“Whoever Does Not Thank People Has Not Thanked God”: Understanding the Relational Gratitude of Muslim Patients During the COVID-19 Pandemic

Abstract

As research on hospital experiences of religious minorities in the Global North increases, we still have scarce empirical knowledge about the role of religion and spirituality during crisis situations in hospitals. This study poses the following question: How do Muslim patients hospitalized with a severe disease express gratitude and how can it be interpreted? This was performed through a qualitative empirical method where twelve patients (eight males and four females) were interviewed at Danish hospitals during the COVID-19 pandemic. A thematic analytical approach was used to interpret and discuss the results. This study found that gratitude is channeled in different directions (God, family, and hospital staff). Patients express shukr, an Islamic theological concept, which means to thank, praise, and commend a benefactor—humans and God—in the Muslim worldview. Ultimately, shukr recognizes a blessing—especially its point of origin—and the response humans need to make for the act of Divine benefaction. Hence shukr for patients is not just a positive emotion but also a practice and a virtue with relational implications.

1. Introduction

I’m not the type of person who disturbs them (Hospital staff), but when I call them, they come. They also come with food, beverages, medicine, and other things. It’s a good service. I am so thankful and a lot of compliments to the staff.

(Hagar)

The above quote is from an interview with Hagar when she was admitted to a Danish Hospital with COVID-19.1

Hagar is a 55-year-old female Turkish migrant and mother to three children who works in a care center for the elderly in Denmark. She had been hospitalized for four days when I met her at the ward for the interview.

There is some confusion around the understanding of gratitude and thankfulness in academic literature. “It has been conceptualized as an emotion, an attitude, a moral virtue, a habit, a personality trait, or a coping response” (Emmons and McCullough 2003, p. 377). The word gratitude originates from the Latin word gratus, meaning thankfulness, appreciation of kindness, and is in the same lingual family as the concepts of appreciation, thankfulness, and graciousness (Khalil 2022). Thankfulness is therefore synonymous with gratitude and appreciation—which is a positive, other-focused emotion (Emmons and McCullough 2004). However, there is a difference between being thankful and practicing gratitude (Nguyen 2022). While being thankful can be understood as an emotion and a momentary condition2 (e.g., upon receiving a gift or benefit), gratitude is an attitude, acknowledging the goodness in life and practicing this recognition as a virtue (Eriksen 2022).

The Arabic word “shukr” has a broad semantic repertoire and extends beyond what is expressed and understood by the words “thankfulness” or “gratitude” in the English language. “Shukr” (for lack of a better word, I will use gratitude in this article) is to “express, glory, praise or gratitude towards Allah or His creation either through words, actions or both” (Ali et al. 2020, p. 1744). Shukr is also closely associated with sabr (patience) and hamd (praise). For the blessings of life, expressing gratitude to God and humans, being patient during tribulations, and praising God (on both good days and bad days) are encouraged in Islamic theology (Hussin et al. 2023; Khalil 2022).

Theory and research have underscored that gratitude and religious beliefs are closely associated (Rosmarin et al. 2011), with some even describing gratitude as a sacred or spiritual emotion that acquires enrichment through religion (Emmons 2005). Since gratitude occurs (in the minimal sense) in relation to receiving a gift—either through the agency of humans or that of God/s—religious commitment may increase the experience of gratitude through a compassionate spiritual/religious agency (Rosmarin et al. 2011). However, gratitude has also been linked to, and defined as, a non-spiritual “affective trait” (McCullough et al. 2002, p. 112). Gratitude also plays an immense role in strengthening intrapersonal relationships and pro-social behavior (Bartlett et al. 2012) in addition to, amongst other things, advancing self-control, minimizing impatience, and increasing general well-being (McCullough et al. 2002).

Gratitude is an underlying attribute of human beings, the mother of all virtues according to Cicero, and a potential key to human prosperity (Emmons and McCullough 2003) and a God-given gift (Khalil 2022). Hence the nature of gratitude is complex and ambiguous and coincides with other moral values and emotions.

This research topic on gratitude amongst Muslim patients and its forms of expression (horizontal and vertical gratitude) can inform us about potential opportunities and consequences for individual and collective functioning in health care services. In other words, this exploration can shed light on the nature of patient gratitude including the pertinent question of to whom it is directed. This study may tell us about patient relationships during critical illness and, through understanding the role of gratitude, help to improve patient hospitalization by encouraging patient-centered care.

