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ISLAMIC MEDICAL EDUCATION RESOURCES 04

0011-THE NURSES PROFESSIONAL CONDUCT FROM AN ISLAMIC PERSPECTIVE

Paper presented at the 4th International Nursing Conference held in Brunei 19-22 November 2000 by Prof Dr Omar Hasan Kasule, Sr. MB ChB (MUK), MPH, DrPH (Harvard); Deputy Dean for Research and Post-graduate Affairs, Kulliyah of Medicine, International Islamic University, Kuantan, MALAYSIA EM: omarkasule@yahoo.com

ABSTRACT

The paper describes Islamic perspectives of various nursing functions grouped in 7 categories:  the patient, the family, informed consent, confidentiality, terminal illness, the dynamics of the health care team, communication, and negotiation. Bedside care of the patient is both a professional undertaking as well as fulfillment of the Islamic obligation to visit the sick and therefore has its own etiquette. Islam gives guidelines on the appearance, mannerisms, and emotional involvement of the nurse. Medical care whether medical, surgical, or supportive must follow Islamic guidelines on striking due balance between harm and benefit in an ambience of compassion for the patient as a human and not a case or structural or functional pathology. The family requires reassurance and support while avoiding undue interference and involvement in family conflicts. Islamic law gives the patient full control of what medical or surgical procedures can be carried out. If the patient is judged legally incompetent to make decisions, the law provides for the closest relatives to make the necessary decisions. Medical confidentiality is part of the religious obligation of kitman al sirr unless there are compelling reasons that are judged by the Law to constitute necessity, dharurat. Care of the terminally ill patient is a continuous process that includes involvement with some aspects of morning and burial after death. The health-care team, besides patient care, provides opportunities for teaching and learning. There are special etiquettes that both teachers and learners have to follow to make this process successful. Members of the team owe to one another the general duties of Islamic brotherhood. The interactions among members of the team must follow the Islamic guidelines on inter-personal relations. All members of the team must understand group dynamics and behave according to guidelines that make group work and interaction successful. Nursing is essentially a process of communication and negotiation with the patients, families, and professional colleagues. Communication and negotiation skills must be developed to the highest levels of perfection.

 

1.0 ETIQUETTE WITH PATIENTS and THEIR FAMILIES

BED-SIDE ETIQUETTE

Obligation to visit the patient, wujuub iyadat al mariidh: The ward rounds fulfill one of the social obligations of visiting the sick (KS 505).  Visiting the sick has a lot of excellence, fadhl iyadat al mariidh, (KS 505). Caregivers get a lot of reward from Allah for fulfilling this social obligation in addition to the rewards for their medical work. The caregiver should interact with the patient as a fellow human. The human relation has priority over the professional patient-physician relation. Some bedside visits should therefore be purely social with no medical procedures or medical discussions.

 

Etiquette of visiting a patient, adab ‘iyadat al mariidh: The prophet regularly visited his companions who fell sick (KS 505, MB #1956). His behavior at the bedside of the patient is good guidance for both the physician and the other visitors to the patient. The books of sirah have preserved for us memories of such visits such as what the prophet said during the visit (KS 505). The following are recommended actions during a visit to the patient: supplication, dua, for the patient (KS 505, MB #1961), reading Qur'an for the patient (KS 505), and asking the patient for supplication, dua. The Qur'an is a cure, al Qur'an dawa (KS p. 338).  Dua is a cure, al dua dawau (KS p. 338). The Prophet gave us guidance on what can be said and what should not be said in the presence of the patient (KS 505). The following are enjoined: asking about the patient’s feelings, sua'al anhu, doing good/pleasing things for the patient, ihsaan, making the patient happy, tatyiib nafs al mariidh, and encouraging the patient to be patient, tashjiu al mariidh (KS 505). The patient should be discouraged from wishing for death wishing death,  tamanni al mawt (KS 524).

