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January 2016 Article of the Month
This month's article selection is by Chaplain John Ehman,
University of Pennsylvania Medical Center-Penn Presbyterian, Philadelphia PA.


Mohamed, C. R., Nelson, K., Wood, P. and Moss, C. "Issues post-stroke for Muslim people in maintaining the practice of salat (prayer): a qualitative study." Collegian: Journal of the Royal College of Nursing, Australia 22, no. 3 (2015): 243-249.


SUMMARY and COMMENT: This month's article, by researchers from Malaysia, New Zealand, and Australia, recalls a topic explored in our June 2003 Articles-of-the-Month: namely, the need to consider how illness affects specific devotional activities of daily living for religious patients. Here, the focus in on salat (prayer) by Muslim patients post-stroke, and the article is aimed at nurses, but chaplains should find this broadly thought-provoking about the need to assess and help facilitate devotional ritual as a physical activity.

The principal investigator interviewed a small, purposive sample of 5 stroke patients discharged from tertiary referral center in Kelantan, Malaysia, 5 family caregivers, and 12 health care professionals. The interviews with patients and caregivers were carried out in their homes and lasted between 17-42 minutes. The patients -- 3 men and 2 women -- "all still had some effects of stroke such as numbness or weakness of limbs" [p. 245]. Open-ended questions covered:

...(i) life changes after stroke and management at home, (ii) the practice of health professionals in relation to provision of education and health information, (iii) interaction with other people and community, (iv) information needs, and (v) other needs for effective rehabilitation in the home. Prayer was not specifically asked about as the intention was to let people reveal what needs were important to them given their experiences. [p. 245, italics added]
Interviews with the health care professionals covered:
...(i) the important aspects of early rehabilitation at home, (ii) the practice related to acute stroke care and the provision of information and education, (iii) additional information needed or that should be included in the educational module, and (iv) the interfaces between the health service and stroke patients and their caregivers post-discharge. [A] representative from the stroke association was asked about issues related to the association’s activities and contributions to the health and education needs of patients and their family caregivers post-stroke. [p. 245]

Among the results, three themes were identified:


...[A]ll groups of participants talked about the impact of stroke as a test and as a gift from Allah, and that they had a responsibility to make an effort to cope with the effects and to aid the recovery. This responsibility was felt particularly strongly by the caregiver. Some participants used…prayer as their main coping strategy post stroke. Others recited the Holy Qur’an.... Caregivers talked about the importance of prayer for the patient as a coping strategy for support and as one of the ways to get help from Allah for recovery. ...Caregivers were generally concerned and worried about not being able to help the stroke person meet their prayer obligations. [p. 246]
Difficulties performing prayer were spoken of by all participants and included managing tiredness, issues with preparation and the need for family to help. ...The caregivers who were in full-time work and had other commitments often found that assisting patients in performing prayer five times a day was a challenge. ...Managing the preparation related to ablution prior to prayer was often difficult for the person and caregiver. ...Bedridden patients and those with severe physical disability or incontinence were particularly challenging. [p. 246]
While health professionals recognised the importance of prayer, there was no consensus about who should be responsible for providing education related to prayers in the hospital or home setting. The differences reflect health professionals’ understandings of their clinical role and hospital policy and workload. ...The health professionals spoke of prayer being important spiritually and had suggestions for how prayer could be managed. Prayer was important 'firstly for memory…then for movement' and finally for mental wellbeing. In regards to helping patients with memory, some felt prayer could be used as part of cognitive therapy. This is because reciting the Holy Qur’an involves saying verses from memory. It was also thought that praying could promote and stimulate movement because it involves standing, bowing, prostration and sitting. Aids such as stools were considered important to assist patients to stand up. [pp. 246-247]