This present article aims to explore and answer the research question: How do Muslim patients hospitalized with a severe disease express gratitude and how can it be interpreted? Particularly, theological interpretations of shukr are introduced and discussed. This is because shukr also plays a significant theological role in the lives of Muslims at various levels (LittleJohn 2016). Hagar and 11 other hospitalized COVID-19 patients’ are included who constitute the empirical data material upon which this article is based. A thematic analytical approach to discuss and interpret the findings is employed.

Previous Research

For the most part, empirical research that is available to us today into the nature and effects of gratitude is primarily focused on the consequences of experienced and expressed gratitude (Emmons 2022).

Studies are unanimous about the benefits of gratitude for positive flourishing in many dimensions of life. They indicate that gratitude not only increases psychical health and prosocial behavior, but it may also reduce stress, and boost positive emotions and life satisfaction (Chalmiers et al. 2023; Emmons 2022)

However, most research on gratitude has largely been limited to Christian samples from the US, and very little is known empirically about gratitude amongst Muslim populations living in crisis situations from the Global North (Aghababaei and Tabik 2013; Chalmiers et al. 2023).

One empirical study from Belgium on elderly Muslim women concluded that spirituality was an important dimension of their patient care and had implications for patients’ ritual needs as well as how they understood and approached illness and suffering (Baeke et al. 2012). This study touched briefly on gratefulness toward God and how praise, patience, and gratitude are interlinked in the understanding of the illnesses and tribulations of the interviewed patients. This is because expressing praise, being patient, and conveying gratefulness to God are all seen as signs of accepting his will and destiny, and relying on God’s plan which may also include trials and sickness (Baeke et al. 2012). The article suggested that the study’s empirical findings confirm what non-empirical studies have said and validate the theological stance of Islam in which accepting God’s will and destiny are part of faith.

Suleman’s extensive empirical study from the UK, which included 76 interviews with Muslim patients, families, staff, and Muslim chaplains/leaders on end-of-life care issues, identified patience and gratitude as integral virtues for Muslim patients during crisis (Suleman 2022). The study found—amongst other things—that expressions of acceptance (of destiny) through virtues like sabr and shukr were common amongst Muslim patients.

Shukr, which is translated as gratefulness in Suleman’s article, is categorized as a virtue in her study, being an act but also a human condition. It is a condition in the sense that patients are grateful to God for the gifts of life despite hardships and an approaching death (Suleman 2022). The data also demonstrated “how virtues, as understood, expressed, and embodied by Muslims, is an active and not a passive undertaking” (Suleman 2022, p. 67).

One recent qualitative study on gratitude among 35 cancer patients in Malaysia (the study did not identify informant faith/non-faith affiliation but central terms from Islamic theology are discussed) found the following themes: “searching for meaning”, “meaningful experience”, “gratitude through the enrichment activities”, and “gratitude as religious cultural expectations” (Hussin et al. 2023). Even though the study suggests that gratitude is an important experience for sick patients, it discovered that some patients experienced the idea of being grateful as a religious/cultural expectation they could not live up to. This was the case for those patients who were—for some reason or another—not ready to be grateful and felt that their families and relatives impelled them to be so.

The empirical material of the abovementioned study suggests that even though the patients knew that gratitude was a religious obligation they did not see their “reservations” as disobedience to God. Furthermore, there were also patients who reported “mixed feelings” and for whom gratitude toward relatives and family became a source of shame because they did not want to be a burden on their loved ones (Hussin et al. 2023). Overall, their research described gratitude as a complex concept entangled in religious, cultural, and existential influences. According to the researchers of the Malaysian study, this multidimensional gratitude perspective is understudied in research which has a discriminate leniency toward the positive effects of gratitude (Hussin et al. 2023).

A literature review of empirical research on the relationship between religious gratitude and mental health amongst Muslims was based on 125 studies from 27 different countries (Chalmiers et al. 2023). This literature review focused on religious gratitude and used theological argumentation to differentiate between different types of religious gratitude. It recommended a need for more research on the lived experiences of gratitude among Muslims (Chalmiers et al. 2023).

The mentioned research studies all touch upon gratitude toward God but do not delve into Muslim patients’ gratitude toward hospital staff. However, one meta-review did identify “gratitude and staff well-being” even though it did not include religious gratitude or explicitly mention religious affiliations. This meta-review on gratitude research in healthcare (the first of its kind) identified six meta-narratives that include “gratitude and staff well-being” and “gratitude as an indicator for quality of care” (Day et al. 2020).

