Reinvigorating the Role of Spirituality in Patient- Centered Care: Islam as a doorway to increased understanding of patient spirituality

Spirituality is seen to be an important aspect of patient-centered practice. However, heavy focus on the scientific and technical aspects in modern clinical teaching misses key elements of holistic patient-centered care. Incorporating spirituality in the provision of healthcare may foster better communication, respect, and empathy. This article focuses on a series of interprofessional education sessions directed at undergraduate health students that have become a regular part of the Broken Hill Rural Clinical School undergraduate training programme. The sessions promote an increased understanding of world faiths to improve the patient-centered focus of healthcare. The authors discuss and outline the findings from interactive interprofessional education sessions focused on the Islamic faith, conducted in a regional city of New South Wales, Australia. A voluntary self-reporting survey was used to gain an understanding of participant reflections and perceptions. Students from a range of health disciplines medicine, nursing, speech pathology, dietetics, and pharmacy attended three separate education sessions focused on Islam. Students indicated that the interprofessional learning (IPL) sessions enhanced their understanding of Islam along with the confidence and readiness to ask questions about the spiritual needs of patients and families. Students indicated the activity was beneficial, both personally and professionally. They also voiced their willingness to attend similar sessions on other world’s faiths. Students who have attended these sessions have articulated their intention to be more aware of the spiritual needs of their patients and to make changes to their practice when engaged in future health activities.


