glennon, 2011). Some Muslims use a combination of traditional folk remedies and Western medicine, such as the use of holy water, olive oil, honey, black cumin seeds, and dates. Accommodating the use of traditional or folk medicines as procedures, as appropriate, and providing culturally sensitive education for the patient and family, demonstrate cultural care (AlRawi, Fetters, Killawi, Hammad, & Padella, 2012). Avoiding eye contact, especially with pregnant women, children, and infants, can be important (Lovering, 2014 ; Rassool, 2015).

Most Muslims greatly value modesty and prefer care be provided by same gender healthcare providers. Islamic law requires same gender providers for urinary catheterization of male or female patients, physical care such as bathing for female patients, and gynecological/obstetrical care (Lovering, 2014 ; Rassool, 2015). Modesty also includes covering the body. After the onset of menses, women are not to draw attention to themselves or reveal their beauty, exposing only their hands and face in the presence of unrelated men (Giger, 2017). Men should be covered from their navels to their knees and not be viewed by female healthcare providers, though Islamic law does allow exceptions in critical emergencies. Specific care must be taken to knock before entering the patient's room, waiting for permission to enter, and assigning same gender healthcare providers (Hammoud et al., 2005 ; Lovering, 2014 ; Saca-Hazboun & Glennon, 2011).

Psychosocial care includes identifying family structure, the main decision makers for the family, and what role the patient plays within the family. Family provides comfort and care for the patient by their presence and involvement in taking care of the sick individual (Saca-Hazboun & Glennon, 2011). Be sensitive to the patient's need for family and family input into their healthcare. Family should be consulted during all communications and involved as much as possible with the care plan. The Qur'an mandates visiting the sick. However, at times, nurses need to explain how visitation impacts the patient by not allowing sufficient rest (Bester et al., 2013 ; Lovering, 2014 ; Rassool, 2015).

When working with Muslim patients, identify and include key family decision makers, typically older male members, in the care plan (Bester et al., 2013 ; Lovering, 2012). Female patients may prefer healthcare providers speak with a male relative regarding their condition, thus overruling patient confidentiality. This male relative's information should be noted in the patient's record.

Interpersonal care includes both verbal and nonverbal communication, such as touch, cultural sensitivity on the part of the nurse, and building trust with the patient and family. It is important to consider modesty with respect to eye contact and physical touch, both of which should be avoided by opposite gender providers and patients. Same gender care teams are preferred by most patients and are essential for obstetric and gynecologic care. When males must care for female patients, include a female (an aide or family member) (Bester et al., 2013 ; Lovering, 2014 ; Rassool, 2015).

Islam poses specific dietary requirements of periods of fasting, permissible food and drink (halal), and nonpermissible food and drink (haram). Muslims are prohibited by religion from consuming any food or drink that contains pork or pork products or medication that is of pork origin (e.g., some older forms of insulin) (Saca-Hazboun & Glennon, 2011). Other prohibited foods are alcohol, animal fat, and meat that has not been slaughtered according to Islamic rites. Gelatin or gelatine made from the skin or products of pigs is prohibited, so medications must be confirmed as halal (permissible) (Rassool, 2015). Accommodate food, drink, and medicine origin requirements during patient care.

Clinical care addresses the skills and knowledge needed to perform nursing care. Family involvement in the physical care of the patient, to the greatest extent possible, shows respect. Nurses should anticipate family to be present with the patient and include family members in personal care and clinical care tasks, as appropriate. Rather than an implication of substandard or questionable care, family members may supervise the physical care of the patient as a means of ensuring modesty (Lovering, 2012). Rassool (2015) notes that there are no restrictions on treatment provided to a Muslim patient in a life-threatening situation.

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Two examples of the COCM in action are Ralph's (2000) description of Mrs. T., a 34-year-old Muslim woman who practiced strict Islam, and Simpson's (2004) summary of Muslim immigrants. Mrs. T., an immigrant in Canada, was receiving hemodialysis treatment for kidney transplant rejection and desired to have a second child. By forming a culturally sensitive care plan, interdisciplinary team members were better able to understand the healthcare needs of Mrs. T. and her family. The team protected Mrs. T's modesty by assigning female nurses and ensuring the same nurses were available to care for her needs during dialysis, prenatal care, and labor and delivery, as much as possible. Attention to culture and religious needs helped Mrs. T. build trust with her healthcare team, experience less stress during her care, and receive a favorable outcome, delivering a healthy girl at 36 weeks.

