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ISLAMIC MEDICAL EDUCATION RESOURCES 04

0010-ETIQUETTE OF HUMAN RELATIONS (PART II)

Lecture to 4th year medical students at the Kulliyah of Medicine, International Islamic University, Malaysia 14th October 2000 by Professor Omar Hasan Kasule Sr.

18.2.3 THE HEALTH CARE TEAM

A. PRINCIPLES OF GROUP WORK

GROUPS: DEFINITION, CLASSIFICATION:

A group is several persons being interdependent and interacting with one another. The minimum size for a group is three. There are no hard and fast rules about group size; it all depends on circumstances. The optimum size for a group is 5-7 members. Larger groups do not give enough opportunity for discussion by individuals. When a group is too large, dividing it into subgroups each specialising on a certain task may be necessary.

 

There are several types of groups: teams, task forces, self-directed work-teams, families, tribes, clans, fraternities, etc. A team is an on-going group that identifies and solves problems; cross-functional on multidisciplinary teams are very effective in solving problems. A task force is a temporary group that dissolves when the problem is over. A task force researches into causes of a problem, and recommends corrective action. In some cases, it may be retained to solve the problem. A self-directed work-team is a group of workers that supervises itself in the identification and solution of problems. It plans, executes, and evaluates its work.

 

The first group you belong to is the family. As you grow you become aware of other groups that you belong to: clan, tribe, nation, religion, and the Ummah. You may freely join groups such as clubs, political parties or you may find yourself a member of groups such as the school, the university, and the community mosque. Groups may be formal or informal. Most groups you belong to are informal and you may not even be aware of your membership. Groups can be defined according to social distance as in-group or out-group. A reference group is one that is accepted as a model. Group work involves people, objectives, and a situation.  A collection of people with no common objective does not constitute a group. A group of people with a common objective may not constitute a group in certain circumstances; for example when members of a local football team attend Friday prayers in the mosque, they are not in the mosque as a group because the situation is different.

 

Traditional society has small intimate groupings that gave people a sense of security. Industrial society is bringing about anonymity. The medical environment provides an opportunity to work in a multi-disciplinary highly trained team with its ethics, procedures, and culture. Group-work has its advantages and disadvantages; the advantages far out-weigh the disadvantages.

 

ADVANTAGES OF GROUP WORK:

Members of groups enjoy the benefits of integration, stimulation, motivation, innovation, emotional support, and endurance. Group performance is generally superior to individual performance. Abundant exceptions do exist. Some highly productive people can not work in-groups. This should be accepted. Forcing them to work in groups will only lead to their frustration and that of the group. Experience throughout history has taught us that productivity and progress are a result of cumulating of hundreds or even thousands of individual efforts. Individual initiative is the backbone. Societies and systems that suppress individual initiative eventually fail.

 

When we talk about group-work being superior we are actually saying that by coordinating, channeling, and complementing activities, as well as canceling contradictions an individual's productivity is higher in a team that outside a team. It is the individual's productivity and not that of the team that is the yardstick. A team of superior individual performers will itself be a superiorly performing team. On the other hand a team that is performing well as a team but has some members not performing to their full potential is essentially a weak team. A team that stifles the individual in the name of conformity will fail very rapidly. This concept of group-work parallels that of congregational prayer, salat al jamaat. An individual praying in a group gets a 27-fold reward he however still has to perform and take personal responsibility for results.

 

DISADVANTAGES OF GROUP-WORK:

The best is to work in groups but like all human endeavors it has its problems and disadvantages that we must be aware of and must guard against. Members of groups may suffer from the following. They may fall into the trap of group think when they start feeling that their group is invulnerable, knows, and can do anything. They may start feeling arrogant and moralize feeling that they are right and everybody else is wrong. The strong to maintain group cohesion may lead to a false feeling of unanimity when actually people disagree but just suppress their opinions in the interests of the group. There is pressure on every member to conform to the group norms even if individuals do not agree. Human history has recorded the plight of individuals who committed many mistakes in order to conform to the group when they knew they were doing wrong. The pressure on individuals to conform may reach the extent that opposing or different ideas are dismissed. This rapidly leads to destruction of creativity. Creative individuals with new ideas are not tolerated. Any dissent from the group norm is rejected. The biggest disadvantage of group work in my view is mis-match of members. Persons who do not share the same vision or who do not have compatible background experiences can not work together comfortably. Mismatch of group members leads to low group productivity and even intra-group conflict.