 

Appearance of the caregiver: The caregivers must make sure that they are clean and are dressed appropriately. The type and style of dress create impressions and convey messages. The dress, hair, and shoes of the caregiver must convey the impression of a serious, organized and disciplined person. The use of cosmetics should be limited to just covering up any defects and restoring the normal, average, and natural appearance. Excessive use of cosmetics conveys the impression of egoism and lack of seriousness. Perfumes should be used in moderation to suppress any unpleasant body odors. Excessive use, when the patient is aware that the caregiver is wearing perfume, is discouraged.

 

Mannerisms of the caregiver: Caregivers must have a cheerful disposition, imbisaat (MB #2045). They must deal with patients with leniency, rifq (MB # 2025). They must strive to do good, ma'aruf (MB #2024). They must also have only good thoughts about their patients,  husn al dhann. They must avoid evil or obscene words (MB #2026). It is important for the caregiver to have full interaction with the patient but must still observe the rules of lowering the gaze, ghadh al basar, except when medical necessity dictates otherwise. Caregivers must not be arrogant and show off (MB #2116). They must adopt an attitude of humbleness, tawadhu'u (MB #2117) all the time.

 

Emotional involvement: It is very wrong for caregivers to adopt a detached emotionally neutral disposition thinking that is the way of being professional. Caregivers must be loving and empathetic, tawadud & tarahum (MB #2018). They must show mercifulness, rahmat (MB #2020). The emotional involvement must however not go to the extreme of being so engrossed that rational professional judgment is impaired.

 

Covering of awrat: Both the caregiver and patient must cover awrat as much as possible. However, the rules of covering are relaxed because of the necessity, dharurat, of medical examination and treatment. The benefit, maslahat, of medical care takes precedence over preventing the harm inherent in uncovering awrat. When it is necessary to uncover awrat, no more than what is absolutely necessary should be uncovered. To avoid any doubts, patients of the opposite gender should be examined and treated in the presence of others of the same gender. The caregivers should be sensitive to the psychological stress of patients, including children, when their awrat is uncovered. They should seek permission from the patient before they uncover their awrat. Caregivers who have never been patients may not realize the depth of the embarrassment of being naked in front of others. An epileptic woman who was embarrassed at the uncovering of her awrat during an attack came to the prophet. He prayed for her and Allah answered the prayer (MB #1954).

 

Medical procedures: Caregivers must be fully aware of their legal liabilities and responsibilities, mas'uliyat al tabiib (Sunan Abu Daud Kitaab al diyaat baab 24, Ibn Majah Kitaab al Tibb baab 16). The rules of seeking permission, isti' dhaan, must be followed whenever caregivers approach a patient. The patient must be forewarned about the approach of the caregiver and should not be surprised. The privacy of the patient must be respected and he or she should be examined after getting permission. Medical care must be professional, competent, and considerate. Medical decisions should consider the balance of benefits and risks. The general position of the Law is to give priority to minimizing risk over maximizing benefit, dar'u al mafsadat muqaddamu ala jalbi al maslahat. Any procedures carried out must be explained very well to the patient in advance.

 

Supporting care: The caregivers must listen to the felt needs and problems of the patients. They should ask about both medical and non-medical problems. Supportive care such as nursing care, nutrition, cleanliness, and ensuring physical comfort are as important as the medical procedures themselves. In terminal cases it is only the supporting care that can be given.

 

Managing fever: Fever is a generalized often non-specific patho-physiological response. It is a cause of much discomfort. Caregivers should detect it early and treat it effectively. The prophet described fever as a blow of hot wind from hell-fire. He recommended using cold water to cool the body during fever (MB #1972). Any additional methods of reducing body temperature should be used.

 

Managing pain: The caregiver should comfort the patient in pain. He can explain that there is reward, ajr, for being patient when suffering (MB #1953). The patient should persevere and not wish for death, tamanni al mawt, because of extreme pain (MB #1958, 1959, 1960). The patient should be reassured that there is eventually a cure for every ailment, dawa li kulli dai (MB #1962) so that there is no loss of hope.