Introduction
There is an apparent disjunct between the importance placed on patient-centred care and the manner in which health Bennett P, Cook A, Soomro N MedEdPublish https://doi.org/10.15694/mep.2020.000273.1 Page | 2 students are educated into their chosen profession. With the primacy given to the biomedical aspects of healthcare provision, elements of patient-centred care can be lost or overlooked. Once such element is the patient's spirituality, which can be a significant omission as a person's beliefs affect their reception of healthcare provision. In order to redress this omission, undergraduate health students should be introduced to patient spirituality in a manner that helps inform their healthcare provision as they develop these practices, rather than being an afterthought. This paper discusses the impact of introducing undergraduate health students to the concept of spirituality and its association to health care. The sessions described in this paper focused specifically on the faith of Islam, utilising it as a doorway to understanding the role of spirituality within patient-centred practice generally.
Patient-centered care is an important aspect of healthcare provision. It combines clinical knowledge and skills with an understanding of an individual's cultural and spiritual worldview (Prentis et al., 2014;Attum et al., 2019). Increased understanding of another's worldview can help to develop awareness of the 'other', and is sometimes at odds with the technical/scientific view in modern health care (Nussbaum, 2006;Hooker and Noonan, 2011). Understanding and awareness of the 'other' can provide insights into the beliefs, views, and feelings of individual people. In turn, these insights can support the provision of more effective patient-centered care particularly in the clinical environment (Patterson et al., 2016). Patient-centered care aims to promote health through a holistic view of the patient, rather than merely focusing on physical attributes. Modern clinical teaching, by focusing on the scientific and technical aspects of healthcare provision, misses key elements of holistic patientcentered care.
Spirituality is an important aspect of an individual's worldview. It need not be formally associated with an organised religion. Seen in the broadest possible context, an individual's spirituality can be defined as "the characteristics by which a person relates to questions of transcendence -how he or she seeks the ultimate answers to questions of meaning, value, and relationship" (Savel and Munro, 2014) . It has been stated that "the spiritual dimension of holistic care has been considered by health care organisations as fundamental to health and well-being" (Attard, Baldacchino and Camilleri, 2014) and "doctors and clinicians should acknowledge and respect the spiritual lives of patients and always keep interventions patient-centered" (D'Souza, 2007). Yet, there is a challenge in achieving this because "Western medicine, unlike traditional Eastern systems, has dichotomised the body/mind and soul/spirit" (D'Souza, 2007). Underpinned by a mind-body dualism, the traditional primacy given to the body within "Western medicine" overlooks important aspects of the wellbeing of the individual patient. One recognised outcome of the primacy given to the body within healthcare is underdeveloped competencies related to spiritual care and poor role preparation in healthcare professional education in this area (van Leeuwen et al., 2008). Given the importance of spirituality for the patient, there is a lacuna within traditional Eurocentric methods of healthcare education that overlooks the incorporation of patient spirituality into the provision of healthcare. Some authors suggest that healthcare professionals lack confidence to initiate conversations around spiritual needs of patients, and that some patients also avoid a similar dialogue because they fear doctors will not understand their faith's importance and values (Mir and Sheikh, 2010;Patel et al., 2014;Alhomoud et al., 2015). The development of educational opportunities such as the Enhanced Rural Inter-Professional Cultural Health (ENRICH) Sessions aims to bridge the gap between health professionals understanding and care of patients, as well as an opportunity to learn new skills such as respectful questioning, active listening and appropriate conversations with individuals about their spiritual worldview.
The Broken Hill Rural Clinical School -University of Sydney hosts undergraduate health students from multiple Australian universities and disciplines. A main focus of the Broken Hill Rural Clinical School is interprofessional learning (IPL) for undergraduates on clinical placement in Far West New South Wales. The ENRICH programme was developed in 2010 (Moore, Bolte and Bennett, 2012).to broaden the perspectives of undergraduates and to encourage a holistic view of patients. The programme consists of weekly workshops that focus on clinical, rural, and cultural issues in an interprofessional learning context. ENRICH is designed to deepen the undergraduate health Bennett P, Cook A, Soomro N MedEdPublish https://doi.org/10.15694/mep.2020.000273.1 Page | 3 students experience, and to further the goal of developing the rural and remote health workforce The ENRICH session described in this article focuses on Islamic practice, and encourages students to consider how these teachings impact on the health behaviours of Muslim patients. This unique activity is a collaboration between the Almiraj Sufi & Islamic Study Centre (ASISC) -Broken Hill, and the Broken Hill Rural Clinical School (BHRCS). Each of the IPL session was co-facilitated by an Islamic academic from ASISC and a BHRCS staff member.
Muslim engagement with Australia has a long and under-explored history. The earliest continuous occurrence started prior to the seventeenth century, when Makassans (Muslims from modern day Indonesia) travelled to northern Australian where "these fishermen engaged with a range of Indigenous peoples along the northern coast of Australia" (Cook and Yucel, 2016). Later, as European-Australians opened up trade routes across the country, "the engagement with Islam occurred through the cameleers, camel drivers predominantly from northern India, Pakistan, and Afghanistan, amongst other regions, from the late 1800s into the early twentieth century" (Cook and Yucel, 2016). On a local note, Broken Hill has a substantial Cameleer heritage, originally sustaining two cameleer camps, each with their own mosque (both buildings now residing at the location of the mosque of the north camel camp). The surviving historical mosque is of particular importance, being the oldest mosque in NSW (Cook and Yucel, 2016;ElSenossi, 2019). As a result of these local and national connections, there is utility in employing Islam as an entry point for students to gain an awareness of other spiritualties and the impact it may have on healthcare provision.
The choice of Islam as a doorway through which to discuss spirituality and patient-centered care within the Enhanced Rural Inter-Professional Cultural Health (ENRICH) Interprofessional Learning sessions was deliberate. Firstly, at least a quarter of the world's population practices Islam and Australian Muslims represent 2.6% of the country's population (Australian Bureau of Statistics, 2016). This makes it most likely that health professionals will encounter a Muslim patient in the provision of healthcare. Secondly, the likelihood of such encounters will, in some instances, play on an individual's prejudices as "Islamic identity can trigger stereotyping in healthcare situations, resulting in people experiencing anger, stress and low self-esteem" and "Muslims, for example, can be seen by healthcare professionals as equally religious and all women wearing veils as oppressed" (Skinner and Cowey, 2019). Thirdly, there are specific practices that may be impacted by or impact on the provision and reception of healthcare. For example fasting during the month of Ramadan may involve some medical complications and for this reason "pre-Ramadan consultations can be used to plan how spiritual and medical needs may best be met" (Patel et al., 2014;Skinner and Cowey, 2019). Similarly, an awareness of the direction of prayer (qibla) may be seen to show a level of respect to Muslim patients within a hospital setting, increasing the receptivity of the patient to the provision of other healthcare. Students are encouraged to see that Islam is not a monolithic, prescriptive, and restrictive set of beliefs and that there are just as many differences within one school of Islamic law (madhhab) as there are between the schools of Islamic law. Patient-centered care requires more than an awareness of a patient's formal religious affiliation, as their personalised practice will need to be incorporated and negotiated into their healthcare provision.
Focusing on Islam in this manner within the ENRICH session allows it to become a doorway through which future health professionals can better understand, and thus cater for, spiritual practice in their provision of patient-centered care (Mir and Sheikh, 2010). Religion and spirituality are an integral part of a patient's personality and, as a result, can impact significantly on an individual's health seeking behaviours. This program provides the opportunity for students to deepen their understanding of world faiths and in this instance Islam, to improve their patient-centered service delivery of health care. The aim of this pilot learning activity is to increase students' comfort with discussing a patients' spiritual worldview, and the skills to incorporate a patient's spirituality into the provision of patientcentred care.

