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2001 12: 228J Transcult NursPaul Lawrence and Cathy Rozmus

Culturally Sensitive Care of the Muslim Patient  

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JOURNAL OF TRANSCULTURAL NURSING / July 2001Lawrence, Rozmus / CULTURALLY SENSITIVE CARE OF MUSLIMS

Culturally Sensitive Care of the Muslim Patient

PAUL LAWRENCE, MSN, RNUniversity of Alabama at Birmingham

CATHY ROZMUS, DSN, RN, FACCEGeorgia Southwestern State University

The number of Muslims in the United States is growing. Thisarticle outlines a few of the major beliefs in Islam. Religiousand philosophical factors that affect health care are dis-cussed, and practical suggestions are made for nursingactions that lead to culture care preservation, culture careaccommodation, and culture care restructuring. Major topicscovered include the need for cleanliness, preparation forprayer, modesty, family structure, fasting and diet, and care ofthe dying.

For nurses who have not cared for a Muslim patientrecently, there is a growing chance that they soon will. Thereare around 6 million Muslims in the United States, and thatnumber is increasing steadily. At current growth rates, thenumber of Muslims in the United States will surpass the num-ber of Jews by 2010 to make Islam the nation’s second largestreligion (Power, Joseph, & Rhodes, 1998). A monotheisticfaith, the word Islam means submission to the will of God(Ali, 1996). A person who practices Islam is a Muslim orMoslem. (Variations in spelling come from the transliterationof the Arabic words.) The Middle East was the birthplace ofIslam, and around 90% of Arabs are Muslim (Zahr &Hattar-Pollara, 1998). To most Westerners, Arabs and Mus-lims are synonymous, but that linkage is not necessarily accu-rate. Only 20% of the Muslims in the world are Arab(McKennis, 1999). Muslims are scattered all over the world.In fact, there are more than 100 million more Muslims on theIndian subcontinent alone than there are in all the Arab coun-tries combined (Blank, 1998). In the United States, only 12%of the Muslims are of Arab descent. About 25% of AmericanMuslims are immigrants from south Asia, and around half areconverts to Islam, primarily African Americans (Blank, 1998;Power et al., 1998).

BASIC ISLAMIC BELIEFS

Islam respects the prophets who are revered in Judaismand Christianity such as Abraham, Moses, and Jesus (Athar,1999b). Mohammed is the “seal of the prophets” or finalprophet. He lived in Saudi Arabia and founded Islam in theearly seventh century (Ahmed, 1988). The Muslim holy bookis the Koran, and it is believed that the Koran is the uncreatedand eternal word of God that God revealed to Mohammed inArabic (Braswell, 1996). The sayings and traditions of theProphet, the Hadith, are also accepted as truth. This collec-tion, which was gathered into 97 books, is second only to theKoran in authority (Ahmed, 1988; Braswell, 1996). Shortlyafter the death of Mohammed, Islam split into two mainbranches. The Sunni account for the vast majority of Muslimstoday. Where present, the Shiite are minorities except in Iranand Lebanon (Luna, 1989). Table 1 provides a brief summaryof the five basic articles of faith, which are often called the“Pillars of Islam.”

THEORETICAL FRAMEWORK

The Sunrise Model, which illustrates Leininger’s theoryof culture care diversity and universality, provides a theoreti-cal framework for the nursing care of Muslim clients(Leininger, 1995, p. 108). This theory helps to guide nurses’thoughts and actions as they work with people from a varietyof cultures. The goal of this article is to provide knowledgeabout Islam that can provide a holistic way to know, explain,interpret, and predict nursing care needs of the Muslim client.This information can provide a basis for all three modes ofnursing actions and decisions including culture care preserva-tion, culture care accommodation, and culture care restruc-turing. As the Sunrise Model illustrates, religious and philo-sophical factors are only one of many cultural and socialstructure dimensions that affect the care expressions, pat-terns, and practices of a culture. These various dimensions,such as kinship and social factors, cultural values and

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lifeways, political and legal factors, and educational factors,are also interrelated.