The authors' perspective emphasizes "the pragmatics of prayer rather than its spiritual dimension" [p. 247], seeing salat as a "short duration mild-to-moderate psychological, physical and brain activity" [p. 245], that "provides benefits in terms of psychological, musculoskeletal and cerebral effects improving the muscular functions of older persons who are disabled or have dementia" [p. 247]. They support "routine screenings about religious activities" [p. 247] and the creation of educational materials for patients and families, and they also recommend specific and very practical education for nurses:
To be able to provide culturally safe care for Muslim patients post-stroke, nurses need knowledge of the preparation and importance of performing salat, the times that prayer is important as well as what is involved. This knowledge could be used in nursing practice through such actions as placing a patient in a room to face Mecca (note when a patient is in bed or unable to move by him/herself, they do not always have to reposition to face Mecca, there is always some flexibility based on patients' ability), offering assistance with ablution (for example for those who cannot do it using the normal approach, a bottle of spray water can be provided), establishing quiet times or arranging appointments or home visits to align with prayer expectations, and advising relatives about the presence of hospital prayer rooms if these are available. Even the very ill and the bedridden patient can pray by using eye movements. Familiarity with what is involved with salat including the preparatory rituals as well as knowledge about Muslim beliefs generally will be useful for nurses in their conversations with Muslim patients with stroke and their caregivers on how to manage praying. [p. 247]
The authors hold that "more recognition needs to be given to the importance of maintaining salat by people who have had a stroke," and "[t]here is a crucial need to work through strategies with people and their carers about how they can manage salat post-stroke" [p. 248], but they understand the broader implication of this attention to physical accomplishment of devotional ritual and at one point cite prayer needs for Orthodox Jewish patients [--see p. 247]. This study, they say, "highlights issues related to the barriers and enablers to praying by stroke patients and potentially other patient groups who experience physical and cognitive disability" [p. 248].

While one of the findings from the interviews with the health care professionals was a "suggestion...that religious people could be included in the stroke rehabilitation team" [p. 246], the article does not mention a role akin to chaplaincy. Nevertheless, chaplains may see in this research not only the needs of Muslim patients but a call to help facilitate the assessment of religious activities of daily living by partnering with Physical Therapists and Occupational Therapists as well as with nurses and physicians, and further to help engage a variety of patients and family members about strategies to provide continuity of personal spiritual practice. What, for instance, can be done for the Catholic patient who has difficulty making the Sign of the Cross, or the Protestant patient who finds it hard to hold a Bible? What about the desire of Buddhists to assume certain postures or to be still for prolonged periods for meditation? What about the ability to perform ablution and its potential importance to the spiritual lives of religious and non-religious individuals alike, especially if incontinence is a problem? And, how might difficulty speaking hinder congregational participation and be an obstacle to many religious acts? This month's article may presents only a small study, but its one that should spur thinking about the practical needs involved in the embodied ways that we live out our spirituality.


Suggestions for the Use of the Article for Student Discussion: 

This article could certainly be used simply to raise awareness of Muslim patients' and families' needs, but for CPE groups that have a mix of Muslim and non-Muslim students it could be a means to engage that diversity through a topic of professional practice. In general, this study challenges chaplains to think about the spiritual implications of physical impairments that disrupt devotional activity. Can students cite examples from their pastoral visits? How physical are patients' devotional practices? How do patients' experience -- or wish to experience -- their spirituality through activities of daily living? Discussion might consider how this perspective on prayer stands in relation to the perspective in the health care literature that sees prayer essentially as "promoting health, preventing severe illness, speeding recovery, and...a coping strategy and method of pain management" [p. 245]. Also, the article could be used to emphasize the spiritual needs specifically of stroke patients, and discussion could be an opportunity to connect with specialized stroke practitioners. One subtheme in the findings here is the situation of patients whose religion may provide exceptions to normal devotional activity because of illness. What do students think about how patients' experience their need to take advantage of such exceptions, or to see themselves as in this way exceptional? Another theme in the findings is the understanding of stroke as a "gift" or "test" from the Divine. That should raise a number of avenues for discussion among students. Finally, from a research point of view, what do students think about not raising the subject of prayer explicitly in the interview process?


Related Items of Interest:

I.  A couple of references to older studies from the article’s bibliography may be of particular interest:

Reza, M. F., Urakami, Y. and Mano, Y. "Evaluation of a new physical exercise taken from salat (prayer) as a short-duration and frequent physical activity in the rehabilitation of geriatric and disabled patients." Annals of Saudi Medicine 22, nos. 3-4 (May-July 2002): 177-180. [(Abstract:) BACKGROUND: The major function of rehabilitation and physical medicine specialists is to provide the proper therapy that helps in improving the physical activities of impaired, disabled and handicapped persons through improvement in their muscle strength. In performing their function, the rehabilitation team should always take heed of the social and mental well-being of such patients. Having observed millions of Muslims perform the salat (prayer) regularly at specified times throughout the world, we postulated that salat, along with its various postures, can play a role in increasing psychological well-being including self-reliance and self-esteem, improving musculo-skeletal fitness, motor behavior and cerebral blood flow that may be beneficial in the rehabilitation of geriatric and disabled persons. SUBJECTS AND METHODS: The various postures of salat were studied and a range of joint motions were measured by goniometer, an instrument for measuring angles. Brain blood pressure was calculated from the effect of gravity on blood pressure at different positions. RESULTS: We found that during the offering of salat, most of the joints and muscles of the body were involved in physical activities with little effort, which probably play a vital role in cerebral blood flow and postural reflexes. CONCLUSION: The physical activities involved in the performance of salat helps in the rehabilitation process in disabled geriatric patients by improving blood flow and increasing musculoskeletal fitness. The salat prayer involves little effort (standing, bowing, prostration and sitting), has a short duration and is beneficial for mental and physical health. More studies are needed in future to determine the full beneficial effects of the salat prayer on the rehabilitative process of disabled persons.]

