Should Female Muslim Psychiatric Patients Be Allowed to Wear Hijabs?

macawake, MSN · May 28, 2017

However, it got me thinking...do they allow these patients to wear their head coverings while in the psychiatric hospital? It seems like a silly question, but if the patient is in their for suicidal ideation, it seems like they might not want them to have it since they could possibly use it to hang themselves or strangle themselves. Our psychiatric hospital is very strict and anything that could possibly be used to attempt suicide is banned.

When you say that your hospitals bans all items that can be used in a suicide does that mean that none of the psychiatric patients are allowed anything made of cloth/fabric? No bed linen, blankets, t-shirts, pants etc. for anyone, ever? A t-shirt or even a pillowcase can just as easily be used to attempt a suicide, as a head covering could. I see no reason to single out head coverings and ban them as a general rule, there are many other clothing items that can be used for self-harm/suicide. I guess that I think that it needs to be decided on a case-by-case basis. Not all psychiatric patients are suicidal.

I don't work on a psychiatric floor, but I would assume that if you've identified a patient as being a high risk for suicide, they would have one-on-one sitters, or at the very least very frequent checks by staff? If a person is sufficiently motivated, pretty much anything can be used to attempt a suicide.

Back when I worked in law enforcement we'd allow arrestees to wear a t-shirt, sweatpants and slippers and have blankets in their cells and only removed these items if a person actually attempted using any of them for self-harm/suicide attempt.

Sour Lemon · May 28, 2017

This morning I had the assignment of performing a task on a lady in our psychiatric hospital. Based on her name, I am pretty sure she was Muslim (although you never know, of course). However, when I was working with her, I noticed she was not wearing a hijab, or the head covering many Muslim wear. Now, I'm pretty sure not all female Muslims wear the covering, nor am I confident that this particular patient was, in fact, Muslim. However, it got me thinking...do they allow these patients to wear their head coverings while in the psychiatric hospital? It seems like a silly question, but if the patient is in their for suicidal ideation, it seems like they might not want them to have it since they could possibly use it to hang themselves or strangle themselves. Our psychiatric hospital is very strict and anything that could possibly be used to attempt suicide is banned. At the same time, if you do not allow these patients to wear them, you are not respecting their religious beliefs. My thought is that their safety is more important than their religious beliefs, but, obviously, they might not agree. What are your thoughts?

I agree that safety is the number one concern. I work in a locked unit, but it's also voluntary. There are things that are never allowed on the floor, and other things that may be depending on the current population. I'm not sure we have a rule that specifically addressees hijabs ...just the broader "contraband" (which can be anything).

Our suicidal patients have 1:1 sitters and it's true that anything can be used by a determined patient. They even slam their own heads into the wall on occasion. I think the bigger concern would be patients' interactions with each other. We have common areas and encourage appropriate interaction, but sometimes people get agitated and "scuffle". A scarf wrapped around someone's head/neck is just a little too convenient. While it's true that a bed sheet could also be used to assault someone, that would take a little more time, pre-planning, and be a little more obvious.

Here.I.Stand, BSN, RN · May 28, 2017

I have never worked in psych, but don't see how a hijab is any more dangerous than a bed sheet. Actually a sheet would be a more effective noose, because hijabs are usually 3-4 ft square. So not a lot of fabric to wrap around the neck AND secure to the location of choice.

There is a huge Muslim population where I live.

In my ICU, we use either a towel or a bouffant cap to cover the ladies' hair.

Did you ask the pt or other staff about it? My other thought was she may not even be Muslim. I mean a Syrian Muslim and a Syrian Christian would likely both have an Arabic sounding name, because the official language of Syria is Arabic. Or like my son's best friend, whose mom is originally from Iraq. She has an Arabic name, but she's not religious and dresses like any other suburban soccer mom

macawake, MSN · May 28, 2017

I think the bigger concern would be patients' interactions with each other. We have common areas and encourage appropriate interaction, but sometimes people get agitated and "scuffle". A scarf wrapped around someone's head/neck is just a little too convenient. While it's true that a bed sheet could also be used to assault someone, that would take a little more time, pre-planning, and be a little more obvious.

As a side note, this is why I never wear my stethoscope around my neck when I'm around conscious patients

I understand the point you're making. But I think what's most important is that a unit is adequately staffed with healthcare professionals who are trained to identify triggering/escalating behavior, monitoring patient interactions. Head cover or not, what's to stop one patient from punching someone else's light out? The majority of psychiatric patients aren't homicidal, but violence/attacks do of course happen occasionally.