Methods
Participants: Fifty three undergraduates (N=53) from nursing, medicine, pharmacy, dietetics and speech pathology of a potential 117 undergraduate students on clinical placement in Broken Hill -far west New South Wales volunteered to attend three separate two and a half hour ENRICH sessions titled: 'World Religions, Culture and Health -Islam. The three sessions were held over an 18 month period from 2018 until 2020. The majority of participants were female (N=43, 81%).
Prior to attending the ENRICH session, all undergraduate students were sent an expression of interest email. This email contained learning objectives, and an invitation to attend the session (see Table 1).  (Schumm and Kohler, 2006) and areas where these may impact on the administering of healthcare.
By discussing the five pillars of Islam students have an opportunity to understand some of the central practices and beliefs of Muslims and how these are enacted on a daily basis. In doing so, students are encouraged to reflect on an individual's spiritual beliefs and practice and how this may impact the provision of and reception to healthcare needs. Sessions conclude with what is pitched as an informal question and answer section. Students are encouraged to raise queries related to their experiences of Islamic practice and/or Muslim patients and scenarios are explored as a group. While the answers provided are specific to Muslim practices, the purpose of a question and answer session is to support student comfort and courage to ask, at times difficult, questions that relate to an individual's spirituality within a healthcare setting.
Broken Hill Rural Clinical School has used an anonymous voluntary post-session survey and post-event debrief as a quality assurance tool since the inception of ENRICH sessions in 2010. The survey consisted of a series of questions that asked participants whether they felt the learning objectives of the session were met, whether they perceive the session helped them to be more prepared for future day-to-day practice, whether the teaching strategies effective, and how future sessions could be improved. There were three additional short-answer questions that provided participants opportunities for comments and suggestions on the delivery of the session with an aim for future improvement. The post-event debrief asked students to critically reflect on the session. They were also encouraged to discuss what they have learnt and how this might be included into their current and/or future practice. The authors were guided by the Declaration of Helsinki (World Medical Association, 2013) and the Australian Code for the Responsible Conduct of Research (National Health and Medical Research Council, 2018) in our data collection and handling. Since its inception in 2010, the ENRICH interprofessional activities have used an anonymous post-session survey as a quality control measure.
All authors participated in the review of the survey and considered the responses from the students. Collating the feedback from students identified a range of key phrases for identifying the benefit of these ENRICH session. From these key phrases, two loosely define areas of benefit for students can be identified, namely increased knowledge and self-reflection on the attitudes they bring to their interactions with patients. At the beginning of each ENRICH interprofessional learning session participants were informed that there would be an anonymous post-session survey.
Despite the voluntary nature of the survey, all 53 participants attending the sessions titled: 'World Religions, Culture and Health -Islam', completed the post-session survey. This is taken as an encouraging sign in that students felt that the sessions had enough value to provide feedback. Completion of the survey is considered informed consent from participants.

Findings
Three main categories emerged from the survey results. They were: skills, knowledge and attitude. These results are similar to those previous reported by a number of authors who suggest that although undergraduate training is heavily focused on the bio-medical model of care -and rightly so -there is a need for clinicians to continue to consider the whole patient, and this includes the spiritual needs of an individual in their care (Hooker and Noonan, 2011;Hodge and Bonifas, 2017;Jaberi et al., 2017). Savel and Munro (2014) argue that for clinicians to know their patients well they need to understand them from a holistic perspectives which includes body, mind, and spirit (Savel and Munro, 2014). The results from students attending the ENRICH session have indicated a willingness to explore a broader perspective of patient need. Firstly, by volunteering to attend the ENRICH session, students showed an openness to explore a broader approach to patient care than has been taught in strictly bio-medical models. Secondly, the critical reflections documented in the post-activity survey indicated a willingness to take this broader perspective into their general practice.