Patient gratitude toward staff may have a protective effect on staff burnout, the review found, and some studies found it increased the emotional and physical health of hospital medics (Day et al. 2020). This meta-review also confirmed that an overwhelmingly large part of the research on gratitude, led by the field of positive psychology, concerns the benefits of being grateful (Day et al. 2020; Khan et al. 2022).

The present article is, to the best of my knowledge, the first time when Muslim patients’ gratitude toward hospital staff (predominantly adherents of other religions/life stances than Islam) during times of crisis has been studied empirically in the Global North. A research study of Muslim gratitude in the Global North is significant not only because it contributes to our understanding of religious and virtue-ethical expressions in health care as such, but it also challenges the stereotypical portrayals of hospitalized Muslims and by extension, Muslims in society.

Emmerich’s (2022) empirical research from Germany found that Muslim organizations improved their public image by following government guidelines concerning COVID-19 more strictly than any other religious community. Outreach campaigns by imams, Muslim healthcare staff, and Muslim organizations in Denmark—sometimes in cooperation with government agencies—confirmed the need for the secular state and religious organizations/individuals to cooperate for the greater good of society (Kühle 2021). Despite “Muslims during the pandemic” being an important area of investigation, this particular study is interested in the lived hospital experiences of Muslims during crises. The Coronavirus-infected patients are inducted as the sample group and the COVID-19 pandemic is not the focal point of this study.

2. Method

2.1. Participants

Twelve Muslim patients living in Denmark who were diagnosed and hospitalized with the Coronavirus were part of this qualitative empirical study. Semi-structured interviews were conducted between April 2021 and September 2021 with hospitalized (second wave) and discharged (first wave) patients from three public hospitals in Copenhagen. All patients, four females and eight males, were above 18 years old, they all spoke Danish and had eight different national backgrounds: Moroccan (3), Palestinian (2), Turkish (2), Afghani (1), Pakistani (1), Algerian (1), Iraqi (1), and Albanian (1).

2.1.1. Procedure

Being enrolled at the University of Oslo, approval from the NSD (the Norwegian Center for Research Data) for conducting this research was granted (research project reference nr. 324644). This approval, in line with data protection regulations and ethical standards for research projects, also covered Danish hospitals.

Different hospital wards were contacted by telephone and through email. Written information material about the PhD project was sent electronically to specific hospital ward management where Corona-infected patients were hospitalized. The patient interviews were all conducted in Denmark.

Once the hospital ward in question responded positively to the request for patient recruitment, an in-person meeting in most cases (some meetings were digital) was arranged to provide more information and to clarify questions from the ward staff. All hospital wards that were contacted were accommodating and three out of four wards recruited patients for this research project. After the hospital ward management approved the research project, the hospital staff—doctors and nurses—recruited hospitalized patients once they felt that they were mentally and physically capable of giving interviews. Separate information material about the project was provided to hospital staff that they could give to potential patients before they decided to participate or not.

From one hospital, a contact list of discharged patients, who had been hospitalized earlier for a Corona infection (first wave), was provided. All interviews were conducted in person. Seven interviews were conducted with hospitalized patients who were second-wave Corona patients and five (first-wave, earlier hospitalized) at other locations of patients’ choice, including their homes. All interviews were recorded on a digital recorder and notes were taken afterwards.

2.1.2. Ethical Aspects

Given the serious nature of the health conditions of the participants at the hospitals and of those discharged (most of them having COVID conditions also known as “long COVID”), all health regulations recommended by the Danish health authorities were followed. This meant that all patient interviews that were conducted in the hospitals (7) were carried out wearing a protective suit, a mask, and/or practicing distancing. It was necessary to be attentive and express an understanding of the conditions of the interviewees. For instance, during one patient interview, the conversation was shortened due to the deteriorating condition of the participant at a hospital, who started coughing heavily, and another interview was stopped well in time because the patient was going through a (non-medical) family crisis and had a tight time frame.

The participants gave verbal and written consent before the interviews started and were also informed about the right to withdraw at any time without giving any reason. Recordings were stored in an authorized secure university-supplied server and erased from the audio recorder after the interviews. Names and other material that could identify the participating individuals were anonymized in text and transcripts. All the interviewees were notified—in writing and orally—that the results from this research project would make individual identification impossible.