Robinson-Smith, G. "Prayer after stroke. Its relationship to quality of life." Journal of Holistic Nursing 20, no. 4 (December 2002): 352-366. [(Abstract:) Research has documented that recovery from a stroke is stressful, often necessitating significant coping efforts. Difficult life events such as stroke may encourage patients to reexamine spiritual aspects of life, and the challenges associated with stroke can promote spiritual growth and development. Because of the life-changing experience of stroke, spiritual practices may assist patients in finding meaning and wholeness through the confidence they offer. The purpose of this article is to report how 8 patients used prayer after stroke as a coping strategy to improve self-efficacy and quality of life after stroke. A qualitative approach using the long interview method was employed to expand on spiritual practices expressed through prayer as a way of coping after stroke. Potential strategies are suggested for nurses that address patients' spiritual needs.]


II.  The following articles address broadly the intersection of spirituality and the experience of stroke.

de la Mare, B. "The experience of stroke and the life of the Spirit." Medical Humanities 31, no. 2 (December 2005): 105-108. [(Abstract:) In this paper, I have tried in the first instance to describe the experience of stroke, and to set my own story in the context of more general observations on strokes and on the appropriate care of stroke patients. The paper makes clear that the stroke brought my active working life to an abrupt end, but I am keen to stress that in my case at least the thinking must go on. The production of this paper offers a test case of this last proposition. The paper does not attempt to survey my whole working life (mainly as a Church of England parish priest) and its interaction with my faith, but it does try to explore some of the consequences for faith, and for prayer, prompted by the stroke. There is a personal story of sometimes bewildering complexity behind every stroke. "But why is stroke any different from other serious illness?" This paper seeks to identify some of the distinctive characteristics of strokes; but I leave it to others to answer the question more adequately. It only needs to be stated here that all strokes, in some measure, affect mental processes, sometimes profoundly; and we easily underestimate the extent to which our performance is affected by our states of mind.]

Lamb, M., Buchanan, D., Godfrey, C. M., Harrison, M. B. and Oakley, P. "The psychosocial spiritual experience of elderly individuals recovering from stroke: a systematic review." International Journal of Evidence-Based Healthcare 6, no. 2 (June 2008): 173-205. [(Abstract:) Objectives The objective of this review was to appraise and synthesize best available evidence on the psychosocial spiritual experience of elderly individuals recovering from stroke. Inclusion criteria This review considered qualitative studies whose participants were adults, mean age of 65 years and older, and who had experienced a minimum of one stroke. Studies were included that described the participant's own experience of recovering from stroke. Search strategy The search strategy sought to find both published and unpublished studies and papers, not limited to the English language. An initial limited search of MEDLINE and CINAHL was undertaken followed by an analysis of text words contained in the title and abstract, and of index terms used to describe the article. A second extensive search was then undertaken using all identified key words and index terms. Methodological quality Each paper was assessed by two independent reviewers for methodological quality prior to inclusion in the review using the Qualitative Assessment and Review Instrument (QARI) developed by the Joanna Briggs Institute. Disagreements were resolved through consultation with a third reviewer. Data collection Information was extracted from each paper independently by two reviewers using the data extraction tool from QARI developed by the Joanna Briggs Institute. Disagreements were resolved through consultation with a third reviewer. Data synthesis Data synthesis aimed to portray an accurate interpretation and synthesis of concepts arising from the selected population's experience during their recovery from stroke. Results A total of 35 studies were identified and of those 27 studies were included in the review. These qualitative studies examined the perceptions of elderly individuals who had experienced a stroke. Findings were analyzed using JBI-QARI. The process of meta-synthesis using this program involved categorizing findings and developing synthesized topics from the categories. Four syntheses were developed related to the perceptions and experiences of stroke survivors: sudden unexpected event, connectedness, reconstruction of life and life-altering event. Conclusion The onset and early period following a stroke is a confusing and terrifying experience. The period of recovery involves considerable psychological and physical work for elderly individuals to reconstruct their lives. For those with a spiritual tradition, connectedness to others and spiritual connection is important during recovery. The experience of stroke is a life-altering one for most elderly individuals, involving profound changes in functioning and sense of self.]