 

GROUP FORMATION AND BREAK-UP:

There are three bases in the Law for group work: consensus, leadership, and co-operation. The consensus of the group is protected by Allah from error, al ijma ma'asum. Thus, a group is less likely to reach a wrong conclusion than an individual working alone. Humans must select and follow a leader for proper and purposeful conduct of their affairs; this means those followers must congregate in groups under a leader. The general directive of the Qur'an to believers to co-operate in doing good requires that people work in groups. Some groups are formed by individual choice. In some cases individuals find themselves put together by circumstances beyond their control.

 

The health care team falls between these two ends of a spectrum; health care workers freely made the choice of the medical profession but they can not choose whom to work with in the ward, the clinic, or the operation theater.

 

There are four stages in group formation. Groups and individuals that compose them go through various stages as they learn to work together. The four stages are: forming (acquaintance and learning to accept one another), storming (emotions and tensions), initial integration (start of normal functioning), total integration (full functioning), and dissolution.

 

Mature groups develop a group identity and have optimized the following characteristics: feedback, decision-making procedures, cohesion, flexibility of organization, resource utilization, communication, clear goals accepted by members, interdependence, participation in leadership functions, and acceptance of minority views.

 

Like everything in life groups are started, they grow and eventually break up. Some groups fail because they are constituted on the wrong basis. The members can not get along together, communicate with or understand one another. There is no commonality of interests, attitudes, and goals. In such a case individual effort will be preferable to a non-performing team.

 

There are behavioral diseases that destroy groups. All of them have been described and have been defined by the Qur'an: hasad, nifaq, namiimah, gaybah, kadhb, riyah, kibriyah, hubb al riyasa, tajassus, and dhun al soo. Seeking personal credit for group work alienates and demotivates. Denying credit where it is due annoys and alienates.

 

CHARACTERISTICS OF THE IDEAL GROUP:

An effective group has the following five attributes: First: An ideal group follows the Qur'an and sunnat in all its activities. It has a common clear and inspiring goal to which the whole group and its individual members adhere. Having a common goal helps make the group result-oriented. The group has its distinctive culture and norms. The culture should reflect both underlying Islamic values and the nature of activity. The most important aspect of culture is to develop a spirit of brotherhood. Group work does not thrive in cultures that instil and encourage extreme individualism and competition. Group norms help improve interpersonal relations because expectations are clear. Each group must establish norms defining standards and acceptable behavior. People may adhere to abnormal group norms because of the need to belong. A strong desire to conform and achieve consensus may be detrimental to a group. Individual members may be reluctant to challenge wrong assumptions and conclusions of the group. This phenomenon is called groupthink.

 

Second: Members in the group must feel secure and not suppressed. They must know that they are accepted in the group as they are with their shortcomings and human weaknesses. They therefore will express their opinions freely, criticize, and accept criticism.

 

Third. Understanding and sincere practice of group dynamics that are necessary for success of group work. Good communication and interaction are the bed-rock of positive group dynamics. Members must be interdependent, mutually influence one another, and have face-to-face communication. An ideal group should be solid like a building. Each member should be a brick holding the building together. Members must be loyal to group and to one another. It will develop a group spirit that puts group interests before individual interests. Members of the group may belong to several other groups. They may also have several different loyalties. However, these should never deviate from the teachings of Islam. Group feeling, asabiyyat, is a double-edged sword. In moderation it is positive in keeping the group together. In the extreme it pits the group against other groups and engenders conflict. It may reach a stage when truth, fairness, and justice are overlooked in order to maintain group solidarity. Asabiyyat that leads to giving member interests priority over the interests of Islam is strictly forbidden. Group members must trust one another and not fear that their colleagues will act or talk against them when they turn their back. A climate of collaboration and Cupertino in doing good must exist at all times. Group members must share their sorrow, happiness, failure, and success. Openness and no concealment of facts are the way of life for effective groups. An atmosphere of confidence, trust, and supportive of members.

 

Fourth. All members must be competent and committed to the group. They must take both group and personal responsibility for group activities. They must set and adhere to standards of excellence and superior performance levels. Only good planning, effective organization, and good use of human and material resources ensure superior performance. The members must understand group roles. There are several ways of cross classifying group roles. Group roles are of various types: expected, perceived, enacted, and assigned. Groups' roles may be group or individual ones. Group roles are either task roles (the roles that the group has to carry out) or building and maintenance roles (roles necessary to maintain the group. Group task roles include: initiating activities, managing activities, collecting and disseminating information, collection and discussion of opinions, reaching consensus, orientation, setting performance standards, implementation, evaluation, and control. Group maintenance roles include: encouraging, empowering, harmonizing, setting group norms, conflict resolution, communication, compromise). Some members in the group may play individual roles. These roles could be negative but in many cases, they may not be supportive of the group as a whole. Negative individual roles include: aggressor, blocker, recognition-seeking, player, and dominator, playing politics.