2.1.3. Analysis of Data

All the 12 interviews were transcribed by a hired professional and the material was coded using the NVIVO 12 software program. The questions posed to the data were as follows: “who are critical ill patients grateful toward during hospitalization and what type theologies are in play when gratitude is being expressed?” The questions for the analysis tend to be more specific and can inform the overall research question (Swinton and Mowat 2016).

Thematic analysis (TA) is a qualitative research method that formalizes the process of developing themes, and because TA has plasticity, it is used in many different academic disciplines (Floersch et al. 2010). According to one definition, a theme “represents some level of patterned response or meaning within the data set” (Braun and Clarke 2006, p. 82).

When saturation was reached, the recruitment process was brought to a halt. Saturation means that there comes a point during the research work where interviews do not deliver new knowledge (compared to earlier research) and interviewing can come to a halt (Grossoehme 2014; Swinton and Mowat 2016).

Themes can emerge from a dialogical effort between the empirical material and the researcher’s theoretical grasp of the subject matter (Ryan and Bernard 2003). By using this form of TA as my methodical strategy and technique, consistent themes across and within the participant interviews were identified. The seven TA stages of Braun and Clarke were condensed to five. They were transcription of all interviews, familiarization of the data by reading and taking notes, coding the entire data, searching for themes, and finally reviewing, comparing, and mapping themes. Analysis can be understood as a persistent dialogue between the empirical material and the theoretical comprehension that is brought into play by the researcher (Ryan and Bernard 2003).

3. Results

The process of thematic analysis yielded three categories that were identified as “grateful to staff”, “grateful to family”, and “thanking God”. In the following sections, the three categories are presented with empirical evidence.

3.1. Grateful to Staff: ’She Touched My Heart’

Badr, a Danish–Albanian man in his sixties, who came to Denmark as a labor migrant was very categorical about his thanks to the staff:

I would like to thank the hospital that has helped in every possible way. I don’t know what more to say—many thanks to all in the hospital. That is the only thing I can say about the hospital. They should just continue in this manner. It was not only me but also others. Once there was a patient who was drunk or something. He was somewhat disturbing and noisy. Then the nurse came and talked politely to him and asked him to lay in his bed. She didn’t become angry with him but was very compassionate and kind. They [the hospital staff] talk to everyone like this here. I can’t really describe it [the hospital staff’s attitude] with justice, but they are all so compassionate.

(Badr)

Other patients also associated thanks to the staff with the care and compassion that they had received from them. After giving a formal statement of thanks to the doctors and nurses, Hamide, a Turkish woman in her 50s, explained what she meant by one nurse’s compassionate behavior:

It’s her [the nurse’s] tone that is soothing and makes me breathe naturally. It’s the way she enters the room, the way she looks at you and it’s something totally different. So, you become totally calm.

(Hamide)

Hamide added:

There are many [who are caring], all are compassionate in their own unique way. But there is one called Sulaima—maybe it was the chemistry between us—she was like, when I had difficulties in breathing, she would give me breathing techniques. So, I don’t know, maybe it was the connection between us. But they were all kind, nothing there. But she was a little more compassionate. She would say “do you need this?”, “Have you done this?” She touched my heart.

(Hamide)

Hamide specified that all staff are kind but still identified one nurse (Sulaima) who outshone the others because of her special compassionate care and maybe because of the intuitive endearment between them. “Gratitude is the memory of the heart”3, and Hamide’s personalized expression “she touched my heart”—may be understood as heartfelt gratitude. Normally, it is understood that gratitude points outwards (through words, acknowledgment, body language, etc.), but it may not be. Hamide is feeling gratitude and moved in her innermost being—the heart.

Zainab, a Syrian refugee woman in her 20s who was hospitalized with Corona while pregnant, said:

Once a nurse came to me and she knew I had problems with my mobility. If I move, I start coughing. So she massaged my back even though it was hard for me. It was very kind of her, and I hadn’t asked for it. I don’t think it’s part of her job description.

(Zainab)

According to Zainab, the nurse does more than is expected of her, which is something Zainab appreciates.