 

Control of infections: The prophet forbade a sick person visiting the healthy (KS 504) to prevent spread of infection. Precautions against spread of contagion were also recommended (MB #1969). Caregivers are obliged to make sure they have all their infectious diseases treated so that they are not a risk to their patients.

 

DEALING WITH THE FAMILY

Support: The family is also a victim when any member falls sick. The caregiver must provide psychological support to them. Sometimes even material support may be necessary. It should be remembered that part of the well being of the patient is to know that the family left behind is not suffering.

 

Reassurance: Illness is a cause of much anxiety for the family. The caregiver must take time to reassure the family by explaining what is going and assuring them that the best care is being given. They must be told not to give up hope because Allah in His power can reverse the most serious or critical conditions. In communicating with the family caregivers must make sure they do not violate medical confidentiality except where it is necessary, dharurat.

 

Involvement: Caregivers should similarly realize the importance of visits by relatives and friends and should plan their ward routines to maximize such visits. The family can be involved in some aspects of supportive care. This is helping them fulfill kindred obligations, silat al rahim. It uplifts the patient's morale to see that the family care and are around being involved.

 

Interference: Caregivers should be on the guard to make sure that the eagerness of the family to be of assistance and to be involved does not step beyond the limits. The family may interfere with medical care causing disturbance of the medical routines. This should be resisted with firmness.

 

Conflict: Illness is a stressful condition that generates anxiety in the family. It may initiate conflicts or aggravate existing ones. Caregivers may unwittingly find themselves in the middle of such conflicts. They should have the clarity of mind to understand that it is none of their business solving family conflicts. If they do they may regret it since they may become party to the conflict and are considered by some members of the family to favor other members.

 

2.0 INFORMED CONSENT

Choice of physician: As long as patients are conscious and are in full control of their mental faculties, they should be consulted about choice of physicians. Minors, unconscious patients, and those who have lost legal competence cannot choose physicians. Their legal representative, waliy, will have to make the decisions. The caregiver must realize that choice of a physician is a continuing resolution and must make sure that there has been no change of mind on the part of the patient or the legal guardian. Permission to treat must be sought at every visit though not necessarily in a formal way. It is illegal to treat a patient against their will unless provided for otherwise by the Law in defined exceptional circumstances. As guidance to the patient in physician selection, the following order of priority is followed: Muslim of the same gender, non-Muslim of the same gender, and Muslim of the opposite gender.

 

Choice of treatment, food, and drink: The sunnah has given us guidance about forced feeding and forced treatment (KS 505: Sunan al Tirmidhi Kitaab al Tibb Chapter 3). The patient retains freedom to accept treatment or to reject it. The patient cannot be forced to take any medication or undergoes any medical procedures. Treatment with new/experimental drugs or procedures requires informed consent. If the patient has lost legal capacity, ahliyat, by being unconscious or by losing mental capacity, the guardian, waliy, will take binding decisions on behalf of the patient. Illogical refusal of treatment or food could be grounds for finding a patient intellectually and legally incompetent making it necessary for the guardian to make the necessary decisions. Some situations of refusal of treatment are not issues of freedom of choice but have criminal implications. For example a patient with pulmonary tuberculosis who refuses treatment is committing the crime of endangering the lives of other members of the community. A parent who refuses immunization of a child is endangering the health of that child and other children in the community. 

 

3.0 CONFIDENTIALITY

The secret, al sirr: The Qur'an mentioned the term secret in many verses (p. 570 2:77, 2:235, 2:274, 5:52, 6:3, 9:78, 10:54, 11:5, 12:19, 12:77, 13:10, 13:22, 14:30, 16:23, 16:75, 20:7, 20:62, 21:3, 25:6, 34:33, 35:29, 36:76, 43:80, 47:26, 60:1, 64:4, 66:3, 67:13, 71:9, 86:9). The term secret is relative. What may be a secret for one person may not be for another. What may be a secret in one place and at a particular time may no longer be a secret when time and place change. Secrets are of various degrees of importance. Revelation of some secrets could hurt an individual. Others can hurt the whole community or the whole ummat. Some secret information could be harmful if it is related directly to one individual but could be harmless if it is generalized.