The reader should keep in mind that Muslims are not ahomogeneous group of people. This is especially true inNorth America where Muslims come from a wide range ofcultural, political, and racial backgrounds and from differingeducational and socioeconomic levels. Their faith is only oneinfluencing factor in their lives. Therefore, their generic carepractices, as well as their openness to professional care knowl-edge, will be different. This article concentrates on the reli-gious and philosophical factors and their impact on other cul-tural and social structure dimensions. A cultural assessmentis recommended so that care is based on the individual’sneeds and preferences. The appendix accompanying this arti-cle illustrates how one group of nurses was able to meet thespecial needs of their Muslim patient.

Religious and Philosophical Factors

Cleanliness has been called “half the faith” (Athar,1999b). It is very important because a clean body implies apure soul (Luna, 1989). This value of cleanliness is true at alltimes, but it is especially important during prayer. Prior toprayer, each individual must perform ritual ablutions orcleansing. The ablution consists of washing the hands; rins-ing out the mouth, nose, and ears; and finally, washing the feetwith clean water.

Because the body and clothing must be free of urine andstool, the nurse may be asked to assist with bathing or the

changing of clothing prior to prayers if there is any doubtregarding cleanliness. The prayer rug is also important inmaintaining cleanliness during prayers. Prayers are donewhile standing and kneeling on the rug. The patient may bringhis or her own prayer rug. If not, a towel or any clean materialcan be used as a floor covering (McKennis, 1999).

During prayers, an individual assumes several differentpositions including standing straight, bending over at thewaist, and kneeling with the head to the floor. These positionsmay be difficult for some people. Therefore, the sick may beexempt from prayer, or they are allowed to pray sitting or evenlying down.

In addition to the ritual purification before prayers, thereare other strict practices regarding cleanliness. Having themost impact on nursing care is cleansing after using the toilet.Water is used to cleanse the anus after defecation. If available,water should also be used for cleansing after urination. Ifwater is not readily available, both men and women can usetoilet paper for cleaning the meatus.

Muslims believe that God causes everything that happensto people and in nature. A major illness is considered God’swill (Zahr & Hattar-Pollara, 1998). Therefore, anger is aninappropriate response (Ali, 1996). For many people, illnessis received with patience and prayers and is considered atone-ment for sins (Athar, 1999b). Illness may be perceived asGod’s punishment. Therefore, only he can bring healing(Zahr & Hattar-Pollara, 1998). Although most Muslim peo-ple appreciate modern medicine and will seek health care, the

Lawrence, Rozmus / CULTURALLY SENSITIVE CARE OF MUSLIMS 229

TABLE 1Basic Islamic Beliefs

Although there are many tenets and regulations, there are five basic articles or “pillars” of faith in Islam (Ahmed, 1988).

1. The profession of faith: There is no god but Allah, and Mohammed was the messenger of Allah. (La Allah illa Allah wa Mohammedrasul Allah.) It is this profession that makes one a Muslim. Allah is simply the Arabic word that is translated “the God.” ChristianArabs also use the word Allah.

2. Daily prayers with the individual facing toward the holy city of Mecca in Saudi Arabia: Sunni Muslims pray five times per day (Suther-land & Morris, 1995). The times for prayer change as the season changes. The first prayer of the day is before sunrise and the finalprayer an hour after sunset. Prayer is the ceremonial recitation of prescribed words in Arabic accompanied by different body posi-tions from standing to kneeling with the head to the floor. Prayers can be performed anywhere, but it is best to pray at the mosque.Midday prayers on Friday are the most auspicious time of the week for prayer. These prayers are usually accompanied by a sermon.There are opportunities for supplication or Du’a at the end of the prescribed prayer. During prayers, an individual assumes severaldifferent positions including standing straight, bending over at the waist, and kneeling with the head to the floor. To help maintaincleanliness, the floor is covered by a prayer rug or other clean piece of material (McKennis, 1999).