 

Fifth: Every group must have a leader. Success of a group depends on the leader. The leader may be assigned or may emerge in the group and becomes accepted by the others. An ideal group leader should not be selected on the basis of expertise because he may use his power to stifle open discussion. A leader should be selected on the basis of effective leadership, ability to run meetings well, ability to make sure the work is done, and ability to hold the group together. Leaders form groups and delegate specific tasks to them. A very directive domineering group leader may not succeed in leading a performing group because he denies others participation. Group leadership must be principled. It must have a vision that is shared with all group members. It must encourage talent. The leadership must subject its ego to group interests. The leader must be able to identify conflicts early and resolve them. A major role for the leader is to manage conflict to maintain the unity and smooth functioning of the group. When goals, actions, and interests are incompatible, there is conflict. Conflicts may not always be negative. A group may learn from a conflict situation and emerge stronger. Poorly managed conflict situations may end with the break-up of the group.

 

C. ETIQUETTE of  TEACHING and LEARNING in THE HEALTH CARE TEAM

COMPOSITION OF THE HEALTH CARE TEAM:

The health care team in a teaching hospital is very complex. It is multi-disciplinary and its members play complementary and inter-dependent roles. It consists of both university and hospital personnel all engaged in the care of patients. The academic personnel are the medical faculty as well as the students (under-graduate and post-graduate). The hospital staff is the consultants, nurses, nursing aides, auxiliary medical personnel. All members of the team have the dual function of both teaching and delivering health care. The teaching process is complex. There is programmed and structured teaching. However most of the teaching is passive; there is a lot of learning of attitudes, skills, and facts by being present and watching what is being done to the patient. There is also continuous learning from one another. Students learn from consultants but consultants may also get new insights from students.

 

THE TEACHER'S ETIQUETTE:

Teachers should take their task very seriously. The education process, involving giving and receiving knowledge is noble (MB#70). Teachers should have the humility to know that their knowledge is limited and that they can always learn more. Arrogance because of knowledge is condemned (MB#102). Teachers must make the learning process interesting and avoid boredom (MB#62). They should make the atmosphere and circumstances of learning easy for the students (MB#63). Teachers must be careful in their actions, attitudes, and words at all times because being models and leaders they are seen and are emulated. They must be aware that sometimes they can teach using body language without saying anything (MB# 75 and 76); they have to be careful about their public dispositions They should be ready to carry out their function at all times and at any opportunity (MB#74). They should have an appropriate emotional expression. They can raise the voice to emphasize an important point (MB#55). They can show anger or displeasure when a mistake is committed (MB#79, 80, and 81). Asking students questions to ascertain their level of knowledge is part of the teaching process and is not in any way a humiliation for them (MB#56). Teachers should make sure that the students understand by constant repetition (MB#82).

 

THE STUDENT'S ETIQUETTE:

The Islamic etiquette of the relation between the student and the teacher should be followed. In general the student should respect the teacher. This is respect to knowledge and not the individual. The prophet taught admiration and emulation of the knowledgeable (MB#66). Students should be quiet and respectfully listen to the teacher all the time (MB#101). Students should cooperage such that one who attends a teaching session will inform the others of what was learned (MB#78). Students can learn a lot from one another. The student who hears a fact from a colleague who attended the lecture may even understand and benefit more (MB#61). Students should ask questions to clarify points that they did not understand or which seem to contradict previous knowledge and experience (MB#88). Taking notes helps understanding and retention of facts (MB#93). Study of medicine is a full-time occupation; students should endeavor to stay around the hospital and their teachers all the time so that they may learn more and all the time. They should avoid being involved in many other activities outside their studies (MB#98).

 

D. ETIQUETTE of  CARE DELIVERY in THE HEALTH CARE TEAM

Each member of the team carries personal responsibility, mas'uliyat (KS p. 45 and p.338). Leaders of the team carry more responsibility than the others. Leaders must be obeyed (KS p. 44) to be able to carry out their work well. They however should not be obeyed in committing illegalities, corruption, or oppression, dhulm (KS p. 45).