 

Concept of keeping secrets, kitman al sirr: Humans are capable of deliberately hiding and sitting on information (p. 986 3:72, 2:228, 2:271, 3:167, 4:42, 4:149, 5:61, 5:99, 6:28, 14:38, 21:110, 24:29, 27:25, 33:54, 60:1). Allah knows all what humans hide and reveal (p. 986 2:33). The natural default situation is for humans to divulge and share information during conversations even without being obliged or expecting any benefits. Keeping a secret therefore requires effort and discipline. Hiding information may be praiseworthy for example if a person does not reveal is iman in front of enemies, kitman al iman (p. 986 40:28). Keeping a secret, hifdh al sirr, entrusted to you in confidence is a sign of good Islamic character (      ). You may keep your own secrets from people who are potential enemies. The Prophet taught us to rely on keeping secrets in managing our affairs, al i'itimad ala al kitman fi qadhai al hajat (     ).  Secrecy could be negative if it involves hiding the truth that should have been spread to others, kitman al haqq (p? 2:42, 2:146, 2:159, 2:173, 3:71, 3:187, 4:37, 5:15, 6:19). It is also negative to hide evidence, kitman al shahadat (p. ? 2:140, 2:283, 5:106). The basic position is to keep secrets and information and not reveal them even if there is no foreseeable harm. It is part of good Islamic character not to reveal all what a person knows. The Prophet taught that people should listen more and speak less. 

 

Written Records: Secrets are kept within the person, al kitman fi al nafs (p. 987 2:235, 2:284, 3:29, 3:118, 3:154, 27:74, 28:69, 33:37, 40:19). With development of writing and electronic technology, we now have other ways of keeping secret information. The Qur'an mentioned the tools for producing written records as paper, sahifat (p 979 20:133, 52:2-3) and the pen, qalam (p 979 68:1, 96:4). The Qur'an used the term kitaab to refer to written records such as scriptures (p. 977 4:153, 6:7, 17:93, 21:103, 29:48, 34:44, 35:40, 37:157, 34:21, 62:5), the Qur'an (   ), the record of pre-destination, kitaab al qadr (p. 978 3:145… 57:22), the record of values, kitaab al qiyam (p. 979 98:3), the record of knowledge, kitaab al ilm (p. 979 27:40)., and correspondence letters (P. 979 27:28-29).  He process of writing was mentioned about evidence, kitabat al shahadat (p 979 43:19) and contracts, kitabat al uquud (p. 979 2:235, 2:282-283). Writing of false records was severely condemned (p 979 2:79). The prophet gave guidance about writing and writers (KS p. 452). In a modern medical environment, many records are generated about each patient. These prove a challenge as far as keeping of secrets is concerned because many people can access them. Besides their use in medical care, the records ca be used for medical education, medical research, and for legal purposes. Prevention of access to records for educational purposes may fall under the prohibition of hiding knowledge, kitman al ilm.

 

Basis for medical confidentiality: Medical confidentiality has psychological, social, and legal bases. The psychological basis is the private and privileged relationship of trust between the patient and the caregiver. Revealing secrets that occurred to a third party is a violation of the trust. Such violation destroys future co-operation because the patient will hold back some information from the caregiver thus impairing correct diagnosis and appropriate management. The social basis lies in the prohibition of spreading rumors, namiimat (MB #2032) and backbiting. The legal basis is three Principles of the Law, qawaid al sharia, and the Law of Property. The Principle of Injury, dharar, states that an individual should not harm others or be harmed by others, la dharara wa la dhirar. The Principle of Hardship, mashaqqa, states that hardship mitigates easing of the sharia rules and obligations, al mashaqqa tajlibu al tayseer. Necessity legalizes the otherwise prohibited, al  dharuraat tubiihu al mahdhuuraat. Necessity is defined as what is required to preserve the five Purposes of the Law (religion, life progeny, property, and intellect). If any of these five is at risk, permission is given to commit an otherwise legally prohibited action. The ownership of the records is not clear. Do they belong to the patient, the caregiver that wrote them, or the institution?. Using the law of property, a product belongs to the person who made it. In this case, the patient is the 'maker' of all the medical facts that are written and should be the acknowledged owner of the records. The patient is also the only person involved who has most to lose if records are misused. Thus, the contents of the medical records cannot be revealed without the express permission of the owner. The general position regarding medical records is that they are a secret that cannot be revealed without specific necessity, dharurat, as defined by the law.