3. Fasting during the holy month of Ramadan: The timing of Ramadan is based on a lunar calendar, and Ramadan begins approximately10 days earlier than it did the previous year. For example, in 2000 Ramadan started on November 27th, and in 2001 it will beginaround November 17th. During Ramadan, eating, drinking, smoking, and sexual intercourse are prohibited from dawn to dusk. TheKoran teaches that fasting during Ramadan has many benefits: It helps people learn to obey God, it strengthens their ability to forgothings they desire, it makes them more thankful to God, it increases their compassion for those who have little, and it rests vital bodyorgans (Ali, 1996).

4. Giving of alms to the poor or Zakat: The prescribed amount is 2.5% of a person’s wealth each year. It can be given to a committee withinthe Muslim community or directly to people in need.

5. A pilgrimage to Mecca during one’s lifetime: This pilgrimage is made around 70 days after the end of Ramadan and is called the Hajj.Of course, not all the Muslims in the world are able to go on the Hajj, but everyone who is able is encouraged to do so.

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belief in predestination may lead some patients to not follow atreatment plan or to not even seek health care. This beliefprobably affects nursing most in the area of health teaching.When teaching about a medication or treatment plan, provideas much information as possible about how and why the treat-ment will help. It is also advisable to involve a member of thefamily who can then reinforce the information after discharge.

Kinship and Social Factors

The family structure for most Muslims is patriarchal andbased on the extended family (Daneshpour, 1998). Therefore,expect the patient’s family to be constantly at the bedside.There also may be many visitors and friends who come toshow their concern because it is considered a good deed tovisit the sick. Traditionally, the family provides spiritual careand support for its members. Because the Koran encouragesdirect supplication for healing, the family may recite or readfrom the Koran and offer supplications for healing (Ali,1996). A large family and a host of friends continuously in theroom can make nursing care difficult on some units. However,if the patient is a fairly new immigrant, the family and friendscan be an important asset to the nurse as they can help inter-pret words and events to the patient. Prayer is often a commu-nity activity, and the male patient may want to pray with fam-ily or friends at prayer times. All they will need is a secludedplace. A public restroom can be used for ablutions.

The family head is usually an older man in the nuclear orextended family. It may be helpful to seek his assistance.Nurses should ask the family who the leader is and seek hiscooperation. Health-related decisions might be made in con-sultation with members of the extended family. Even in emer-gency situations, it is best to involve male family membersbecause making the decision alone can place a woman in anawkward situation (Zahr & Hattar-Pollara, 1998).

The roles of members of the family may be different fromthe typical American family. The Koran teaches that men andwomen are equal but different because their natures are dif-ferent. The primary role of the man is to provide for the eco-nomic support of the family (Daneshpour, 1998). The man isconsidered the head of the family (McKennis, 1999).Although women are not forbidden to work outside the home,their primary role is to nurture the children and the marriage.They are also expected to care for and be attentive to theirmates (Luna, 1994). These beliefs about the roles of men andwomen may affect the dynamics of the family and how theyparticipate in the care of the patient. In most families, the manwill be the decision maker, and the woman will be the primarycaregiver.

Cultural Values and Lifeways

Modesty is very important for both sexes but especially sofor women (McKennis, 1999). In the West, some Muslimwomen have adopted Western style clothing. However, Mus-lim women who strictly adhere to Islamic customs will keep

their hair, body, arms, and legs covered (Ali, 1996). Modestyis a concern any time a woman might be seen by men who arenot from her immediate family. Special provisions for mod-esty should be taken with the female Muslim patient. Thenurse should also be careful to maintain the patient’s modestyduring examinations and procedures. Screen the patient fromview, and uncover only the part of the body being examined.Because the Muslim woman is not to be alone with a man whois not her husband or a close relative (Ali, 1996), a femalenurse should be assigned to care for Muslim women andshould be present when a male physician examines thepatient. Sometimes, a husband may ask to be present whilehis wife is being examined (McKennis, 1999).

