Transcultural Nursing

1. Transcultural Nursing Providing Culturally Congruent Care for Muslims

2. Providing Culturally Congruent Care for the Muslim • Review of the Literature • Cultural Assessment Data • Culture Care Theory • Discussion

4. Review of the Literature Cultural Expectations of Muslims and Orthodox Jews in Regard to Pregnancy and the Postpartum Periods: A Study in Comparison and Contrast

5. Cultural Expectations of Muslims and Orthodox Jews in Regard to Pregnancy and the Postpartum Periods: A Study in Comparison and Contrast • Traditionally childbirth is viewed as a female event and many Muslim men are not accustomed to being overly involved in this experience. • These views are changing however as greater assimilation occurs into western society. • Muslims may have special dietary needs. Many Muslims also fast during certain times of the year.

6. Cultural Expectations of Muslims and Orthodox Jews in Regard to Pregnancy and the Postpartum Periods: A Study in Comparison and Contrast • Muslims may recite verses from the Koran or use a blue stone to ward off evil spirits in regards to the newborn. • Modesty is important to consider when performing procedures. • Muslim women traditionally are expected to adhere to a period of confinement for forty days after childbirth.

7. Typical Prayer Rug and Prayer Beads

8. Review of the Literature Caring for Patients of Islamic Denomination: Critical Care Nurses' Experiences in Saudi Arabia

9. Caring for Patients of Islamic Denomination: Critical Care Nurses’ Experiences in Saudi Arabia • Research-based descriptive study of six critical-care nurses’ experience with caring for Muslim patients in Saudi Arabia. • Findings included three major themes: family and kinship ties, cultural and religious influences, and nurse-patient relationship

10. Family and Kinship Ties • Family involvement in care was found to be a major factor in both providing nursing care as well as the overall emotional, social, and psychological well-being of the patient. • The family unit often “dictated the care” of the patient, even to the extent that the physician would discuss treatment options and decision making solely with the family, without the patient’s involvement. • Visitors often came in great numbers, as many as 20 at a time. Many times visitors would bring food, drinks, and rugs to lay down in the room. This heightened level of visitation was found by many of the nurses to interfere with providing care as well as reduce patient involvement in their own care.

11. Cultural and Religious Influences • The role of Islam was found to be all encompassing and intertwined in every aspect of care. • Patients who were instructed to rest would often insist on getting out of bed to pray five times a day. (Remember, this is on a Critical Care Unit) • Patients accepted any change in condition as “the will of God” and were seemingly apathetic towards any good or bad news. This lead to many nurses reporting a feeling of powerlessness in the care for their patients. • Care was found to be highly gender specific. Older male patients were found to dislike being cared for by female nurses, and female patients often refused to allow male nurses or caretakers to be in the room. This was specifically found to be a problem for female nurses when moving patients who refused to allow males to help.

12. Nurse-Patient Relationship • Since this study was conducted in Saudi Arabia, language was a huge barrier to communication. • It was found that patients were eager to converse with nurses in their native language, even though they knew the nurses did not understand. Nurses admitted to often simply smiling and trying to listen. • Many nurses found it difficult to form patient bonds and develop the family’s trust when communication was limited and attempts to do so often resulted in frustration. • Cultural differences in application of care, such as one example where a young boy had third-degree burns over 80% of his body yet his parents refused to allow him pain medication, were a cause of great frustration and stress for many nurses. • Nurses often felt powerless in helping sad or depressed patients since comforting was not seen as part of the nurse’s role. Attempts to be emotionally sensitive, especially through caring touch, were not welcomed or appreciated by most patients.

13. Review of the Literature Neonatal End-of-Life Care in Sweden: The View of Muslim Women

14. Neonatal End-of-Life Care in Sweden: The View of Muslim Women • Research-based study exploring the views of Muslim women’s views of neonatal end-of-life care in Sweden • Participants: Eleven immigrant Muslim women living in Sweden • The study was divided into sections regarding care before birth, care directly after birth, and during and after the death of the infant.

15. Care Before and After Birth • Most of the women would like to be informed of potential problems with the baby before birth; however several felt that information contradicted their idea that God was giving them this child to take care of regardless of its condition. • The majority of the women agreed that the nurses and medical staff were trying to do what was best for the mother during the phase directly following birth, including describing the infant to the mother. • Visitation from family was important and most did not want to be left alone to deal with their own thoughts regarding the newborn.

16. During and After the Death of the Infant • During the dying phase of the infant, the mothers were given information regarding terminating life support or withholding medicines. • Most chose to stop ventilator support or medicines if there was suffering involved. • Most of the women agreed that memories aggravated grief. They only would take mementos or photos of the infant from when they were alive. • Another member of the family should take care of the religious dressing and care of the dead infant for burial. The infant was usually sent home with the family in order to bury within their religious beliefs. • It was believed this was God’s will for the baby to not survive.