Here.I.Stand, I agree with you. Not all people with Arabic name are Muslim, and not all Muslim women wear hijabs/head covers, especially not the women who have moved to Western countries. I work with dozens of Iranian and Iraqi female nurses and physicians, not a single one of them covers their head or face (other than in the OR :))

~Mi Vida Loca~RN, ASN, RN · May 28, 2017

This could be more than just a risk for the patient, but a safety risk in the unit. It would be easy for a patient to have a psychotic episode and yank the headpiece off and wrap it around someone's neck. At the end of the day I think in a hospital type setting like that, safety for the patient and other patients will trump everything else. I could be wrong though. The choking someone else I have seen and why they ban wearing lanyards, shoelaces, stethoscopes and such in a lot of psych units.

Places I have seen if the person is actively suicidal they will be on continuous watch, the other patients get 15 min. checks when they are allowed in their rooms.

Sour Lemon · May 28, 2017

As a side note, this is why I never wear my stethoscope around my neck when I'm around conscious patients
I understand the point you're making. But I think what's most important is that a unit is adequately staffed with healthcare professionals who are trained to identify triggering/escalating behavior, monitoring patient interactions. Head cover or not, what's to stop one patient from punching someone else's light out? The majority of psychiatric patients aren't homicidal, but violence/attacks do of course happen occasionally.

All true, but we could use that rational to allow them to keep their pocket knives, too. I guess it's all about balance ...but there is no "perfect" system. Luckily, since my unit is voluntary, people can choose to accept or not accept any restrictions places on them. I think things like this would be a bigger issue in non-voluntary units.

On a unit I visited as a student, I recall a Catholic woman who chose to wear a towel on her head like a nun's habit. I'm not sure how that's relevant, but it just popped into my head and onto my post.

oceanblue52 · May 29, 2017

Every Psych hospital I have worked has allowed them, even with very ill patients. Otherwise it falls under religious discrimination.

OlivetheRN, ADN, BSN, RN · May 29, 2017

In our ER we have what some people call strict policies on what behavioral patients are and are not allowed to have. When someone comes in for evaluation of a psychiatric nature, whether it's anxiety, depression, what have you, all of their belongings are taken from them whether they are voicing SI/HI or not. This includes their underwear, bras, hair bands, jewelry, socks, shoes, everything. They are provided with paper scrubs, mesh panties and non-skid socks and they have to change in front of a staff member of the same sex. They are allowed to keep eyewear, dentures and things of that nature. With that being said, I have not yet had a Muslim woman who wears a head covering come in. My guess is that our policies would allow them to keep it after it had been searched by a staff member.

We do this for several reasons. We keep all of our behavioral patients in one area of the department, so if even that particular patient is not SI/HI, we can't risk a patient who is getting their hands on something dangerous and harming themselves or

someone else. For those who are SI/HI, well, it's obvious.

Our rooms in that area are basic stripped down rooms, with a dedicated tech for that area to do 15 minute checks and if someone needs 1:1 they will have a 1:1. There is also an officer in that area pretty much 24/7 because we pretty much always have someone under IVC at any given time, but even if we don't have an IVC patient they tend to stay there. We have phone hours and visiting hours, patients can't have straws or eating utensils, no pens or pencils unless it's being used with supervision, they're not allowed to have any hard fruits such as apples, no caffeinated beverages, only water after evening snack, etc.

Meriwhen, ASN, BSN, MSN, RN · May 29, 2017

I have never worked in psych, but don't see how a hijab is any more dangerous than a bed sheet. Actually a sheet would be a more effective noose, because hijabs are usually 3-4 ft square. So not a lot of fabric to wrap around the neck AND secure to the location of choice.

I'm more concerned that someone else would take and use the fabric to hurt the patient or another person, than the patient deciding to use it to hurt herself. As someone else mentioned, it's a little too convenient for someone to get.

In our facility, religious head/neck gear (hijabs, scarves, coverings, rosaries, prayer beads, etc.) that is to be worn on the head or neck is allowed but only with a doctor's order, and that patient is usually placed on more frequent watch for their safety. But anything that requires safety/bobbie pins, strings or clips to secure it to the head or neck is a no-go unless they're on the open unit.

While we try to honor a patient's religious needs as much as possible, the safety of the entire milieu trumps everything.

OlivetheRN, ADN, BSN, RN · May 29, 2017

When you say that your hospitals bans all items that can be used in a suicide does that mean that none of the psychiatric patients are allowed anything made of cloth/fabric? No bed linen, blankets, t-shirts, pants etc. for anyone, ever? A t-shirt or even a pillowcase can just as easily be used to attempt a suicide, as a head covering could. I see no reason to single out head coverings and ban them as a general rule, there are many other clothing items that can be used for self-harm/suicide. I guess that I think that it needs to be decided on a case-by-case basis. Not all psychiatric patients are suicidal.