The story of Rufaidah is very instructive in the etiquette of medical care for a Muslim. Rufaidah, the first professional nurse in Islamic history. She lived at the time of the Prophet Muhammad (PBUH) in the 1st century AH/8th century CE. Her history illustrates all the attributes expected of a good nurse. She was kind and empathetic. She was a capable leader and organiser able to mobilise and get others to produce good work. She had clinical skills that she shared with the other nurses whom she trained and worked with. She did not confine her nursing to the clinical situation. She went out to the community and tried to solve the social problems that lead to disease. She was a public health nurse and a social worker.

 

Rufaidah is an inspiration for the medical and nursing professions in the Muslim world. Rufaidah bint Sa'ad, is recognized as the first Muslim nurse. Her full name was Rufaidat bint Sa'ad of the Bani Aslam tribe of the Khazraj tribal confederation in Madinah. She was born in Yathrib before the migration of the Prophet Muhammad (PBUH). She was among the first people in Madina to accept Islam and was one of the Ansar women who welcomed the Prophet on arrival in Madina. Rufaidah's father was a physician. She learned medical care by working as his assistant. Her history illustrates all the attributes expected of a good nurse. She was kind and empathetic. She was a capable leader and organizer able to mobilize and get others to produce good work. She had clinical skills that she shared with the other nurses whom she trained and worked with. She did not confine her nursing to the clinical situation. She went out to the community and tried to solve the social problems that lead to disease. She was both a public health nurse and a social worker. When the Islamic state was well established in Madina, Rufaidah devoted herself to nursing the Muslim sick. In peace time she set up a tent outside the Prophet's mosque in Madina where she nursed the sick. During war she led groups of volunteer nurses who went to the battle-field and treated the casualties. She participated in the battles of Badr, Uhud, Khandaq, Khaibar, and others. Rufaidah's field hospital tent became very famous during the battles and the Prophet used to direct that the casualties be carried to her. At the battle of the trench (ghazwat al khandaq), Rufaidah set up her hospital tent at the battle-field. The Prophet Muhammad (PBUH) instructed that Sa'ad bin Ma'adh who had been injured in battle be moved to the tent. Rufaidah nursed him, carefully removed the arrow from his forearm and achieved hemostasis. The prophet visited Sa'ad in the hospital tent several times a day. Sa'ad was to die later at the battle of Bani Quraidhat. Rufaidah had trained a group of women companions as nurses. When the Prophet's army was getting ready to go to the battle of Khaibar, Rufaidah and the group of volunteer nurses went to the Prophet Muhammad (PBUH). They asked him for permission "Oh messenger of Allah, we want to go out with you to the battle and treat the injured and help Muslims as much as we can". The Prophet gave them permission to go. The nurse volunteers did such a good job that the Prophet assigned a share of the booty to Rufaidah. Her share was equivalent to that of soldiers who had actually fought. This was in recognition of her medical and nursing work.

 

Rufaidah's contribution was not confined only to nursing the injured. She was involved in social work in the community. She came to the assistance of every Muslim in need: the poor, the orphans, or the handicapped. She looked after the orphans, nursed them, and taught them. Rufaidah had a kind and empathetic personality that soothed the patients in addition to the medical care that she provided. The human touch is a very important aspect of nursing that is unfortunately being forgotten as the balance between the human touch and technology in nursing is increasingly tilted in favor of technology.

 

History has recorded names of women who worked with Rufaidah: Umm Ammara, Aminah, Umm Ayman, Safiyat, Umm Sulaim, and Hind. Other Muslim women who were famous as nurses were: Ku'ayibat, Amiinat bint Abi Qays al Ghifariyat, Umm 'Atiyyah al Ansariyat, and Nusaibat bint Ka'ab al Maziniyyat.

 

D. THE HEALTH CARE TEAM: GENERAL GROUP DYNAMICS

GENERAL DUTIES AND RIGHTS OF BROTHERHOOD:

The following are general rights of brotherhood that all members of the health care team owe to one another: returning greetings, following the funeral procession, accepting invitations, visiting the sick, and responding to sneezer. The following are additional duties: tolerance, forgiveness, helping the oppressed, solving problems, fulfilling needs, compassion and kindness, gratefulness, protecting the honor of others, fulfilling promises and commitments, respect, sincere advice or nasiiha. It is part of the duties of brotherhood to avoid underrating and humiliating others. It is considered part of good behavior to remove any annoyance from the public places, imatat al adha an al tariiq (KS p. 69). In general, everybody must behave with the best of manners, husn al khulq (KS p. 69).