 

Release of information by the patient: The patient should consider any injurious information as a secret and cannot reveal it. If it is about his sins or dishonorable shameful things, fahishat, he is forbidden. The prophet condemned al mujahir. A Muslim should repent and conceal his sins (MB #2037).

 

Release of the information by the caregiver: It is prohibited for the caregiver to use the privileged medical information he has for any personal gain. For example, he cannot use his knowledge of the health of a businessperson to buy shares in a certain company. He cannot advise his relatives about marrying or not marrying a certain person because of what he knows about their health. Release of information in the public interest is a more complicated situation. The question arises whether a caregiver is obliged to reveal disease in a leader or airline pilot that could endanger the public? What should the caregiver do if he knows of a patient with a contagious disease that is in the community and is endangering others? Is it a violation of privacy for the caregiver to share medical information with other caregivers caring for the same patient? What about using the data for medical research or medical education? How much can the caregiver tell the relatives of the patient without compromising the regulation of keeping secrets? What should the caregiver do if approached by law enforcement agencies asking for specific medical information that can help them solve a crime? Can a caregiver testify in court against his patient using information obtained during the medical examination? All these are questions for which no easy answers can be given most of the time. The simplest situation is when the patient, the owner of the records, consents to their release provided no other individual is directly hurt by such a release. There are situations in which over-riding public interest will require refusing to release information even if the patient consents. If the patient or his guardians do not consent, the caregiver cannot release information except in situations of legal necessity, dharurat, as defined above. Education, research, and crime investigations do not fall under the category of necessity. In cases of court litigation, the caregiver could testify in criminal cases that involve dhulm. The Qur'an forbids the revelation of the shameful unless there is dhulm (p 308 4:148, 24:19). The caregiver cannot give false testimony (MB #1176). One of the ways for the caregiver to decrease his risk of revealing secret information is to have only the minimum needed for his work. This means that during history taking only those questions directly related to the medical problem should be asked. There should be no probing or digging for unrelated facts.

 

Giving bad news: The patient: tell half-truth, do not tell at all, white lie/technical lie.

 

The relatives: to convey info to patient in their own way.

 

Officials: return to work, sick leave. Body language:

 

4.0 ETIQUETTE WITH THE DYING

A. COMFORT:

Narcotics are given for severe pain. Drugs are used to allay anxiety and  fears. The caregivers should maintain as much communication as possible with the dying: patience. They should attend to needs and complaints and not give up in the supposition that the end was near. Attention should be paid to the patient's hygiene such as cutting nails, shaving hair, dressing in clean clothes. As much as possible the dying patient should be in a state of ritual purity, wudhu, all the time.

 

B. IBADAT:

The dying patient should as far as is possible be helped to fulfill acts of worship especially the 5 canonical prayers. Physical movements should be restricted to what the patient's health condition will allow. There us guidance on salat even for the unconscious patient (KS 505)

 

C. SPIRITUAL PREPARATION.

Death of the believer is an easy process that should not be faced with fear or apprehension. The process of death should be easier for the believer than the non-believer (KS 525). The soul of the believer is removed gently (KS 525, 525, 525).  Believers will look at death pleasantly as an opportunity to go to Allah. They should be told that Allah looks forward to meeting those who want to meet Him (KS 525). Dying  with Allah's pleasure (KS 525) is the best of death and is a culmination of a lifetime of good work. Thinking well of Allah is part of faith (KS 525) and is very necessary in the last moments when the pain and anxiety of the terminal illness may distract the patient's thoughts away from Allah. Having hope in Allah at the moment of death (KS 525) makes the process of dying more acceptable.