Much has been written about the therapeutic use of touch.Some Muslims believe it is forbidden to ever touch membersof the opposite sex other than close family members (Ali,1996). However, others will shake hands if they have not per-formed ablutions for prayer. Because of the importance ofmodesty and the emphasis on separation of the sexes, thenurse should refrain from touching a patient of the oppositesex other than when giving direct care. Even a touch on thearm or a pat on the shoulder may make the patient feel veryuncomfortable. Nurses should not hesitate to touch a patientof the same sex as they would with any other patient.

Muslims follow a dietary code called Halal, whichrequires that meat be slaughtered in a certain way (Ali, 1996).Halal permits the eating of beef, lamb, fish, and other types ofmeat but forbids pork, pork products, blood of dead animals,and the consumption of all intoxicants such as alcohol (Athar,1999b). The Halal requirements can be incorporated into anytherapeutic diet and will not be an insurmountable obstacle.Some will follow the code strictly and may want all their foodbrought from home. They will not want to eat meat, althoughnormally permitted, if it is not slaughtered in the correct way.Jewish kosher laws are not the same as Halal but include allthe important regulations. If the institution does not provideHalal meals, the patient could ask for a kosher (Athar, 1999b)or vegetarian meal. For many, it will be sufficient to avoidalcohol and pork, which are important aspects of the code,and they will be satisfied to order from the regular menu.

Ramadan, the month of fasting, also affects eating habitsand health. Ramadan is a festive time in the Islamic commu-nity (Arif, 1992). Each evening, family and friends meet atsunset to break the fast together. The family will also awakenearly in the morning before dawn to eat. Often, food con-sumption actually increases during Ramadan. Fasting is notrequired for children, but by the early teens they often beginfasting for at least part of the day (Ali, 1996). Women who aremenstruating or lactating as well as sick individuals and trav-elers are exempt from fasting (Ali, 1996). However, theseindividuals are required to fast at another time during the year.Someone who is admitted to the hospital during Ramadanmay have a feeling of personal failure. Some people who areunable to participate in the fast may have significant feelings

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of loss and may need emotional support (Arif, 1992). This sit-uation is another time when the extended family may be ofhelp; they can remind the patient that Ramadan is not justabout fasting but also about prayer and reading the Koran(Arif, 1992). Even those who are exempt may try to fast out ofdevotion and the desire to be a part of the family and the Mus-lim community. If it is not therapeutic for the hospitalizedpatient to fast, explain the reason. If there are no contraindica-tions and the patient desires to do so, the dietary departmentcan provide a snack that can be eaten just before dawn.

Long periods of fasting from both food and drink alternat-ing with feasting can be a challenging time for those with achronic illness such as diabetes. The health care team must bewilling to work with the patient to adapt the treatment plan tothe fasting schedule if at all possible. It is important to explainwhy it is necessary to continue the treatment plan duringRamadan and to explain how the plan can fit into the fastingschedule. The fast may be more important to the devout indi-vidual than the treatment plan. So it is important to find aworkable compromise even if it is less than ideal.

In addition to Ramadan, there are other prescribed fastdays that some Muslims may choose to observe. These fastsare for shorter periods of time. Once the patient and healthcare team have a workable treatment plan for Ramadan, it caneasily be adapted.

For a Muslim, death is the transition from the earthly formof existence to the next (Sheikh, 1998). It is just a part of thejourney in anticipation of meeting God (Athar, 1999b). Thedaily prayers become even more important during times ofsuffering. Patients will be encouraged by their families tocontinue to pray as long as they are able to do so (Sheikh,1998). The conscious, dying patient may wish to face towardMecca. Family and friends will recite passages from theKoran. They are encouraged to pray for the patient’s welfarein the life to come (Sheikh, 1998). If no family members areavailable, assistance can be sought from the local Muslimcommunity to provide religious comfort for the patient.

