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Nursing with dignity - Sikhism

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VOL: 98, ISSUE: 14, PAGE NO: 39

Balbir Kaur Gill, BSc, RGN, is nurse lecturer, Thames Valley University, Slough

Sikhism originated in the Punjab, northern India, in the 16th century. Its founder, Guru Nanak, drew features from Islam and Hinduism to establish a reformist movement with the aim of creating a new world order based on equality and social justice for all. His writings, along with those of nine subsequent gurus, several Muslim and Hindu saints, and Sikh poets, form the Sikh holy book, the Guru Granth Sahib.

About 300,000 Sikhs live in Britain, many of whom settled here in the 1950s and 1960s. One can either be born into a Sikh family or choose to become a Sikh. Sikhism does not condone coercion in any form; it supports the right of free belief, the pursuit of knowledge and free inquiry.

Beliefs

Sikhism is a monotheistic religion so Sikhs believe in one God. It does not advocate blind following of the faith and Sikhs are instructed to accept the word of the guru only after they have been convinced of its value: ‘first evaluate and only then accept the wares’ (Guru Granth Sahib).

After the founding of the religion, a succession of gurus provided religious guidance for about 250 years until the holy book was written and mediation was considered unnecessary. The holy book personifies the ‘eternal guru’ and is the focus of spiritual, moral and social guidance. It is a code of conduct for daily life and an instruction for reaching true understanding and unity with God, the ultimate goal. It is regarded with great respect.

Sikhism encourages people to make the most of the opportunity afforded by the human form of life to achieve reunion with God through truthful conduct, humility, family life, meditation and prayer, and by serving the needs of the community (sewa). This includes donating money, clothes, food and shelter to those in need. Failure to do so means the person will ‘languish’ in the cycle of birth, death and rebirth.

Practising Sikhs are baptised in their place of worship, known as a Gurdwara. This may occur at any age, although children would need to have reached the age of responsibility. During this ceremony, followers commit to the Sikh faith and the worship of God. From this point they are expected to follow strict dietary, dress and social codes. If a person transgresses or lapses significantly from the path one may recommit to the faith at any time by undergoing the ceremony again.

Symbols of the faith

Sikhism has a symbolic dress code that is often referred to as the five Ks, as each item begins with the letter ‘k’:

- Kesh: uncut hair for both men and women is a symbol of saintly qualities and a nature-loving disposition. For men, this includes an untrimmed beard and moustache;

- Kangha: a small (3-4cm) wooden comb, symbolising cleanliness. This is worn in the hair, above the top-knot of men and above a bun or plait in women;

- Kara: a steel bangle, worn on the right wrist (it is considered social vanity if this is made of precious metals), symbolising strength and restraint. It is a reminder of the Sikh’s bond with the guru;

- Kirpan: a short sword or dagger, representing the Sikh’s duty and right to take up arms to defend the weak and meek, and destroy evil. This is often worn secured in a cotton body belt under the clothes;

- Kaccha: a particular design of unisex undershorts, similar to modern-day boxer shorts, but often with a drawstring waist. These represent chastity/sexual morality.

Nurses should not disturb these symbolic items without permission or before washing their hands. For initiated Sikhs, it is preferable not to remove any of these items unless absolutely necessary as the symbols are mandatory. However, most ordinary Sikhs maintain only Kesh and Kara, with many third-generation Sikhs opting to follow a western style by having their hair cut short.

Illness tends to increase people’s dependency on their faith and religious symbols often acquire more significance. For this reason nurses need to think about how to prepare patients for surgery or other medical and nursing procedures. For example, think about the possibility of padding and taping over a patient’s Kara rather than automatically instructing the patient to remove it. Offering disposable underwear, and paper caps for men wearing turbans, may also be appropriate. If preoperative shaving is necessary, most Sikhs will comply with medical advice. However, instead of performing the procedure routinely, it would be appreciated if nurses inquired whether there was a specific need for this.