Simpson (2004), a faith community nurse, noted a high rate (50%) of unintentional pregnancy and low healthcare for Islamic women. One reason why the women did not seek healthcare was discomfort with providers and provider lack of understanding of strict Islamic codes. Simpson met the needs of the women in her community by translating healthcare literature into Arabic, offering training for breast self-exams, cervical and breast cancer screenings, and acceptable means of birth control. She also worked with and educated local healthcare providers on Islamic culture so that the providers could meet the needs of the Muslim population in a culturally sensitive manner.

Several studies have investigated how Islamic or Arabic community members view healthcare, compared with other religious or cultural groups. Most studies can be divided into pregnancy and childbirth, cancer, and end-of-life care.

Pregnancy and childbirth. For Arabic Muslims, an all-female care team is mandated by Islamic law. Male practitioners are permitted in caesarian births under specific circumstances. Female family members play key roles in supporting the new mother and infant during labor and delivery and the 40-day in-residence period practiced by most Muslim women (Bester et al., 2013 ; Missal, 2013). The 40-day period after birth is a cultural and religious marker that ends the new mother's period of uncleanness, allows her to be completely devoted to bonding with her child and learning the basics of childcare (Missal). Bester et al. described cultural practices of family members that show care for the new mother and infant, such as specific Qur'an readings, giving the baby a soft date (fruit) to suck on before the first feeding, and the use of specific religious expressions and blue beads to protect against the evil eye.

In a study comparing Swedish and Arabic pregnant women in a gestational diabetes clinic, Hjelm, Bard, Nyberg, and Apelqvist (2007) found that Swedish women were more likely to complain if they were not able to reach nurses quickly and were less compliant about blood glucose monitoring, whereas Arabic patients felt well-cared-for by clinic staff. The Swedish women were expected to be less stressed during a complicated pregnancy because they perceived a manageable condition and used problem-based coping strategies. However, they were more frustrated and stressed than the Middle Eastern women, who practiced emotional responses to their diagnosis. Because the Arabic women were refugees having limited education and experiencing cultural, economic, and linguistic barriers, the researchers expected that the Middle Eastern women would experience higher levels of stress.

Missal (2013) studied the transition of Arabic women to their new roles of motherhood at the personal, family, and religious levels within the Muslim community. The transition from the role of wife to the role of mother consisted of four stages during prebirth to the completion of the 40-day in-residence period. Personal transition was marked by a sense of freedom before birth to a loss of freedom after the birth, though the new mothers did not feel resentment toward their infants at this loss of freedom. Participants also reported an increased sense of dependency on family, particularly their mother/mother-in-law, who lived with the new mother during the 40 days in-residence, and the female family members who took care of household chores for the postpartum mother.

Anxiety and fear of the birth experience and infant care before giving birth were replaced with development of the mother–child relationship, a desire to care for their child immediately following birth and confidence in the mother–child relationship at the end of the 40-day period. The mothers reported family influence and support as they moved from being supported by the family to full integration into family life by the end of the in-residence period. After the birth of a child, and the role change from wife to mother, there was an increase in perceived respect from family members and friends, particularly from their husband and mother or mother-in-law, and an increased sense of security and more firm integration into the family. Participants also reported an integration of cultural and religious practices, where they had a sense of being an observer in their culture before giving birth and becoming an active participant after giving birth.

Research with Muslim Arabic women supports a family approach to caring for the mother and baby and the influence that this care has on the mother. Including the patient's mother or mother-in-law in the plan of care for the new mother after discharge is culturally competent care. Inclusion of female family members, such as mother, mother-in-law, sisters, aunts, and grandmother in the birth and postpartum experience is perceived as caring and culturally appropriate (Bester et al., 2013 ; Hjelm et al., 2007 ; Missal, 2013). Missal suggested a follow-up call or home visit may be appropriate and shows a high level of care, though this will vary by patient and culture.

Cancer. Cancer is a sensitive cultural issue for many Muslims. Although they accept the diagnosis as Allah's will and trust in him to heal them or prepare them for death, some avoid persons with cancer and view them as already dead, and thus, unclean. Cultural views of cancer, as well as education levels, appear to be predictors of when patients sought Western care for their illness, participated in healthcare screens for cancer, and how they reacted to sharing their cancer experiences after treatment (Goldblatt et al., 2013 ; Saca-Hazboun & Glennon, 2011).

