Erdogan Ozen, a 54-year-old Turkish Muslim engineer visiting the United States on business, has an acute MI. As the ED nurse prepares to administer morphine, Mr. Ozen voices concern, asking if it is absolutely necessary. The nurse is dismayed; what possible reason could the patient have for questioning the use of morphine?

Amira Assan is brought to the women's wellness center by her granddaughter. Mrs. Assan speaks only Arabic; her granddaughter explains she has complained of stomach pains for several months. Mrs. Assan is fully covered, with only her eyes and hands visible.

Would you, the nurse, know how to interview, assess, and treat these patients while respecting their beliefs?

The Arabic word for peace is Salam; it’s also the word from which Islam is derived. Unfortunately, after Sept. 11, 2001, anti-Muslim feelings (or “Islamophobia”) have increased. American Muslims may perceive that they are being singled out and their actions monitored. This may present a threat to health promotion and the delivery of care to this growing population.¹ Nurses should be open to the worldview that followers of Islam have and understand how it may affect health care.

Islam ... 101

Islam is the second largest and fastest-growing religion in the world. While Islam is often associated with the Middle East, only about 25% of Muslims are Arab; the majority are African or Asian. About 30% of U.S. Muslims are African American.² Followers of Islam are known as Muslims or Moslems. It’s also acceptable to refer to followers as “Islamic.” The supreme being of Islam is Allah, the religion’s founder is the Prophet Muhammad, and the holy book is the Koran, or Quran. Additional teachings of Muhammad, the Hadith and the Sunna, complement the Quran and guide Muslims in daily living. While not mandatory, some Muslims use prayer beads and prayer rugs, and pin amulets and charms to clothing. Statues, figurines, or other likenesses that attempt to personify Allah or Muhammad are considered idol worship and are forbidden.

Sunnis represent about 90% and Shiites 10% to 15% of traditional Muslims. There are also several smaller sects, including Sufi, Ahmadiyya, Wahhabi, Ismaili, and Dawoodi Bohra.³

Sunni Muslims pray five times a day even during illness. The more fundamentalist Shiites pray three times a day. Patients with conditions that prevent praying on the floor may pray in bed. Regardless, all prayers are to be said while facing Mecca, to the northeast of the United States. A quiet, uninterrupted environment is necessary, except in emergencies.

First and foremost, healthcare providers should remember that not all people who identify with a particular religion practice all aspects of that faith. Geographical, cultural, and ethnic factors significantly influence the beliefs, values, and practices of Muslims. Remember that differences in practices may exist between Arab, Asian, African, and African American Muslims.

Nurses may have difficulty accepting and understanding unfamiliar healthcare values and beliefs. U.S. health care, rooted in Western beliefs, centers on autonomy, individuality, individual decision making, taking responsibility, and “looking out for No.1.” Muslim beliefs focus on interconnectedness, benevolence, and care for others and the community.⁴ “Good” health is the absence of visible disease or disability. Limited appreciation exists for preventive care or screening for silent or insidious diseases.⁵ This is often in sharp contrast to mainstream U.S. beliefs about health care and may predispose nurses to form derogatory opinions of the Muslim worldview, thus negatively influencing interactions and care delivery. Muslims may interpret caregivers’ lack of awareness of Muslim values as disrespectful, which may reduce their willingness to seek care.

Traditional Muslims have a concept of modesty different from that of mainstream U.S. culture. More than just appropriate clothing, modesty, defined as hejab, is primarily about respect: It’s an attribute to be admired and attained and while it is not one of the five pillars of the Islamic faith, in some countries and cultures, it is however, taken so seriously that it is considered a "sixth pillar."⁶ “Keeping covered” and appropriate relationships between the sexes are integral to modesty. Traditionally acceptable clothing typically doesn’t reveal the shape of a woman’s body. Again, individual interpretation determines the extent that Muslim women cover themselves. Some women cover all but the area around the eyes while others wear Western clothing.

Nurses can respect modesty by asking permission to uncover or touch any body part. Even entering a patient’s room should be done with respect, ideally by knocking and asking permission rather than “barging in."

Direct eye contact with the opposite sex and discussing bodily functions with the opposite sex are inappropriate. This may challenge clinicians’ assessment skills, particularly when screening a patient of the opposite sex for mental health issues, such as depression, or performing neurological exams. Some nurses may interpret the lack of eye contact as rejection, a lack of interest, mistrust, or diminished self-esteem.⁴ The downward glance is, however, a sign of humility and respect.

In extreme emergencies, patients may be cared for by members of the opposite sex.⁶ When it is absolutely necessary for a male provider to care for a female patient, a female chaperone — a staff member or a family member — should remain with the patient at all times.