Ahmad, a Danish-born male in his 30s with a Turkish Muslim academic background was in a coma for three weeks and spent 64 days in hospital. He reflected:

There are some things they [the hospital] could do better. The hospital is worn out and there is not so much space. More staff would be welcome, and I can feel that the extra workload is pressurizing them. And then there is the nurse’s strike going on. If there is illness amongst the staff, then there are only 2 nurses on duty for 14 patients? So sometimes when I call them, I must wait a long time before someone comes to help.

(Ahmad)

Ahmad, who has no curtains in his present room, which means it is hot and stuffy on sunny days, is generally satisfied with his treatment but suggests areas for improvement. Ahmad’s comments indicate that while his satisfaction with the hospital staff is relatively high, it is obstructed by structural and organizational gaps that he experienced.

Another patient, and not the only one, mentioned that after illness, the “biggest” problem at the hospital is dietary. Sultana is a 46-year-old Danish–Algerian woman who has spent three months in the ICU. She was born in Denmark, studied social sciences at university, and lost her parents to COVID-19. She said about the dietary situation:

There was never really any food even though I had told the ICU that I was lactose intolerant. There were many days in a row that I ate eggs and snacks like carrots and bell pepper. Morning, midday, and evening. It was a bit extreme. So, on this point it [the hospital stay] was unsatisfactory. But the ICU did what they could. Some nurses tried to order food from outside when they didn’t have lactose-free options.

(Sultana)

Sultana’s husband, as with the family members of other patients, brought food from home even though there were hospital restrictions on it because of the Corona pandemic. One patient commented:

So, he [the nurse] says: “I am not allowed to do this but ask your wife to make some food for you and I will bring it up to the ward, but she must stay outside of the main entrance.” This was remarkable of him, and it was because he could see that I was not eating and had lost 15 kilos. So this was one of the [positive] things about [the hospital stay] I just remembered

(Hafiz)

Hafiz told me he was not fond of the hospital food and praised the staff’s ability and courage to go beyond rules and make exceptions. Hafiz also told me that his abstaining from hospital food was not a matter of halal or haram diet while at the hospital, but the fact that he was inclined toward “native” food and taste.

In the above descriptions, gratitude toward hospital staff is closely linked to care and compassion. Furthermore, patients are grateful for the exceptions that are made for them during their stays. However, some issues surface alongside gratitude where some patients express concern and even disappointment over the quality, portioning, and availability of the food. However, this disappointment is not directed toward the hospital staff as such and does not seem to belittle the relatively high level of gratitude that patients feel and express toward hospital staff.

3.2. Grateful to Family—What to Do Without Them?

Hussain, a Danish–Moroccan man in his mid-50s, was hospitalized with the Coronavirus. He has previously had lymphoma and his wife was allowed to stay in the same room for assistance. Hussain said:

Thanks to my wife—she has been here with me all the way. She has supported me. I thank the doctors and nurses as well, but my wife has been a massive help for me. If she hadn’t been here, I would not have been in this state [a stable condition] as I am in now… I have used her assistance all the time. We are together 24 h, she is here night and day and whenever I need something she helps me. She can adjust the oxygen levels, take me to the toilet and give me a bath.

(Hussain)

Hussain obtained special permission to have his wife admitted with him and is grateful to the staff and his wife. He praised his wife many times during the interview and gave examples of how she helped him with practicalities including arranging for food (from inside and outside of the hospital) and communicating with staff. In some ways, his wife had taken over the service and care provision from the hospital staff, a matter which Hussain had an opinion about:

A hospital cannot have resources for all this [services for patients]. It’s worth thinking about, if my wife hadn’t been here, would I have recovered so fast? I don’t believe so.

(Hussain)

Even though Hussain was admitted with his wife in the same hospital room, many others were not so fortunate. One now-discharged patient thinks back to her time of hospitalization when many patients used online video solutions to see and speak to their loved ones:

It was a very, very unusual time. Normally when somebody is very ill, the family are around to relieve you, to do practical things and care for you. But during Corona it wasn’t like this. In fact, it was a very special time to be hospitalized in.

(Rabia, 48 years old)

Ahmad, the Danish–Turkish man in his 30s, has this to say about what he is grateful for:

They [his family] are my pillar. I would probably go mad without them. For example, my wife comes daily. I have something to look forward too. We humans are not created to be solitary; we are social beings. I am very much a social person and I like to talk and share my thoughts.