Mundle, R. "’I should be closer to God because of this’ --A case study of embodied Narratives and spiritual reconstruction in spinal cord injury and stroke rehabilitation." Journal of Disability and Religion 19, no. 1 (2015): 30-49. [(Abstract:) This instrumental case study demonstrates the need for patients to be able to draw upon their own spiritual and religious vocabularies in order to reconstruct narrative self-continuity in the wake of debilitating illness. Through the presentation of case material taken from a series of semi-structured interviews with a 77-year-old female Roman Catholic patient who suffered a crisis of faith following a spinal cord injury and a stroke, the author illustrates key aspects of life history and religious beliefs and practices—such as lives of the saints, devotions, mystical experiences, sacred time, sacred symbols, and sacred space—to engage narrative ethics around typologies and therapeutic plots supplied by others. Narrative analysis of such discursive resources from the perspective of spiritual health can help inter-professional healthcare teams understand more fully patient needs and holistic best practices within rehabilitation environments.]

Mundle, R. G. "Engaging religious experience in stroke rehabilitation." Journal of Religion & Health 51, no. 3 (September 2012): 986-998. [(Abstract:) In this article, I respond to the problem of engaging with religious experience in health care environments. In particular, I illuminate the relational aspects of religious experience in the context of stroke rehabilitation by providing a commentary on data gathered from existing qualitative research and personal narratives in the acute and rehabilitation phases of stroke recovery. In so doing, I address the necessary balance of empathy and alterity in the art of resonant listening. I also provide some critical reflections on interdisciplinary approaches to engaging with religious experience with reference to a largely overlooked group of health care professionals-hospital chaplains.]


III.  One of two articles featured by our Network in June 2003 was Margolis, S. A., et al., "Validation of additional domains in activities of daily living, culturally appropriate for Muslims," Gerontology 49, no. 1 (January-February 2003): 61-65, in which the authors propose a patient assessment that addressed Muslims’ physical movements used in prayer, capacity to speak or otherwise accomplish the ritual of prayer, and ability to wash for prayer. The data in that research was collected by nurses. However, assessments of Activities of Daily Living (ADL) are more typically performed by Physical Therapists or Occupational Therapists, and they may be good partners with chaplains in this process.

For a window on how spirituality currently plays into the field of Occupational Therapy, see:

Morris, D. N., Stecher, J., Briggs-Peppler, K. M., Chittenden, C. M., Rubira, J. and Wismer, L. K. "Spirituality in occupational therapy: do we practice what we teach?" Journal of Religion & Health 53, no. 1 (February 2014): 27-36. [(Abstract:) This mixed-method study examined the responses of 97 occupational therapists on the subject of spirituality in occupational therapy practice. The inclusion of spirituality into the Occupational Therapy Practice Framework (2008) implies that clinicians address spirituality as a component of client-centered practice. This research revealed a gap between education, theory, and practice as evidenced in the quantitative and qualitative data. Although occupational therapy is intended to be holistic, therapists require a more complete understanding of what spirituality is and what the role of the occupational therapist is when addressing spirituality in evaluation or treatment. The discussion of this research provides information for future occupational therapy educators and educational programs as they seek to incorporate the construct of spirituality into curricula.]

And, in light of our featured article, it may also be instructive to look at the following article describing the adaptation of a physical capacity measure for a largely Muslim population.

Maki, D., Rajab, E., Watson, P. J. and Critchley, D. J. "Cross-cultural translation, adaptation, and psychometric testing of the Roland-Morris Disability Questionnaire into modern standard Arabic." Spine 39, no. 25 (December 1, 2014): E1537-1544. [Among the points in this article, there is special note of a particular item on the Roland-Morris Disability Questionnaire (RMDQ): “Because of my back, I try not to bend or kneel down.” (From the abstract:) The expert committee found the Arabic RMDQ clinically and culturally appropriate. They reviewed item 11, addressing bending and kneeling, because this has a clinical significance and cultural/religious implication regarding prayer positions. ]


IV.  Note also: Our March 2011 Article-of-the-Month dealt with issues of Muslim patients, with attention to the provision of pastoral care.



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