Cleanliness is crucial for Muslim patients. More than just an AM bath and PM care, Muslims will want to rinse their mouth and wash their hands, face, forearms, and feet before praying. Cleaning one’s body before prayer is called ablutions, or wudu.⁷ Perineal washing is required after urination or a bowel movement. Provide patients of both sexes with a perineal wash squirt bottle or at least make sure that disposable cups are handy by the bathroom sink.

Death, dying, and pain

Muslims believe in divine predestination — the occurrence of illness, injury, and suffering as the will of Allah and atonement for sins. This belief, however, does not preclude Muslims from seeking treatment and relief from discomfort, because the Quran charges Muslims with the responsibility of protecting their health.⁷ Stoicism and the reliance on prayers to reduce suffering are common. For this reason, nurses should be especially attentive to physical manifestations of pain (such as elevated pulse and blood pressure and guarding), question patients often, and offer measures for pain relief. Pain assessment scales designed for patients unable to verbally communicate may be helpful, such as the Pain Assessment Behavioral Scale.⁸ Don’t forget about nonsedating, nonopioid comfort measures like heat and cold, massage (when acceptable to the patient), and topical medications such as capsaicin cream or lidocaine patches (Lidoderm), when appropriate.⁹

Muslims regard death as an inevitable event that results in a return to their creator in an afterlife. Suicide and euthanasia are strictly forbidden; organ donation is permissible if this was a patient’s wish. After death, specific customs must be observed, and withholding them may lead to spiritual distress and altered grieving among those left behind.¹⁰ Sunni Muslims typically believe that showing emotion at the time of death is a rebellion against the will of Allah. Shiite Muslims may openly mourn. Regardless, do not view a lack of overt emotional expression by family members as denial or inappropriate grieving.⁹

When death is imminent, the patient’s face should be turned toward Mecca. After death, family members often conduct postmortem care rituals, including cleansing of the body under running water by a family member of the same sex and shrouding in simple white cloth. Ideally, burial takes place in 24 hours, and the funeral may take place sometime after the burial.¹⁰ Muslim beliefs require handwashing after providing postmortem care, but nurses should still be sure that gloves are available in the room. This is especially important if any potentially infectious body fluids or drainage poses a risk for infection, such as with hepatitis B, C, or HIV. Many Muslims make arrangements for washing and shrouding to take place at a funeral home rather than in the hospital. This varies by state and the resources available at funeral homes.

Muslims will most likely reject grief counseling and traditional Western psychotherapy. However, they may embrace counseling focusing on enhancing spiritual qualities as a coping mechanism because psychological disorders are often interpreted as a manifestation of a soul that has become distanced from the creator. Some Muslim families may consult a religious adviser, such as an imam or sheikh, to help during a medical crisis and especially for end-of-life situations.¹¹

Screening and wellness

The impact of modesty on healthcare screening encompasses the lifespan, and with age, this becomes a concern. Interactions with health providers tend to diminish significantly for Muslim women after childbearing, reducing healthcare screening and promotion opportunities. Even if they agree to screening despite modesty concerns, older foreign-born Muslim women may face transportation, language, and financial issues.^4,12 Islamic teachings encourage Muslims to seek treatment when they become ill. Yet because Muslims seek care primarily for illness, not prevention, they may be at a higher risk for preventable diseases and from diseases that can often be successfully treated when detected early, such as breast, prostate, and colon cancer.⁶ Younger Muslims may have greater access to screening because of work and school requirements.

Perspectives on health and healthcare interventions may also differ from Western beliefs and choices. Many predominantly Muslim countries view being overweight as a sign of prosperity and well-being, so Muslims who are overweight may seek treatment for medical problems later than other people. Muslims may use holistic interventions — including herbs, meditation, music and art therapy, and modifications in diet and exercise — before seeking, or in conjunction with, care from Western healthcare practitioners.⁴

Touchy topics

Muslim customs and practices condemn pre- and extramarital sexual relationships, homosexuality, and drug use. Male circumcision is mandated, a practice that has been found to be associated with a lower risk for HIV transmission. Accordingly, the incidence of HIV/AIDS and other STDs among practicing Muslims is significantly less than among the general population.¹³ This does not, however, eliminate the need to obtain the same history, including information about sexual practices, that you would from any other patient, using extreme sensitivity. When language barriers exist, the patient’s responses to such highly sensitive questions may be dramatically different if family or friends are interpreting as opposed to a staff member.¹³ Patients may be less likely to disclose substance abuse or sexual contact outside marriage in front of family or friends. Using a trained staff member to interpret may yield more accurate information.