 

D. LEGAL PREPARATION

Helping patient make a will: During the long period of hospitalization, the health care givers develop a close rapport with the patient. A relationship of mutual trust can develop. It is therefore not surprising that the patient turns to the caregivers in confidential matters like drawing a will. The health care givers as witnesses to the will must have some elementary knowledge of the law of wills and the conditions of a valid will, shuruut al wasiyyat. One of these conditions is that the patient is mentally competent. The law accepts clear signs by nodding or using any other sign language as valid expressions of the patient's wishes. The law allows bequeathing a maximum of one third of the total estate to charitable trusts, waqf, or gifts. More than one third of the estate can be bequeathed with consent of the inheritors. Debts must be paid before death or before the division of the estate.

 

E. DEATH, BURIAL, and MOURNING

The last moments: The last moments are very important. The patient should be instructed such that the last words pronounced are the kalimat, the testament of the faith. Once death has occurred the body is placed in such a way that it is facing the qiblat. Eyes are closed and the body is covered. Qur'an and dua are then recited.

 

Etiquette of morning:  The health care giver should take the initiative to inform the relatives and friends. They should be advised about the shariah rules on mourning. Weeping and dropping tears are allowed. The following are not allowed: tearing garments, shaving the head, slapping the cheek, wailing, and crying aloud. On receiving the news of death it suffices to say ' we are for Allah and to Him we will return'(KS 525). Telling them hadiths of the prophet about death comforts relatives. These hadiths talk about the reward of the person who loses his beloved one and he is patient (KS 524) and the excellence of one who loses three children (KS 524).

 

Preparation for burial:  The health care team should practice total care by being involved and concerned about the processes of mourning, preparation for burial and the actual burial. They should participate along with relatives as much as is possible. The body must be washed and shrouded before burial. The washing should start with the right. The organs normally washed in wudhu are washed first then the rest of the body is washed. Perfume can be used, Women's hair has to be undone. After washing the body is shrouded, kafn, in 2 pieces of cloth preferably white in color.

 

Salat al janazat: The books of sunnat have given guidance about the etiquette of salat al janazat (KS 162). As many persons as possible should participate in this salat. If 100 persons pray for the dead, it is shafaa (KS 162). Dua (istighfar) in salat al janazat (KS 162).  

 

Accompanying the funeral procession, tash'yii al janazat:  Burial should not be delayed, ta'ajil bi al janzat (KS 161). Following the procession is enjoined (KS 159). There are big rewards for accompanying the funeral procession (KS 159). There is more reward for accompanying the funeral procession and staying until burial is completed (KS 160). Men carry the funeral bier. Hurrying in marching to the grave is recommended.

 

After burial: consoling relatives, making food for the bereaved, adab of mourning (hidaad), condolences (ta’ziyah), inna lilaahi wa inna ilayhi rajiuun. Talking good about the dead.

 

Talking about the deceased: Say only good things. The good words about the dead, thanau al nass ala al mayt (KS 160)

 

Special cases: Case of woman who dies with a fetus in her womb. Opening grave for forensic exam. Carrying the dead for burial in another country

 

5.0 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 specializing 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 cannot 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 co-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 cannot 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. Allah protects the consensus of the group 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 cannot 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 cannot 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.

 

THE 5 ATTRIBUTES OF THE IDEAL GROUP:

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 instill 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 is necessary for success of group work. Good communication and interaction are the bedrock 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.

 

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 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 a public health nurse and a social worker.

 

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 favorite names, ahabb al asma (MB #2055, 2056); recognizing 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), rumor 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 behavior, 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 complementarities that are supposed to exist between the two genders. The complementarities are 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)

Professor Omar Hasan Kasule, Sr. November 2000