17. Review of the Literature Globalization and the Cultural Safety of an Immigrant Muslim

18. Globalization and the Cultural Safety of an Immigrant Muslim • Research-based study focusing on the social health of immigrant Muslims following terrorist attacks of September 11, 2001 (9/11). • Sample of 26 Muslims residing in the province of New Brunswick, Canada were interviewed in 2002-2003. • Participants experienced a sudden transition from cultural safety to cultural risk following 9/11.

19. Cultural Safety Before 9/11 • Participants indicated they had a sense of well-being in the respective communities. • They had friends among mainstream residents and participated in local life. • Participants emphasized the peacefulness of the area.

20. Cultural Risk in the Aftermath of 9/11 • Participants sense of security altered abruptly. • Most attributed to intense media coverage with unfair attention on their religion. • Muslims became a visible minority. • Greatest source of cultural risk involved the feeling of being under constant surveillance and that they would be falsely reported for terrorist activity.

21. Conclusions: Cultural Safety • Social disadvantage of a cultural minority has been linked to culturally unsafe health services. • The findings should alert the international community of nurses to be aware of the cultural safety of this particular group.

22. Cultural Assessments

23. Cultural Assessment Data Assessment #1 and Application of Culture Care Theory

24. Assessment #1 • A. S. is a modern American Muslim that immigrated from Pakistan in 1978. • A. S. is involved with his children more so than his father. • A. S. is the head of the household and the primary breadwinner for the family. • A. S. has a Bachelors degree in computer science.

25. Assessment #1 • The family is vegetarian. • The family speaks fluent English and are bilingual with Urdu the national language. • His wife does not wear traditional Muslim dress but does wear a Hijab, head wrap, in public. • Doctors and nurses are viewed positively by A. S. and his family.

26. Assessment #1 • Illness is perceived as a test or punishment by God. • A. S. believes in abstaining from things that are forbidden in Islam and views the body as a temple. • Western medicine is to be taken advantage of but the family also has home remedies that they practice for common illnesses.

27. Culture Care Theory Assessment #1 • The preservation of modesty should be a priority for the Muslim patient as well as showing respect. • Nurses should accommodate for these patients to bring in their own food and allow a place for storing these items if possible or discuss the special dietary needs with the physician to allow for vegetarian meals. • Based on the assessment with A. S., no aspects are found to need restructuring or repatterning.

28. Cultural Assessment Data Assessment #2 and Application of Culture Care Theory

29. Assessment #2 • B.A. is a modern American Muslim born in the United States, residing in Chicago, Illinois. She is married with two children. • B.A. and her husband work as a team although he is considered the head of the household. He works from home and she is a stay at home mother. • B.A. and her husband have many friends who are Muslim and many who are not. There are many mixed religion marriages in their family.

30. Assessment #2 • B.A. attended Mosque for three years for Muslim schooling. • She does not formally pray 5 times a day however she prays before each meal and before bed. She also prays before driving an automobile. • She does not wear traditional Muslim clothing. She can wear short sleeved shirts and a bathing suit in public. She does not cover her head. • Her family observes all Muslim holidays and she fasts one day a year. These are traditions she was taught growing up.

31. Assessment #2 • B.A. and her family believe cleanliness is very important. • They do not eat pork or drink alcohol. • B.A. does not believe illness is a test or punishment. She believes God does not give you more than you can handle and that illness and trying times make you stronger. • She prefers female healthcare workers and her husband prefers males. They will accept care from either if necessary.

32. Assessment #2 • B.A. and her husband were married in a Mosque with a Hodha presiding who instructed them in their marital rights and obligations. • B.A. states that her husband says a blessing in a new baby’s ear as they come home for the first time. • A red bracelet is placed around a new baby’s wrist to protect from the evil eye. • Her family follows traditional Muslim ceremonies regarding death and burial.

33. Red Bracelet around a Child’s Wrist to ward off Evil Eye

34. Culture Care Theory Assessment #2 • Preservation/Maintenance • Question patient in advance as to special needs regarding religion and culture. • Take care to preserve modesty and privacy for patient. • Provide pork- and alcohol-free meals and medications. • Accommodation/Negotiation • Allow time for patient to pray daily as necessary. • Provide male or female health care workers for patient as requested if available. • Repatterning/Restructuring • Based on B.A.’s assessment, no repatterning or restructuring is necessary.