After death, the body is thought to belong to God andshould not be cut or harmed in any way (Green, 1989). A post-mortem examination will not be done unless required by law(Athar, 1999b). A non-Muslim should not touch the bodyafter the patient dies, and after death, a woman’s modestyshould be maintained as if she were alive (Athar, 1999b). Thefamily may wish to perform after-death care of the body. Ifnot, it is acceptable for a non-Muslim to wear gloves whentouching the body. If the nursing staff must care for the body,these guidelines should be followed.

• Close the eyes, secure the mouth, and turn the face to the right.This is done so that the face will be toward Mecca when buried.

• The body should be straightened.

• The hands should be placed on the chest with the right handover the left.

• It is necessary to wash the body after death, but a Muslim ofthe same sex should do this.

• The body should be covered with a sheet so that no part is ex-posed (Green, 1989).

The dead are treated reverently and are buried quickly, prefer-ably within 24 hours (Sheikh, 1998). The Islamic teaching ofa quick burial without embalming may conflict with locallaws. If the family is not sure how to proceed, seek assistancefrom the local Muslim community.

Families will not express their grief in a uniform way.Nurses have witnessed the full range of emotional displayfrom quiet stoicism to loud crying and wailing. Men are morelikely to suppress their emotions, whereas women are moreexpressive (McKennis, 1999). Some Muslims may feel thatexpression of grief is inappropriate because God predestinedthe person’s death.

Other Religious Influences on CareExpressions, Patterns, and Practices

• The patient may receive great comfort in reading, reciting, orlistening to tape recordings of the Koran being chanted. If thepatient has a Koran at the bedside, health care workers shouldbe very respectful of it because it is considered holy. If per-sonal items or equipment must be moved, avoid placing any-thing on top of the Koran. The Koran should never be put onthe floor.

• Immediately after the birth of a baby, it is customary for aprayer to be whispered in the infant’s ear. Some will also de-sire to bathe the baby, or they may have other traditions.Usually, any Muslim can perform these rituals, but if the fa-ther is present in the delivery room, he may want to do them(Hutchinson & Baqi-Aziz, 1994).

• All males should be circumcised (Athar, 1999a). The circumci-sion does not have to be done by a religious leader on a certainday, nor is there a prescribed ritual. The family may choose tofollow whatever the procedure is at the local hospital.

• Clitoridectomy or female genital mutilation is a controversialsubject. Although inaccurate, the procedure is sometimes re-ferred to as female circumcision. Female genital mutilationmay be performed in a variety of ways ranging from removalof only the clitoral prepuce to the removal of the clitoris, labiaminora, and most of the labia majora (Davis, Ellis, Hibbert,Perez, & Zimbelman, 1999). It is performed in the name of Is-lam in some parts of the world. However, the vast majority ofMuslims around the world do not practice female genital mu-tilation (Davis et al., 1999). It is not a direct teaching of theKoran, and one Hadith counsels against the more severeforms of the practice (Winkel, 1995). It is especially commonin countries along the Horn of Africa and in sub-Saharan Af-rica and may be done also by non-Muslim people of those re-gions. Health care workers in the United States are seeing anincreased number of female immigrants who have been cir-cumcised (Davis et al., 1999). Sexual purity and chastity forwomen are extremely important in some cultures; the honorof the entire family depends on it. It may be for these reasonsthat this procedure was originally performed (Winkel, 1995).

• The sanctity of life is a very important teaching in Islam.Therefore, abortion is strongly opposed on religious grounds

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by most Muslims (Sheikh, 1998). Some authorities would al-low an abortion to preserve the life of the mother (Athar,1999b).