Dress

The Sikh turban can be worn by both sexes, although it is usually worn by men. Traditionally, women cover their heads with a light headscarf (dupatta). Removing a turban without permission, except in an emergency, is considered an insult. Although the scriptures contain a reference to avoiding provocative or gaudy clothing, there is no restriction on what women may wear. They may dress exactly like men if they wish, but the traditional Punjabi female dress consists of salwar kameeze (loose trousers and tunic) and a dupatta.

Gender

Sikh theology teaches that all people are equal, irrespective of caste, colour, gender or creed. Men and women enjoy equal status in all aspects of Sikh life, including marriage and participation in religious rites/roles. The scriptures suggest specific gender roles, but this is mainly for social guidance. Culturally, women tend to adopt a subservient role, at least in public. However, in the family setting, the mother-in-law or oldest female has significant power, which can affect the choices open to younger women. It is important to consider this when planning or delivering care to ensure autonomy for female patients.

Birth

There is a conflict between faith and culture, as the former preaches equality of the sexes while Sikh society values boys more highly. The birth of a daughter, especially in a family with girls, can have a devastating effect on a couple and there is a tendency to blame the mother. Family elders may be miserable and their behaviour can make the parents feel guilty. Attitudes are changing but staff need to be vigilant and ready to offer support to parents if necessary. Although infanticide is forbidden, couples have been known to seek a termination, either voluntarily or under family pressure, if they know the unborn child is female. In contrast, the birth of a son is seen as a joyous occasion.

Most Sikh names are unisex. Gender is differentiated by the shared middle name bestowed by the 10th guru, demonstrating the unity of all and the eradication of caste. All Sikh men have the second name Singh which means lion, while women have Kaur, meaning princess. These should not be confused with surnames. The correct way to address a person is to use their first and middle names: so Balbir becomes Balbir Kaur. However, many younger Asians follow the western practice of using only their first name.

Marriage and sex

Married life is accorded the highest status: ‘Such is the glory of the True Guru, that in the midst of children and wife, man obtains emancipation’ (Guru Granth Sahib). Marriage is seen as a physical and a spiritual relationship, and a way to achieve balance in life: two bodies with one soul. Symbolically, a Sikh marriage is an attempt to unite the individual soul with the universal soul. Monogamy is the Sikh ideal. However, divorce is permissible and divorcees, widows and widowers are allowed to remarry.

Sexual activity is allowed only within marriage. Great cultural importance is attached to sexual behaviour and celibacy, and both are promoted through the concept of Izzat or family honour. While this applies to both sexes, the onus on girls is greater because of the risk of pregnancy from premarital sex. The belief that sex education may encourage experimentation means that information is limited, occurring in single-sex groups or in the home.

Homosexuality

Homosexuality is frowned on, as the family is the base unit in both religious and secular terms. As a result of the religion’s innate tolerance, Sikhs who are homosexual or lesbian are not actively castigated. However, a family would be devastated to hear that a relative was homosexual.

Contraception

Large families are encouraged, more for cultural than religious reasons. However, the use of contraceptives is not prohibited and most methods are acceptable. Termination of pregnancy is not approved of, either socially or religiously, and is accepted only where the health or safety of the mother is in danger.

Infertility treatments

The importance of children to a Sikh family is enormous, from both religious and cultural perspectives, and most families would suppress news of infertility problems or treatments. While many forms of infertility treatment would be considered, most Sikhs would not agree to egg-and-sperm donation. In India, infertility is still regarded as a curse or social stigma and assumed to be the woman’s fault, often resulting in the husband marrying his wife’s sister or cousin. In the UK, this is rare as the attitudes of second and third-generation Sikhs are more tolerant towards childlessness.

Mental illness, learning and physical disabilities

Socially and culturally, these condition are stigmatised mainly because of the unlikelihood of arranging marriages for children with such conditions. They would therefore become a burden on the rest of the family as it would be considered morally wrong to place them in a care home.

