January 2016 Article of the Month
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:
1) PRAYER AND THE MEANING OF THE STROKE EVENTS FOR PARTICIPANTS
...[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]2) DIFFICULTIES PERFORMING PRAYER FOLLOWING STROKE
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]3) PRAYER AS PART OF REHABILITATION THERAPY
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:
II. The following articles address broadly the intersection of spirituality and the experience of stroke.
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:
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.
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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