Skills
As a result of the ENRICH sessions, students indicated they felt better prepared for future day-to-day practice with patients and their families of the Islamic faith. They described being more comfortable to start a discussion about an individual's health needs that has an explicit awareness of a patient's spiritual needs. Students appreciated having a facilitator who could speak of their faith with both an awareness of academic rigour and be able to pepper the discussion with personal anecdotes. This allowed for a mix of both formal and informal discussion of how the health beliefs of the Islam faith can influence health behaviours.
"Personal anecdotes/experiences, good brief introduction to Islamic faith." "The overview of Islam was helpful. Learning work-arounds for patients was fantastic." "The openness of the session and ability to ask questions (was good)…"

Knowledge
The ENRICH sessions offered the students a space wherein they could learn about and question their experiences of a faith that many have had only an outside perspective. Discussing the five pillars of Islam and their relationship to healthcare allowed students an inside glimpse into the relationship between faith and practice for Muslim patients. Students were encouraged to think about how their practice could impact the faith based practices of Muslim patients and how the receptivity of these patients could be increased through caregivers highlighting an awareness of this practice. Consistently across the sessions there have been questions from students regarding gender specific care and how they as health professionals could provide respectful and appropriate care. While these questions tend to be the result of bias and limited engagement, through the discussion opened up during the ENRICH session, students come to see that Islamic practice has a broader application than gender relations and an increasingly diversified array of questions ensure about the potential healthcare implications of a range of Islamic practices. Students indicated an increase in their understanding of Islamic practice. They also mentioned an increased awareness of the similarities and differences between Islam and other faiths. Students were able to consider these differences in relation to their previous understanding and how this new learning could benefit their future practice. One important outcome of the ENRICH sessions was students mentioned increased comfort in asking questions about another's faith. Of the session, students stated: "Good to learn about religious practices and connection to health." "Resources provided i.e., booklets on Islam and health were helpful." "Very informative with the difference between Catholicism and Islam." Beyond the ENRICH session and discussion, students were also given a range of resources. Students responded most positively to A Brief look at Islam and Muslims for Health Care Workers produced by the Almiraj Sufi and Islamic Study Centre. This brief overview provided students with a document that they can refresh the information covered in the ENRICH session while also providing them with resources to further deepen their knowledge through independent research.

Attitude
The quality and number of questions asked by students indicate to the authors that they were positively engaged with the session. Students spoke of their perceived difficulties and barriers in caring for people of different cultural and spiritual backgrounds. This included some specific instances of patients of the Islamic faith. Often these perceived difficulties arose from a lack of understanding the patient's faith, the bias of the student, and the student's limited ability to ask the patient about the incorporation of spirituality in to healthcare provision. An aspect of student bias was apparent in that often the question and answer potion of the sessions started with questions primarily focused on gender relations and the provision of care. Once students became comfortable with the concept of including their patients into the discussion of the provision of care to increase the receptivity of patient, the questions became increasingly focused, such as provision of care in emergency situations where the discussion of healthcare provision and receptivity could not take place. Students were encouraged to ask difficult questions, in line with the Islamic position of "they did not let shyness keep them from understanding their religion properly" (al-Qazwini, 2007). In doing so, students increased their awareness of the regular healthcare practices, such as regular washing for ablution (wudu) or the trimming of nails, and the healthcare benefits of religious practices, such as fasting (sawm). This session had allowed students to consider and discuss their patients more carefully within the healthcare context and to reflect on their role within the patient's journey, the importance of curious inquiry, and the impact that the inclusion of spirituality into healthcare provision can have on patient receptivity.
"I feel I will be able to ask questions about my patient's needs…" "I will take more time with my patients…" "Good to learn about religious practices and connection to health." Overall, the session was well received by students, who commented on the quality of the speakers, their knowledge, and their willingness to answer questions about the Islamic faith, in providing information on appropriate/respectful behaviour, and communication between health staff and Muslim patients and their families.
All participants agreed that the three learning objectives were met during the session (N = 100%). Approximately 80% of participants (42 of 53) agreed they felt 'better prepared' for future day-to-day practice with patients who are of the Islamic faith. When asked if they would recommend this training be held again, approximately 85% (44 of 52) of participants indicated they would recommend that this type of session should continue. Some students suggested that other world faiths should be included in future sessions.