Dignity and hygiene

For intimate procedures, Sikhs prefer a nurse or doctor of the same sex. Both sexes should be given privacy if their turban or undergarments are to be removed. At all times the symbols of faith (the five Ks) and turban should be treated with respect. I recall a Sikh woman, who was wearing Kachara, being terribly embarrassed by a nurse laughing at the ‘baggiest pair of knickers [she’d] ever seen’.

Personal hygiene is extremely important. Before even drinking a cup of tea most patients will want to brush their teeth and, at least, wash their face and hands. Showering is preferred to bathing, and douching with water after using the toilet is normal practice.

Diet

Dietary habits vary from not eating beef, eggs or fish to vegetarianism. Ritualistic fasting is forbidden by the faith but may be performed as part of a person’s culture, especially by Sikhs whose families originated in or near Hindu towns or villages. Eating meat prepared as part of a ritual, for example halal meat, is forbidden.

Many Sikhs also avoid beef and veal out of respect for the Hindu faith, in which the cow is a sacred animal. Offering an accurate description of the ingredients in unfamiliar hospital dishes can be extremely reassuring, particularly for older people who may refuse food they do not recognise.

The use of tobacco, alcohol and other intoxicating substances is prohibited. Some Sikhs find the smell of tobacco offensive, so ensuring that the doors to any room used to smoke in are closed would be appreciated.

Blood transfusion

There are no restrictions on receiving blood transfusions.

Organ donation

There are no restrictions on organ donation on religious grounds. Sikhism is concerned with the soul, which is considered indestructible. Once the soul has left the body, there are few restrictions on what becomes of the body. However, this does not mean that all Sikhs are culturally comfortable with being organ donors and nurses should carry out the usual discussions with sensitivity.

Resuscitation/suicide/euthanasia

There are no restrictions on resuscitation attempts. Sikhs value the human form of life as a way to achieve unity with God, which conflicts with committing suicide or euthanasia, so both are frowned upon.

Community worship

Worship is a fundamental part of Sikh philosophy. The congregation meets in the local Gurdwara, which also serves as a community centre for educational and social events. The Gurdwara can be an excellent resource for health care professionals: it is a natural focal point for health education/promotion activities, with translators on hand, and a useful resource for determining the local population’s health needs. The local priest (granthi) can offer spiritual support to patients who are admitted to hospital.

Death/rituals

Sikhs may be comforted by reciting passages from Guru Granth Sahib. If they are too ill, a relative or someone from the local temple may be asked to read. Giving patients and their families or friends some privacy is appreciated: reciting is done quietly and should not disturb other patients. Holy water from the Gurdwara may be given to sip, or be sprinkled on or around the patient.

As a mark of respect, as many friends and relatives visit the patient as possible. This can cause problems on busy wards, but a little planning and quiet discussion with the family on safety protocols can enable nurses to manage the situation.

Sikhs believe that after death the soul re-enters the cycle of birth and death, taking on different life forms depending on one’s actions in the preceding life. Non-Sikhs are permitted to care for the body of the deceased and health care staff may perform normal last rites, remembering not to interfere with the five Ks and, crucially, not to cut or trim hair from the face or head. Most relatives prefer to carry out these tasks themselves, but this should not be assumed.

The body may be viewed several times before the funeral, so care should be taken to ensure that the eyes and mouth are closed and the facial expression is peaceful. Almost without exception, Sikhs are cremated and this should take place as soon as possible. If a delay is likely, the family should be given a full explanation.

WEBSITES

- Gateway to Sikhism: www.allaboutsikhs.com

- BBC Overview: www.bbc.co.uk/religion/religions/sikhism/index.shtml

- Individual: photon.bu.edu/~rajwi/sikhism

This series has been endorsed by the Transcultural Nursing and Healthcare Association.

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