(Ahmad)

When asked what his wife does specifically when she comes every day, Ahmad said:

It’s just that she is here. It comforts me and makes me secure. So she helps me with everything as a nurse does. She bathes me, makes food from home, talks to me, and updates me about Emir’s [their son’s] day in the kindergarten. She also informs me about what’s going on in the family. I get to talk as well and time passes faster.

(Ahmad)

Ahmad was also grateful for other family members’ prayers and Quran recitations:

Many people have recited the Quran for me in Denmark and in Turkey. Especially my extended family in Turkey. They have sent videos to me so I could gain more strength. And actually, it did increase my will power and I became calmer. So, they [his family] have certainly done something.

(Ahmad)

3.3. Thanking God

I give thanks to God for surviving, I really do. I am thankful to both God and the Intensive care unit that saved me. But there is always one [God] that is greater than the rest who has been behind this [my survival]. I am immensely thankful to be amid family today even though I lost both my parents one after the other (Sultana).

Sultana expressed thankfulness to God and the hospital ward in the same sentence for the fact that she overcame her disease. Even though she lost both her parents to the Coronavirus and never got to say farewell to them, she is thankful for the family around her today. In the above quote, Sultana expresses her thanks both to God and the medical staff who treated her while being grateful for surviving to see the rest of her family.

Habeeb, the Danish–Iraqi man said:

I have thanked God that I am back again [from being in a coma]. You know in our religion, we always say that it is the good that we have done [in this life] that helps us, and at the end of the day, it is Him [God] that takes life and gives life.

(Habeeb)

Habeeb thanked God for surviving his ordeal where his lungs collapsed due to the Coronavirus and he was put onto a ventilation machine. Habeeb also pondered over God’s omnipotence through his remarks concerning God taking and giving life.

Hussain, whose wife was admitted with him, reflected:

Obviously, a day will come when we say: farewell and thanks. It’s a just a question of when. But I say alhamdolillah [all praise is to Allah] for everything that I have. I say that (Hussain). Hussains expression of praising God may be said to have a link to gratitude. In Islamic theology shukr (gratitude), sabr (patience), and hamd (praise) are interwoven and are sometimes used interchangeably- especially gratitude and praise.

Ahmad said:

And my wife has meant at least as much as Allah. She has supported me immensely. She has been through a lot as well. She has taken leave from work so she could take care of our child. For five weeks she didn’t know if I would live or die (Ahmad). Ahmad ponders over the role and significance of his wife during his hospitalization and compares her support and care with Allah’s. He is relating to her suffering and expressing gratitude for her sacrifices.

Ahmad also contemplated on his mental breakdowns and its relationship to gratitude and ingratitude:

Occasionally, I have meltdowns where I say, ”Why me and why this difficult?“ I cannot say this of course. I must be content: after all I am still alive. I have both my arms and legs and I can talk. There are so many other people who are in a worse state than me.

(Ahmad)

When asked Ahmad why he felt he should not express what went through his mind when he was “losing it”, he responded:

I feel it is ingratitude if I complain. On the other hand, I must come out with it [verbal expressions], because it’s not easy to be bedridden for 23 h a day. It’s tough.

(Ahmad)

He thanked God every night before going to sleep and added:

I have become more aware of expressing gratitude for the many little things that one does not think over normally. Health for instance.

(Ahmad)

The last recipient of gratitude identified in this study is God. For patients expressing gratitude, it was an active and expressive action and virtue. But in some instances, when tribulations became unbearable, gratitude was a neighbor to ingratitude. Gratitude for patients was not an abstract thing but a concrete—almost ritualistic—practice that took place in the context of their hospitalization.

To sum up, Muslim patients expressed gratitude by using a variety of expressions and directions. Gratitude was channeled to three recipients—namely, staff, family, and God. Shukr was identified as a central theological concept that was in play for patients during hospitalization.

4. Discussion

The overall purpose of this study was to answer the following question: how do Muslim patients hospitalized with a severe disease, express gratitude, and how can it be interpreted?

Through a thematic analysis, the following three categories were identified through which gratitude is manifested: (a) staff, (b) family, and (c) God. In this section, the results are discussed, taking into account the different definitions of gratitude and previous research introduced earlier in this article.

As mentioned in the introduction, shukr is an overall state of “living gratitude” that is practiced under any given life circumstance and directed toward both humans and God. In our present context, “living gratitude” entails not mere verbal thanks toward staff/family/God but also taking stock, feeling contentment, and appreciating the gifts of life—during tribulations and times of good fortune alike. In another word, shukr is a state of being in the world, seeing the real Benefactor behind the gifts of life (Khalil 2016).