Devout Muslims may use (and occasionally share as a sign of respect) a toothstick, or miswak, for oral hygiene. At the end of a pilgrimage to Mecca, or Hajj, Muslims customarily shave or trim their hair. Sharing razors and eating utensils or receiving medical care or blood in less-developed countries (where universal precautions may not be adhered to and the blood supply may not be screened) may place Muslims at risk for bloodborne pathogens.¹³ (Muslims do not have restrictions on receiving blood transfusions.¹³)

Decisions, decisions

Mentally competent Muslim adults of both sexes may accept or refuse medical treatment, but close family members may significantly contribute to the decision-making process. For this reason, when procedures, tests, and treatment options are explained and consent is required, nurses should ask patients whom they wish to be present.⁷ When explaining treatments to patients, nurses should convey expected adverse effects.

Because mind-altering substances are viewed as prohibited, medications that may cause drowsiness and sensory or behavioral changes must be carefully explained with respect to medical necessity. Often, an objection to a medicine is related to a concern that it will alter consciousness, preventing a patient from being in a pure state and therefore unable to complete ablutions and pray.

While alcohol used to intoxicate is forbidden, its use as a medicinal agent is permitted (such as to cleanse before injections or as a component of cough medication). Likewise, while cocaine or morphine as recreational drugs are forbidden, their use as anesthetic agents or for pain relief is acceptable.¹⁴ Some patients, however, will refuse any contact with cocaine or morphine, even for therapeutic reasons, and alternatives must be used. Individual interpretation of spiritual beliefs may dictate which medications are acceptable.

When visitors come to the hospital, they may arrive in large numbers because Muslims are encouraged to visit the sick. Nurses may notice a lack of open expression of affection between the sexes in front of strangers, but shouldn’t misinterpret it as a sign of a dysfunctional family or abuse. Although also cautious when greeting strangers, Muslims are affectionate with friends and family, and men often greet family members and close friends by kissing them on the cheek.

Muslim traditions can benefit nurses’ coordinating care: Islam highly values caring for the ill and elderly at home, and family members view this role not only as responsibility but as an opportunity to be blessed themselves. People with disabilities (social, economic, or physical) are viewed as equals, and Muslims see it as a responsibility to recognize the plight of others and help correct inequities.¹⁵ For this reason, it is important to refrain from using terms that cast disability, poverty, or illness in an unfavorable light.

Truthful communication, even when conveying bad news, is important. Maintaining sensitivity while preserving hope is important, but an inaccurate or incomplete explanation may be interpreted as a lie, considered a great sin, and will undermine a therapeutic relationship.⁷ And yet, most families hold back emotions to avoid stressing or sending a negative message to the patient, especially when the prognosis or diagnosis is poor. Often families will ask providers to keep the news of a terminal prognosis from the patient to preserve the patient’s mental well-being. This may vary among Muslims and is based more on cultural and customary norms than on religious beliefs.

To eat or not to eat …

One of the most misunderstood of Muslim practices is the fasting associated with Ramadan, the ninth month of the Muslim calendar. Ramadan is believed to be the time when the Holy Quran was sent down from heaven. It’s a time when Muslims worship and contemplate their faith rather than focus on everyday concerns. Muslims abstain from physical satisfaction in the form of food, drink, sex, and smoking from daylight until sundown. Illness, menstruation, pregnancy, diabetes, breastfeeding, and travel exempt people from fasting, but some may still do so. If so, the nurse may have to adjust meals and medications. During Ramadan, Muslims often rise before sunrise to eat and pray, fast until sunset, and go to sleep later than usual after a celebratory fast-breaking meal. This affects circadian rhythms and metabolism. The addition of a daytime nap may help combat daytime fatigue.

Because dietary and meat preparation concerns of Muslims are similar to those of Jewish patients who keep kosher, if specific halal (humanely slaughtered and blessed) food is not available, often a kosher-prepared meal may be acceptable. Pork and alcohol are strictly forbidden.

Fasting may affect when you see patients for specific complaints. Changes in dietary intake and sleep patterns during Ramadan have been shown to alter the timing and presentation of acute coronary events.¹⁶ Fasting Muslims are less likely to present to the ED with acute coronary syndromes in the early morning and more likely to present in the afternoon.¹⁷

Healthy eating

Muslims, especially those from rural areas and those with less formal education, may lack knowledge about dietary recommendations for specific disease processes (such as avoiding a high-fat diet with coronary artery disease and a high-sodium diet with hypertension). But a lack of knowledge may be mitigated by shying away from a Western diet. The traditional diet of many Muslims, especially those from Europe, Africa, and Asia, are rich in fiber and low in fat, and feature nuts, fruits, and vegetables, similar to a modified Mediterranean diet.¹⁷ The absolute lack of pork products is also beneficial; pork is one of the highest sources of dietary fat, and eliminating it can reduce cardiac risks.^18,19

A traditional diet appears to have other health benefits, as well. A study comparing Muslims and Christians receiving hemodialysis revealed that while the Christians scored higher on a nutrition questionnaire, the Muslims were less likely to experience fluid overload, hyperkalemia, and hyperphosphatemia.¹⁹