Goldblatt et al. (2013) compared the experiences of Muslim and Christian women from Israel, ages 32-50 years, who had had breast cancer, were treated with chemotherapy and/or radiation, and were currently cancer free. Both Christian and Muslim Israelis felt the need to appear strong and in good health, which put pressure on them not to share the cancer diagnosis. Some commented that shame or stigma would be associated with their family, especially daughters, if their diagnosis was made public. If they decided to share the diagnosis, it was with their husband or close siblings, or parents if unmarried or widowed. Physical changes due to treatment were attributed to changes in hormones, and the women decreased socialization with family and friends. Faith was essential in providing strength during treatment and hope for a cure. Faith mechanisms included prayer, Scripture reading (Qur'an or Tanakh), belief that Allah or God would provide healing, and acceptance of cancer as a test of faith, atonement or punishment for sin, but always as Allah's or God's will. After recovery, the women viewed Allah or God as supportive and caring toward them. A personal values shift was noted in some participants who adapted a more Western view of self-care (their right to rest and family support), regardless of the taboo nature of a cancer diagnosis. Some reported an increased desire to help others who had been diagnosed with cancer, though they preferred to provide support anonymously and/or to strangers. The women represented a culture shift toward the Western paradigm—an increased self-interest and expectation of family support, a higher education and employment rate than more traditional Arabic women, an improving socioeconomic status for women, and an increase in urbanization as a society (Goldblatt et al.).

Nurses have the opportunity to provide Muslims with compassionate care, as many cancer patients will not feel free to speak of their illness to their family members, due to societal taboo. Because Islamic patients derive support primarily from family, a diagnosis of cancer can result in increased feelings of aloneness and frustration that the patient is not able to share. Patients need education regarding cancer screenings and prevention. Muslim individuals need to be assured that they will receive culturally sensitive and appropriate care, such as attention to modesty, assurance of same gender healthcare teams, and increased affirmation of their individual needs (Goldblatt et al., 2013 ; Rassool, 2015 ; Saca-Hazboun & Glennon, 2011).

End-of-life care. Hosking et al. (2000) investigated views on cancer, death, and attitudes toward dying among Muslim and Christian patients in Cape Town, South Africa. Due to the role of family support during illness and old age, Muslim patients receiving a terminal diagnosis were more likely to follow their family's choice of care rather than their healthcare team's advice; Christians followed the advice of their healthcare team over family. As age increased, more patients in both groups were likely to accept healthcare team advice over family advice, though for Muslims, this may have more to do with family's respect for older members. Euthanasia was unacceptable for Muslims, as sanctity of life is mandated by the Qur'an, though they did not object to euthanasia for non-Muslims.

Specific last rites, such as readings from the Qur'an, prayers, facing toward Mecca, lying on the right side, and inclusion of the family in caring for the dying patient, are ways to show cultural sensitivity to Muslim patients (Hammoud et al., 2005 ; Hosking et al., 2000 ; Rassool, 2015). Hospice care is perceived to allow a higher family involvement, control, and cultural accommodations for end-of-life care of the patient, and greater support for the grieving family (Hammoud et al.). Death for Muslims is part of the journey to meet Allah (Rassool, 2015).

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Nurses interested in learning about Muslim faith and culture can attend cultural sensitivity training on a variety of cultures and religions and reach out to friends or others who are familiar with the Islamic religion and culture. Faith community nurses, Crescent nurses in the Islamic religion, can act as intermediaries between healthcare providers and patients. In communities that have a mosque, local religious leaders are open to sharing about their faith and culture. English-speaking Muslim patients may serve as a good source for developing cultural sensitivity. When asked open-ended questions about religion and culture, many patients are happy to share their beliefs (Saca-Hazboun & Glennon, 2011). Nurses may experience a religious conflict of interest with Muslim patients who ask them to read from the Qur'an or use religious sayings, such as “in the name of Allah (Bismi'allah)” or “Allah's will” (Ma'shallah) (Bester et al., 2013). It is acceptable to tell the patient you are not comfortable doing this and obtaining a coworker, especially a Muslim, to assist with these religious activities.

Christian nurses can show care and sensitivity by being respectful of cultural and religious beliefs, seeking to understand cultural practices by asking sincere, open-ended questions, accommodating family involvement in decisions and patient care, and valuing the patient as a unique individual. These actions are common practices to everyday nursing and can be used to provide a physical demonstration of Christ's love and the nurse's faith.

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Crescent of Care Model; culturally sensitive care; health beliefs; Islam; Middle Eastern patients; Muslims; nursing; spiritual care

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