We had a particular patient who was in the locked area of our ED where the rooms are camera monitored (including the bathrooms but the toilet area is blocked out) and he was being a particular moron and lost linen priveleges. He got a pillow with no pillow case, a bare mattress, and no blanket since he insisted on taking his linens off the bed and defecating and peeing on them. When he didn't have them he would use the bathroom. But we also limit them two a max of two blankets in that area and that are camera monitored by security 24/7 (which they are told as soon as they go into that area).

In the main ED some younger patients will end up on a stretcher mattress on the floor if they insist on throwing themselves on the floor from the stretcher (rather than restraining them) or there was a guy who was looking for parts to pick off the stretcher to use as a weapon (we always take the IV poles off, but he had found some spring in between 15 minute checks).

macawake, MSN · May 29, 2017

In our ER we have what some people call strict policies on what behavioral patients are and are not allowed to have.

I guess I would be one of those people. While I do believe that in certain cases we might be forced to take far-reaching steps to ensure the patient's safety and the safety of other patients and staff, it makes no sense to me to treat every single psychiatric patient the same and to subject them to treatment that infringes on their autonomy. It doesn't make sense to me ethically or logically (from a safety perspective).

When someone comes in for evaluation of a psychiatric nature, whether it's anxiety, depression, what have you, all of their belongings are taken from them whether they are voicing SI/HI or not. This includes their underwear, bras, hair bands, jewelry, socks, shoes, everything. They are provided with paper scrubs, mesh panties and non-skid socks and they have to change in front of a staff member of the same sex. They are allowed to keep eyewear, dentures and things of that nature.

So if I were to show up in your ER seven months pregnant and reeling from the shock of having lost the baby's father in a vehicular accident the previous day and telling you that this fresh loss is something I'm having difficulties coping with, your policy dictates that I strip in front of you and don mesh panties and paper clothes? How is that helpful for a person in my situation?

But if I in a rage of unknown etiology stab my unfortunate husband to death in our house and subsequently get in my car and manage to wrap it around a tree (inclement weather being the likely cause for the accident), I am carted off to your ER in an ambulance and get to wear my own panties. (Well, yeah I realize they'll check me over in trauma which will necessitate removal of said panties, but I think you understand the point I'm trying to make).

The psychiatric patient in the above scenario is overwhelmed by grief and needs compassion, stability and support. I don't see why the indignity of having to remove her clothes is at all necessary here for anyone's safety, hers or other patients/staff.

It makes no sense to subject her the same rules as the patient on involuntary hold. Instead of applying the same rule to all, it's a better idea to keep the various populations separate, if one part of it poses a threat, and another doesn't

The homicidal me (with an as of yet undiscovered corpse in my home) is likely a much greater danger to both myself and others.

It's a mistake to designate psych patients as dangerous and the rest of the ER population as not dangerous. I think that the inflexible policies are a blunt instrument and will fail to identify some threats and overestimate others at the cost of people's dignity and autonomy.

From a sheer safety perspective it makes no sense to make a person remove their panties/briefs while letting them keep their eyeglasses so the policy seems arbitrary. (Hygienic considerations aside, I know that I'd rather have a violence prone individual come after me with their panties than some sharp/pointy part of their glasses). Also it's of no use to make a person strip and remove their underwear if you don't perform a cavity search as well. If genuinely concerned that the person will attempt to harm themself or others, you really need to go there. (If this isn't allowed for legal reasons, your only other option if you genuinely consider this person a potential threat, is 1 on 1 monitoring).

To me it's obvious that knifes, scalpels and other obvious type weapons should be kept out of reach of patients, but that includes all patients, not only those who've sought psychiatric care. I was always acutely aware of all the items in my surroundings that could be used as a weapon when I worked in the ER, like for example the IV pole you mentioned.

You simply don't know which person/patient is a threat or could become one, and which patient is "safe". So always assess, be watchful and prepared to respond to/act on verbal, behavioral and body language changes/clues that often herald an escalation, a physical attack or suicidal ideation. It could just as easily be the guy who comes in with a complaint of abdominal pain who goes berserk, as it could be the patient who seeks care for anxiety or depression.

This post ran longer than I intended :lol2: but I guess my point is this; while some baseline security rules certainly are necessary I think the focus should be on tailoring your approach to individual patients and individual situations. One-rule-fits-all in my opinion is seldom the most effective method or the ethically most appropriate. And there is this whole business of stigmatizing an entire patient population (psychaitric), by simply assuming they are all so unstable that they all need to undress and be clothed in paper scrubs, that I find a bit troubling.

Don't think I'm naive. I've worked ~ a decade in law enforcement where you certainly encounter a lot of psychiatric "unwellness" and violent behavior and I have worked in an ER for a couple of years. I'm just not a fan of one-size-fits-all :)