Pregnancy and childbirth

Studies on the impact of fasting on pregnancy have resulted in some interesting findings. While pregnant women may abstain from fasting, a majority do not. One study comparing pregnancy outcomes among 168 fasting and 156 nonfasting women revealed that those who fasted were more likely to have gestational diabetes, require induction of labor, require a cesarean, and deliver an infant who required admission to a NICU.²⁰

Muslims in rural settings may have more traditional approaches to religious observance and health matters than urban Muslims. Women from rural families may be tightly bound to traditions surrounding women’s health and fear deviation. Education may increase the likelihood of being open to alternatives to traditional treatment options during pregnancy, delivery, and the postpartum period. Highly educated Muslim women are more likely to accept Western options. Because decisions are often a collaborative process, when it is necessary to inform a less-educated Muslim woman about her treatment options, involving a highly educated Muslim woman may be beneficial, especially when complex treatment options must be explained.²¹

In the case of a stillbirth or the death of a newborn, nurses may need to alter their routine to assist Muslim parents with grieving. Often, the parents will be unable to make decisions without family or community support. Also, don’t assume that the parents want handprints, footprints, photos, and locks of hair as mementos; Muslims may consider this a desecration of the body. And yet, don’t hesitate to explain that many other parents keep mementos of their infant, and that if they are interested, you can gather items they desire. Let the expressed wishes of the parents guide your actions and recognize that not all Muslims interpret their religious beliefs in the same way.¹⁰

A 40-day maternal home confinement after birth is customary to reduce the risk for maternal and infant illness. Islamic providers and customs encourage showering and sponge bathing during confinement, but discourage immersion in a tub, because of infection risk. Breastfeeding is encouraged, as is circumcision. But do not be surprised if parents reject having the circumcision performed immediately after birth. Some wait until the child is older. Some Muslim parents, to ward off evil, pin amulets or charms on the baby’s clothes. Be sure the pins are secure and do not pose puncture or choking risks.²¹

The extent to which the father participates in labor and delivery varies among couples. Traditionally, female family members attended the mother, and the father waited outside. Today, more men are in attendance. But when a father opts not to attend the birth, do not interpret this as neglectful.

Diabetes concerns

While people with diabetes are exempt from fasting, most do. In a 13-country study, 42.8% of people with Type 1 diabetes and 78.7% of people with Type 2 diabetes fasted for at least 15 days during Ramadan. Less than half adjusted their treatment regimen, and severe hypoglycemia was more common.²²

Insulin, leptin (the protein component of the obesity gene), and the neuropeptide-Y play crucial roles in caloric intake and energy expenditure. Fasting during Ramadan has been associated with hyperinsulinemia, hyperleptinemia, and a reduction in neuropeptide-Y.²³

Taking into consideration the cardiovascular risk factors associated with diabetes, it’s important to note that fat intake is typically higher during Ramadan. Muslims may overeat when breaking fast or eat foods that they ordinarily wouldn’t. Because fast-breaking celebrations often occur outside the home, the likelihood that food will be prepared with diabetic and heart-healthy limitations in mind diminishes.²⁴

Muslims with diabetes are less likely to self-monitor their blood glucose and practice preventive foot care measures, such as visiting a podiatrist and performing daily inspections. Whatever the reason for a healthcare visit, ask permission to inspect the feet of every patient with diabetes and reinforce foot care measures. In observant Muslims, you will likely find very clean feet; your main concern is to check for the loss of protective sensation (neuropathy), pressure areas from ill-fitting shoes, and fungal toenail infections. It may be difficult to persuade Muslims not to go barefoot, because it is often customary to remove the shoes on entering a home or mosque.² However, wearing a designated pair of “indoor-only” shoes is permissible.

When a coworker is Muslim

The Prophet Muhammad apparently knew the value of hand hygiene over 1,400 years ago because he urged frequent handwashing under running water to promote exterior purity.¹⁴ Today, alcohol-based handrubs may be substituted if running water is unavailable. Some Muslim nurses may oppose using alcohol-based products because alcohol is forbidden.¹⁴ Again, this varies by individual. But because alcohol-based handrubs are not used to intoxicate but to clean, most nurses will agree to their use. And patients will not object to nurses using them.¹⁴ Regardless of what is used to clean the hands, remember that the left hand is considered unclean; avoid using the left hand to pass medicine or food to patients.

Salam and goodbye

Islam is not only a religion but a holistic and spiritual way of life that can affect healthcare delivery and health maintenance among individuals and families and in communities. By focusing on the positive health practices of Islam and identifying respectful and sensitive ways to encourage routine screenings and reduce risk factors, nurses can promote wellness among Muslim patients.