• The use of contraceptives is also a topic about which manyMuslims disagree. Many Muslim scholars approve of familyplanning because contraception is not expressly forbidden inthe Koran. In fact, prolonged nursing is encouraged to delayconception. It is also known that some friends of the Prophetpracticed coitus interruptus. Therefore, it is reasoned that ifthe practice were wrong it would have been forbidden in theKoran (Libbus & Kridli, 1997). However, there are scholarswho believe that contraception is forbidden in Islam. Thecommand to “procreate and abound in number” is cited asproof of this prohibition. Some also believe that children areGod’s gift and that procreation is the primary objective ofmarriage. These scholars would argue that only God can de-cide the number of children that a couple will have (Libbus &Kridli, 1997). Health care personnel will not find consistencyin beliefs or practice and should offer counsel in accordancewith the wishes of the couple.

• If there is a miscarriage and the gestational age of the fetus isgreater than 120 days, it is prepared for burial as with an adult.(Sheets & El-Azhary, 1998).

• It is permissible for the married Muslim couple to make use ofreproductive technology if they are unable to conceive(Athar, 1999b).

• There is no injunction against blood transfusions (Athar,1999b).

• Because of the belief in the sanctity of life, there is no placefor assisted suicide and euthanasia according to the IslamicMedical Association of North America. However, when thetreatment becomes futile, it is no longer mandatory. The Is-lamic Medical Association of North America also encour-ages the writing of a living will. It is acceptable for thephysician to write a do-not-resuscitate order if the patient isbrain dead (Athar, 1999a).

• There are no restrictions on organ donations. However, the or-gan should be donated as a free gift, without any sale of the or-gan. Also, no harm can be done to the living donor during theprocess of taking out the organ. Sexual organs should not betransplanted. If the organ is from a dead donor, minimum dis-section should be done and the body should be buried as soonas possible (S. Athar, chairman of Ethics Committee, IslamicMedical Association, personal communication, August27,1999). However, there remains a controversy over the def-inition of death. The traditional definition of death is that itoccurs when there is permanent cessation of heartbeat andrespiration. Now, the person whose brainstem is not function-ing may be pronounced dead. Although some Muslim schol-ars believe that retrieving organs from brain dead patients ispermissible, others are opposed to the practice (Ebrahim,1998).

CONCLUSION

The Koran, the Hadith, and modern interpretations ofthose writings prescribe the beliefs discussed in this article.There are also many health beliefs and practices that fallwithin the realm of “folk Islam.” These may be widelybelieved but are not found in the Muslim holy writings. FolkIslamic practices may also vary widely in different regions of

the world. They should be addressed from a cultural ratherthan religious basis.

Although there are a large number of Muslims living inNorth America, most Americans know very little about Islamand how Islamic faith affects the lives of Muslim people(Luna, 1994). The information provided here can be used as abasis for nursing actions and decisions because nursing carethat is culturally congruent can contribute to the well-being ofclients. Conversely, care that is not reasonably congruent maylead to cultural conflicts, noncompliance, stresses, and ethi-cal or moral concerns (Leininger, 1995, p. 104). As nursescare for Muslim patients, they should not be intimidated orworry about doing the wrong thing. If there is uncertaintyabout a specific practice or intervention, ask the patient orfamily. Without fail, they will appreciate the nurses’ attemptsto provide sensitive care to the Muslim patient.

APPENDIXA Case Study

Mr. Ahmad, 74 years old, was admitted to the cardiology unit ofMemorial Hospital following his first myocardial infarction. He hadimmigrated to the United States from Pakistan in the early 1960s.His wife, also from Pakistan originally, was several years youngerthan her husband. They had four sons and two daughters, ranging inage from 19 to 35. Mr. Ahmad and his family were Muslim. Hismany years in the United States and his gregarious personality al-lowed the nursing staff to gain an insider’s perspective on the influ-ences of his religious beliefs on his nursing care needs. As the nursescared for him following the myocardial infarction and subsequentcardiac catheterization and angioplasty, they learned a lot about hisfamily and his faith.