This chimes with Suleman’s empirical research that suggests that gratitude is expressed and embodied by Muslim patients as an active practice (Suleman 2022). Expressing shukr toward God is an Islamic injunction mentioned in the Quran in several places. Its opposites in the Quranic language are kufr (ingratitude) and shirk (polytheism) (Jones 2006). These two terms are used mainly in the Quran for non-believers, hence underscoring the importance of rebuking ingratitude.

Badr, the Danish–Albanian man was thankful to everybody at the hospital and encouraged the hospital to continue in this fashion. He seemed to establish a connection between his giving thanks and the caring attitude of the nurse which he draws attention to. Without benefaction, it is hard to envisage gratitude. What is he grateful for? Badr is feeling kindness from his benefactor and in return, he desires to respond. For Emmons, “to be grateful, is to be grateful to someone” (Roberts 2004, p. 63).

Ahmad reflected on his expressions of ingratitude during times of crisis. Ahmad was aware that ingratitude was not an option in his religious tradition and that he needed to be grateful to God. The issue was that he just could not feel grateful during those times of desperation. He felt that it was ingratitude if he complained, so his theoretical understanding of gratitude was being content with life and its tribulations. This coincides with the Belgian study (Baeke et al. 2012), which suggests that its empirical findings confirm the theological stance of Islam in which accepting God’s will and destiny is an essential part of faith. This present study too, aligns itself with the Belgian study. However, it nuances and adds to the theological perceptions in which the emotional struggles of patients are brought forward. For instance, Ahmad swayed between ingratitude and gratitude and tried to practice gratitude. He gained an insight or awareness, as he called it, in which he expressed gratitude for the “many little things”.

As Hussin et al. 2023 explain, there can be religious and cultural expectations for expressing gratitude such that one may feel that gratitude is the only right course of action even though one does not feel true to that state at a particular moment. From an Islamic theological perspective, ingratitude toward God’s blessings (kufr al nai’ma) consists of more than just careless behavior and indifference to one’s fate. It can be characterized as a more systemic and “embodied condition which involves the abuse and denial of divine favors” (Khalil 2016, p. 170). Hussin et al. state in their empirical study that patients who were “reserved” and ambiguous in expressing gratitude did not see themselves as being disobedient to God (Hussin et al. 2023).

To understand the concept of ingratitude, we need to understand gratitude more fully. One way of doing this is to study and distinguish between the different words that are used for gratitude to describe human experiences. To take one example, gratitude is not the same as appreciation (Navarro and Tudge 2020). It could be interpreted that Ahmad is not being ungrateful but simply does not appreciate the grave situation he is in at the particular time. Is it morally wrong if one does not appreciate seeing a beautiful sunrise or hearing the burbling of spring water in the mountains? Probably not, and therefore the many layers and dimensions of gratitude that are not easy to define or analyze call for a deeper exploration as the Malaysian empirical study also recommends (Hussin et al. 2023).

There is a need for more research on patient (in)gratitude and its implications for health and hospitalization for patients. The Malaysian empirical study referred to earlier challenges the assumption that gratitude is always positive and describes patient experiences with gratitude as mixed and complex (Hussin et al. 2023). The study underscores the need to consider the multidimensional gratitude dimension where culture, religion, and personal psychological conditions are at work in a complex web.

When Ahmad thanked his wife and God for their help, and Sultana thanked God and the ICU in the same sentence, they are, in a way, declaring the importance of the human and Godly at the same time. The two are not mutually exclusive but integrated (Khalil 2016). Hussain’s praise (alhamdolillah) in addition to his general thanks, signifies the connection between praise and gratitude, just as he also thanks both hospital staff and his wife for helping him overcome his ordeal. Patient gratitude is thus complex and ambivalent.

One way to understand this complexity is through the vision of the Andalusian sufi poet Ibn ʿAbbād on gratitude as a spiritual and existential virtue ethics (Khalil 2016). Ibn ʿAbbād who extols seeing God’s hand even in the darkest places—that is observing God in crisis situations—underlines the necessity of gratitude toward humans.