 

ETIQUETTE OF INTER-PERSONAL INTERACTION:

Greeting is necessary whenever members meet again even after a short separation. A small group will initiate greeting the larger group (MB#2057). The walking person initiates greeting the one sitting down (MB #2068). Everybody must be greeted whether known or not known (MB#2059). Those in an assembly must make room for any new comer (MB#2063). Two individuals should not engage in secret conversation in the presence of others (MB#2018) because that may create an impression of backbiting and suspicion. Standing up when a person enters is a sign of respect (KS 67). You should not force a sitting person from his seat (KS 67). When a person goes away for a temporary period, he has the right to reclaim his seat (KS 67). The following positive behaviors and attributes should be encouraged in the team: mutual love, tawadud, and empathetic caring for one another, rahmat & hilm (MB#2018, KS p. 68); leniency, rifq, in everything (KS p. 68); co-operation and mutual support, ta'awun (MB #2026); generosity, karam (MB #2028); truthfulness, sidq (MB #2039); patience, sabr (MB #2040); modesty, haya (MB #2043, 2044); cheerful disposition, imbisaat (MB #2045); calling people by their favourite names, ahabb al asma (MB #2055, 2056); recognising the rights and the position of those older than you, irfan haqq al kabir (KS p. 68); and self control in anger, malk al nafs inda al ghadhab (KS p. 68). The following negative attributes should be avoided: harshness in speech (MB #2029), rumour mongering, namiimat (MB #2032), excessive praise of others in their presence, al ghulw fi al thana (MB #2033, KS p. 68), mutual jealousy and turning away from other, tahasud & taba'ud (MB #2034 & 2035, KS p. 68), avoiding interaction with a colleague, hijrat, for more than 3 days following a misunderstanding (MB# 2038); anger, ghadhab (MB #2041); spying on the privacy of others, tatabu'u awrat al nas (KS p. 68);  You should avoid repeating the same mistake twice (MB #2046). It is required not to volunteer information about your personal weaknesses, al satr ala al nafs (MB #2037, KS p. 98), unless it involves correcting a mistake related to the general medical work

 

E. THE HEALTH CARE TEAM: SPECIAL GROUP DYNAMICS

The medical team must of necessity include men and women. The interaction between the two genders is close and continuous which creates a special situation. Four basic issues arise: (a) manner of dressing (b) mixing of the 2 genders, ikhtilat (c) seclusion of a male with an unrelated female, khalwat (d) and lowering the gaze, ghadh al basar. Males and females in the team must dress and behave distinctly. Trans-sexual or unisex dressing and behaviour, takhannuth & stirjaal,  removes the instinctual gender identity. Each gender should maintain its psychological, emotional identity and physical appearance in manners of dress, walking or speaking. Trying to blur the distinction interferes with the complementality that is supposed to exist between the two genders. The complementality is necessary to ensure co-operation. Blurring the differences could also make sexual misconduct easier. The Qur'an forbade free mixing of the genders, ikhtilat, in general (33:53). Islam fosters a bi-sexual society. This is however not absolute. There are cases when social and professional intercourse between unrelated men and women in necessary. It is allowed but with strict precautions to prevent any transgressions. A woman is for example allowed to serve male guests according to a hadith reported by Bukhari from Sahl Ibn Sa;d al Ansari.  A woman can treat a male patient if there is necessity. A bisexual society does not prevent the women from being an active member of society. She can pursue her professional interests even outside the home provided she observes the rules of hijab. Forbidding seclusion of a man with an unrelated woman, khalwat,  is a strong temptation for evil and should be avoided. The prophet forbade a man to be with an unrelated woman in the absence of a third person. When a man is in isolation with an unrelated woman shaitan is between the two and could lead them astray (hadith reported by Imaam Ahmad on the authority of Amir Ibn Rabiah). Looking at the opposite sex with desire is prohibited. The eye is a great communication organ. The Qur'an ordered Muslim men and women to lower their gaze, ghadh al basr (24:30)-31. Lowering the gaze could be complete or partial. It is partial because of practical necessity. Lowering the gaze doses not mean closing the eyes. It means being careful not to look fixedly or lustfully at the opposite sex. One of the ways of preventing lustful looks is covering what is considered nakedness, awrat. Both men and women must be modest by covering their awrat. Looking at the awrat of another person is forbidden whether that person is of the same or opposite gender. The prohibition includes both looking with or without desire (hadith reported by Muslim, Abu Daud, al al Tirmidhi). As part of preventing possible illegal relations, display of adornments that enhance natural beauty is restricted by the Qur'an (24:31, 33:59)

 

Go to Part III

Professor Omar Hasan Kasule Sr October 2000