Mr. Ahmad continued to observe his practice of prayer. When hewas unable to go into the bathroom to perform the required ablutionsand his sons or a male friend was not present, he would ask the nurseto bring a basin of clean water to his bedside. A few times, he askedto bathe and change clothes because the body and clothing must befree of urine and stool for prayers. Because the ablutions must be re-peated if the person touches someone of the opposite sex, his nurseslearned to ask before touching him if there was a possibility that hehad performed the ablutions.

As he could not assume the regular positions of prayer, Mr. Ahmadprayed while in bed. The staff positioned his bed so that he could facetoward Mecca in Saudi Arabia, which is east of North America. As hiscondition improved, he was able to sit in a chair facing east for hisprayers. Prayer is often a community activity, and Mr. Ahmad re-ceived great comfort in praying with his sons or other male visitorswhen they were present at the designated times of prayer. The visitorsused the public restroom down the hall for their ablutions.

Mr. Ahmad was also very careful to cleanse himself after usingthe toilet. Most of the time, his family took care of this need until hewas able to go into the bathroom where there was running water. Afew times, the nursing staff assisted by providing a basin of water.

His family was constantly at his bedside. The continuous pres-ence of his large family and friends in the room made nursing caredifficult. Because of his father’s serious condition, Mr. Ahmad’soldest son assumed the role as the head of the family. He had muchmore success than the nurses in explaining to other visitors the needto limit the length and number of visits. At the staff’s suggestion, thefamily brought a notebook so that visitors could register their visit

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and perhaps write a note of encouragement. This notebook allowedfriends to express their concern without making a lengthy visit. Thenurses were also able to provide a place other than Mr. Ahmad’sroom for visitors to congregate.

Memorial Hospital does not offer a Halal menu, so Mr. Ahmadasked for a kosher meal. He asked the nurses to contact the dieticianto confirm that the gelatin was not a pork derivative. In preparationfor his discharge, the dietician was asked to instruct him and his wiferegarding the low salt, low fat diet that his doctor had prescribed. Thedietician did not have a problem with the Halal requirements, but aswith many patients, Mr. Ahmad had some individual customs andtastes that proved to be a challenge in his adhering to a dietary modi-fication. Because these modifications are long term, the nurses wereglad that they started discussing early how to incorporate therapeuticchanges into his eating habits.

Mr. Ahmad believed that his illness was God’s will. When teach-ing him about his discharge medications and treatment plan, thenurses gave as much information as they could about how and whythe treatment would help. His wife and children also participated inthe teaching sessions. As he gained a clearer understanding of thetreatment plan, Mr. Ahmad stated that he thought that God had pro-vided it for his well-being.

Mr. and Mrs. Ahmad visited the cardiology unit, 2 months afterhis discharge, following a routine visit with his physician. He had re-sumed most of his previous activities, and they reported that he wasprogressing very well. They both thanked the nursing staff for theirwillingness to provide care compatible with their faith.

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Paul Lawrence, RN, MSN, is a nursing education consultant inthe Gaza Strip. He received his MSN in adult health from the Univer-sity of Alabama at Birmingham. His teaching interests are primarilyin the areas of adult health and leadership. He has been involved ingeneric nursing education and continuing education for practicingnurses in the Middle East since 1985. In addition to nursing educa-tion, he has participated in many primary health care projects withlocal health care organizations.

Cathy Rozmus, RN, DSN, FACCE, is the vice president for aca-demic affairs and dean of the faculty at Georgia Southwestern StateUniversity. She received her DSN in maternal child nursing from theUniversity of Alabama at Birmingham. Her research, teaching, andclinical interests include health behavior, decision making,transcultural nursing, and pathophysiology. She has served as aconsultant to nurses in the Middle East since 1995.

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