Islamic theology, in general, stresses the importance of thanking others, in line with the famous ḥadith, “Whoever does not thank people has not thanked God”. The role and acknowledgement of human intermediaries is thus an important dimension in gratitude which may explain the “channeling” of gratitude to staff and family by patients in this study. As part of a brief explanation of shukr al-lisān (thanking with one’s tongue), Ibn-e-Abaad also emphasizes the need to praise benefactors and offer them a prayer because of their role as intermediaries or wasāʾiṭ (Khalil 2016). In extension, this would mean that hospital staff, for example, are the hands behind the “Divine hand”. As Sultana says: …but there is always one (God) that is greater than the rest who has been behind my survival.

Also, in the empirical data, there is a stream of gratitude and praise expressed explicitly and solely toward staff and their compassionate and considerate care in which it may be argued that patients do not articulate—at least in any detail—the operation of a “Divine hand”. This gratitude can be explained as an emotion, a habitual characteristic, or a functional trait that can lubricate social relations (Emmons 2022).

For instance, when Badr, addressed the staff and hospital almost in a formal declaration style, he expressed his heartfelt emotions. When Badr exemplified his gratitude, it was in relation to the compassionate care of hospital medics. When Hamide described it, it was in relation to a “unique” nurse who “looks at you” with sensual attentiveness, and Zainab, the pregnant refugee from Syria, experienced unforeseen compassionate care through a body massage. Thus, patients described, recognized, and appreciated when hospital staff went beyond limits to accommodate their well-being in times of crisis and dire vulnerability.

There is reciprocity in this type of gratitude between patients and staff (gratitude in return for compassionate care) that helps the relationship to be fruitful and endure the test of time during the hospitalization period. It would be beneficial to study the patient–staff relationships concerning gratitude, especially how it affects employees’ work satisfaction and health for future research.

Humans are, in the words of Emmons, “called to gratitude” (Emmons 2017, p. 12). This means that people are inherently dependent on others and have an urge to thank their helpers. Patients have come to understand that their self-sufficiency has been eviscerated and they look upwards and outwards in a state of immense vulnerability for help and consolation.

Emmons argues that gratitude is born of humility (Emmons 2016). One might argue that it is born of vulnerability. One must work for humility as it does not come easily or naturally, says Emmons (Emmons 2016). Vulnerability, on the other hand, is an existential condition where human frailty is inherent (Angel and Vatne 2017; Sodemann 2018). Being vulnerable, living life, and becoming fatally sick at the same time is a struggle and calls for gratitude toward all those who can, in some way or another, embrace one’s vulnerability.

5. Limitations of This Study

The study population only included hospitalized Muslim patients with the Coronavirus from Denmark. One of the limitations of this study is the small sample size (n:12), which was due also to the Corona pandemic, meaning that restrictions were encountered in different phases of the study including recruitment. The fact that the interviewer (myself) had to wear protective gear during patient interviews created some difficulties in establishing the intimacy of the personal encounter and may have affected communication and building trust.

Also, due to the fear and uncertainty unleashed by the pandemic, patients might have had an extra urge to bond with staff and enhance social relations through gratitude. Qualitative studies do not aim to reveal definitive results, and the results therefore only reflect the group studied.

6. Conclusions

So, what happens lying on a hospital bed, in a serious medical condition, ruminating on one’s fate and trying to make sense of it all? At some point during hospitalization, patients feel a sense of urgency to express gratitude to the people around them: nurses, doctors, and staff, all working tirelessly to keep them alive. In addition to this, thanking God and feeling indebted to the family for their tireless support is also experienced. Hence, the state of shukr is activated which can be characterized as relational gratitude. Through the lens of shukr, we come to understand the importance of relationships during hospitalization—the horizontal and vertical. As the empirical data tell us, these relationships become personal and valued during crisis situations. But it is also the other way round: the salient features of these relationships rouse and invigorate shukr during times of tribulation. Relationships and their nature determine to whom and to what extent shukr is due. From a healthcare perspective, patient–staff relationships are fortified when gratitude is present, increasing patient satisfaction and well-being.

The implications of these results are threefold: Firstly, gratitude, as the significant virtue it seems to be, influences the hospitalization experience and vice versa. Secondly, the gratitude of Muslim patients, especially towards staff, may have a deeper societal impact concerning issues of cohesion and trust, that needs to be studied further. Thirdly, by using theological reflection and introducing the concept of shukr as one way of interpreting patient gratitude, a new and comprehensive understanding of gratitude may emerge rooted in the empirical reality of patients.