Discussion
In this paper, authors discuss the outcomes of an initial investigation into the perceptions of undergraduate health students to insights into, and an opportunity to discuss, faith/spiritualty and the role this can have in an individual's receptivity to healthcare provision. Religion and spirituality should be considered an integral part of health and wellbeing. Health professionals who consider an individual's worldview in relation to their health are better placed to provide quality care to patients and families (Dalla Colletta de Aguiar, Cazella and Costa, 2016;Jaberi et al., 2017;Attum et al., 2019).
Feedback from students at the end of this interprofessional learning opportunity indicates they felt the activity was beneficial, both personally and professionally. Their understanding of Islam increased and it supported them to gain an understanding of how some healthcare needs of patients are negotiated by incorporating the patient's spirituality.
By reflecting on their current and future practice, participants indicated they felt more confident to ask questions about the needs of Muslim patients and families. Students suggested that a series of future ENRICH sessions should be developed that focus on a range of other world faiths.
The most important part of the session each time it has been conducted is the section that is framed as an informal opportunity for questions and answers. This section is held towards the end of the session and provides two important learning opportunities for students. Firstly, it allows students to have specific questions about Islam and the provision of healthcare to Muslim patients answered. Secondly, by being afforded the opportunity to ask questions, especially difficult or unconventional ones, students are given an opportunity to increase their comfort in asking patients about their spirituality in the provision of healthcare. The inclusion of spirituality into a patientcentred provision of healthcare does not require medical practitioners to become experts on the world's diversified spiritual traditions, rather it requires them to be comfortable in asking patients about their spirituality so that it can be incorporated into healthcare provision. This aims to increase patient receptivity to healthcare provision and allows for an increasingly informed decision making process in the negotiation of that provision.
Pragmatic choices for this study results in some limitations. There is a small sample size, albeit an interprofessional cohort, consisting of five individual health disciplines. Students were chosen opportunistically as they were on clinical placement at the time the ENRICH sessions 'World Religion, Culture and Health -Islam' were held. Those that attended all volunteered to attend the sessions. Due to the sample size of the group it is difficult to generalise our experiences and findings to the broader setting of undergraduate education. It is also important to note there is no measurement tool readily available to assess this type of training. This makes it difficult to formally state that the learning outcomes were achieved from the session. In focusing on the incorporation of spirituality into patientcentered care, the development of comfort in asking takes precedence over providing a prescriptive practical checklist due to the difference in personal practice, even within one religious group. Finally, this article contains selfreported data, which may not be reflective of the true feelings/experiences of participants. Other studies have shown a trend for participants to under or over estimation when completing questionnaires (Jordan and Smith Foster, 2016).

Conclusion
The ENRICH Sessions introduced faith based learning opportunities for a group of interprofessional health students for the better provision of patient-centred care. Students reported an increase in knowledge and understanding, and indicated they now have more skills in their 'tool box'. Students also reported that an awareness of the importance of a patient's spirituality allowed them to feel more confident to act in an appropriate/respectful manner when communicating with patients and their families about their spiritual needs. A beneficial by product of these sessions is that it has increased the community engagement of the UDRH and opened up opportunities for increased collaboration with other community organisations.
While sessions focus on Islam, the intended aim is for students to develop competence in patient-centred care that includes spirituality in the broadest sense. Future sessions have been discussed that intend to focus on Hinduism, Christianity, and Bahá-í faiths. Our initial focus on Islam as an entry point for incorporating spirituality into patientcentred care is not arbitrary. The authors plan to formalise a future study into this important yet under researched aspect of spirituality and undergraduate education. While these findings are tentative and the sample size is limited, there is a strong indication that these sessions add value to student education received through the UDRH and should continue.

Take Home Messages
A patient's spirituality can impact their response to and acceptance of healthcare provision. Spirituality is considered an important aspect of patient-centered healthcare, though it is too often overlooked within the provision of education to medical students. The faith of Islam can be used as a doorway through which students can be encouraged to think about and discuss spirituality and patient-centered care.
Attending interprofessional education sessions that highlight the role spirituality has in a patients' health journey can increase students' awareness of the spiritual needs of their patients.

Notes On Contributors
Paul William Bennett -Paul is currently working as a Nurse Academic for the Broken Hill Rural Clinical School -University of Sydney. He is passionate about working with innovative educators, both clinical and non-clinical. He works to providing students with opportunities to gain new understandings of health and the needs of the community within a safe inter-professional learning environment. Paul has a Grad Dip in General Practice Nursing and a Masters in Primary Health Care. ORCID ID: https://orcid.org/0000-0002-5553-9375 Dr Abu Bakr Sirajuddin Cook -is a Research Fellow as Almiraj Sufi and Islamic Study Centre, Australia. He received a doctorate from the University of Tasmania in 2014. He has presented at a range of international conferences and his first book, Ibn 'Ata' Allah, Muslim Sufi Saint and Gift of Heaven, is available through Cambridge Scholars Publishing. He is currently writing on various aspects of the practice of Sufism and the history of Sufism in Australia. ORCID ID: http://orcid.org/0000-0001-7812-1943 Dr Najeebullah Soomro -is a medical doctor with an interest in medical research. He completed his PhD in the Discipline of Exercise, Health and Performance at The University of Sydney. Currently working as a Medical Officer in Western Australia and associated with Broken Hill Rural Clinical School as an adjunct lecturer.