35. Cultural Assessment Assessment #3 and Application of Culture Care Theory

36. Assessment #3 • M. is a 51-year-old Muslim woman originally from the Ivory Coast, in Africa. She now lives in the middle Tennessee area and works as a nurse at Vanderbilt. • M. considers herself relatively conservative in her adherence to the Islamic faith and abides by most of its traditional teachings. • M. insists that her cultural values and beliefs were largely influenced by the area of Africa in which she was raised and lived most of her life, in addition to her continuing faith.

37. Assessment #3 • M. wears the traditional head covering, but DOES NOT cover her entire face like some other regional Muslim cultures. • M. does not eat pork or drink alcohol and highly prefers medications that do not contain products of either if at all possible. • M. adheres to the five daily prayers that are typical of Islam. • In M’s family, the male is the head of the household but NOT to the extent that other members are excluded from decision making. • For M. and her culture, gender is sometimes an important issue surrounding patient care, especially involving the placement of urinary catheters. Many patients prefer to have a same-sex nurse place their catheter and, as a nurse, M. prefers to have another male nurse place catheters on her male patients, if at all possible.

38. Assessment #3 • Typically in M’s culture, elders are respected for their experience and wisdom. As they grow older, they are often brought to live with and be cared for by the younger adults in the family. Due to this cultural trend, there are NO nursing homes in M’s area of Africa. • Fasting, in M’s culture, can often include refusal of not only food but also medications and even IV fluids. • It is common in M’s community for many, many visitors to come visit people who are sick and in the hospital. They often bring food, not only for the patient, but also for the family in their time of need. • M. emphasized that it would be considered very disrespectful for a nurse, or anyone else, to come into a patient’s room and touch their Quran, even if simply to move it slightly. • M. also stressed the importance of respect for her homeland of Africa, and avoidance of the stereotype that Africa is full of poor people and starving children, as being crucial to providing culturally competent care to African natives of any faith.

39. Culture Care TheoryAssessment #3 • Preservation/Maintenance • Provide pork- and alcohol-free meals and medications. • Refrain from touching patient’s Quran without express permission. • Accommodation/Negotiation • Provide a prayer rug, or if patient is unable to get out of bed to pray, assist in facing bed toward Mecca and provide privacy for praying. • If fasting, discuss options with patient and possibility of postponing fasting until healthier or making allowances for medications and fluids. • Repatterning/Restructuring • If excessive visitation begins to interfere with patient care, nurse may have to more diligently enforce visiting hours and family/friends may have to visit in smaller, less disruptive groups.

40. Compare and Contrast of Various Muslim Cultures • After several personal cultural assessments and reviewing multiple research articles, many similarities and differences were found throughout various Muslim sub-cultures. A few example are as follows: • For many Muslims, modesty is VERY highly valued. However, many Muslims choose not to wear the traditional head coverings that are so highly regarded by many others. • Most Muslims do not eat pork, but many have assimilated so greatly into American culture that they will make exceptions out of convenience. Many others choose to be completely vegetarian. • The five daily prayers are, for many, a cornerstone of Islamic faith. In contrast, some Muslims have incorporated a less formal system of daily prayer into their Western lifestyle

41. Compare and Contrast Cont. • The assessment of several Muslim individuals in combination with research into Muslim culture has shown a large spectrum of values, beliefs, and levels of adherence to Islamic teachings. • Members of the broad Muslim culture can be highly Americanized, or very traditional in their beliefs and daily practices. Within this culture, members can vary from each other as much as they do from members of other cultural groups. • This level of diversity makes providing culturally competent care for Muslim patients a dynamic and individualized process that involves the continual assessment of your patient, their needs, and your progress as a nurse in meeting those needs.

42. Discussion Despite all of the cultural differences that we as nurses might encounter when caring for Muslim patients, one resounding commonality is that most Muslims, especially those in America, place a high level of trust and respect in our healthcare system. We as healthcare professionals must earn that trust and respect by, in turn, respecting individuals and their culture as well as educating and preparing ourselves to provide the utmost of culturally competent care and constantly striving for “the highest attainable standard of health” (Transcultural Nursing Society Position Statement).

43. References Baker, C. (2006).Globalization and the cultural safety of an immigrant Muslim. Journal of Advanced Nursing. 57, 296-305. Cassar, Linda. (2006). Cultural expectations of Muslim and Orthodox Jews in regard to pregnancy and the postpartum periods: A study in comparison and contrast. International Journal of Childbirth Education, 21, 2, 27-30. Halligan, P. (2006, December). Caring for patients of Islamic denomination: critical care nurses' experiences in Saudi Arabia. Journal of Clinical Nursing, 15(12), 1565-1573. Lundquist, A., & Dykes, A. (2003). Neonatal end of life care in Sweden: the views of Muslim women. Journal of Perinatal and Neonatal Nursing. 17, 77-86.