Editorial

Challenges for spiritual care-giving in the millennium

Carrie Sanders
Project Manager, School of Nursing and Midwifery, University of Auckland, Auckland, New Zealand

PP: 107

Article Text

The role of spirituality in promoting health and improving patients' responses to illness has received increasing attention over the past two decades. During this time spirituality has been variously described as the "cornerstone of holistic nursing practice" (Nagai-Jacobson & Burkhardt 1989), and as "the integrating aspect of human wholeness which is…integral to quality care" (Clark et al 1991). There is little doubt today that it is perceived to be an essential element of the professional nursing role. The World Health Organisation (WHO) (1998) has proclaimed that the definition of health includes four domains of well-being: physical, mental, social and spiritual. The Joint Commission for Accreditation of Healthcare Organisations (JCAHO) now requires that procedures reflect the need to recognize and meet the spiritual needs of patients, including those from diverse cultural and religious backgrounds (JCAHO 1998). The North American Nursing Diagnosis Association recognizes "spiritual distress" as a nursing diagnosis (Carpenito 1999) and the Nursing Interventions Classification System designates "hope instillation", "spiritual growth facilitation" and "spiritual support" as nursing interventions (McCloskey & Bulechek 2000).

Despite the emergence of spirituality as an integral component of patient care, there is no consistent definition among nursing authors. Our understanding is limited by the fact that spirituality is usually discussed in the context of a holistic notion of the human person or from the perspective of Christian theological tradition. Concept clarification has enabled the identification of five main attributes of spirituality, which have been variously defined as:

1. Meaning-the ontological significance of life; making sense of life situations; deriving purpose in existence (Burbank, 1992; Narayanasamy, 1991; Orley 1994)
2. Value-beliefs and standards that are cherished; having to do with truth, beauty, worth of a thought, object or behaviour; often discussed as "ultimate values" (Stoll 1989; Uustal 1992)
3. Transcendence-experience and appreciation of a dimension beyond the self; expanding self-boundaries (Burkhardt, 1994; Reed, 1991)
4. Connecting-relationships with self, others, God/higher power, and the environment (Burkhardt, 1989; Harrison & Burnard 1993)
5. Becoming – an unfolding of life that demands reflection and experience; includes a sense of who one is and how one knows (Burkhardt 1994)

Narayansamy (1999) argues that spirituality should be seen from a broader perspective including its biological root because contemporary existentialism emphasizes that spirituality is a universal phenomenon. He suggests that each individual is capable of actualising this unique potential i.e. the spiritual component during times of emotional stress, physical distress or death. Twerski (1997) points out that the spiritual life of an individual includes the ability of the person to be responsible, to be trusting, to achieve deeper levels of intimacy, and to realize his or her potential for growth. What constitutes our spirit is our ability to contemplate the purpose of our existence, ways to better ourselves, to delay our gratification, and to think about the long-term consequences of our actions. It is the spirit that enhances the individual's capacity to make moral decisions. Twerski (1997) also feels that it is possible to be spiritual without being religious, since there appears to be no innate human imperative to practice religion. Alexander (1997), who has studied Buddhism in addition to working with people in recovery, quotes the Buddhist monk Thich Nhat Hanh in his description of mindfulness (spirituality) as "keeping our appointment with life."

A growing body of research evidence demonstrates that addressing the spiritual dimension of care makes a considerable difference in physical and psychosocial outcomes for patients and clients throughout the lifespan, reducing the incidence of postoperative complications and mortality rates (Byrd, 1988; Harris et al, 1999; Oxman, Freeman and Manheimer, 1995), enhancing coping mechanisms for dealing with the stress of surgery and illness (Landis 1996; Saudia et al, 1991) and coming to terms with terminal illness (Reed, 1987, 1992). In times of crisis, spirituality may help individuals to interpret the crisis in a growth-producing way and can instil hope and motivation toward change and coping. Coping strategies incorporate both religious and existential methods, which include hoping that things will get better, praying and trusting in God, attending church, seeking out sources of support by means of relationships with family and friends.

Despite the increasing recognition of the benefits of spiritual care, evidence suggests that the provision of spiritual care by nurses is nonexistent, inappropriate, or seldom provided (Boutell & Bozet, 1990; Narayanasamy, 1993). Specific barriers to spiritual care-giving are identified as:

1. nurses' knowledge and skills related to spiritual care are impoverished because of a poor role preparation in this area of care;
2. that many hold a belief that a patient's spirituality is a private and individual thing outside of the nursing role;
3. lack of time;
4. fear that the nurse will not be able to cope with or confront issues raised;
5. lack of self awareness of the nurse's own spirituality (Boutell & Bozet, 1990; Doyle, 1992; Harrison & Burnard, 1993; Narayanasamy, 1993; Ross 1995, 1996; Summer, 1998; Taylor & Amenta, 1994).

These perceived barriers have however, been debated in the literature for over a decade and ways to reduce their effects have not been widely studied systematically. A critical incident study of nurses' responses to the spiritual needs of their patients gives some indication that patients' religious background, shared religious background, and spiritually/religiously loaded conversation and diagnosis acted as strong prompters to spiritual care-giving (Narayanasamy & Owens 2001). It indicates that the approach to spiritual care was largely unsystematic and delivered haphazardly yet there was an overwhelming consensus that faith and trust in nurses produces a positive effect on patients and families. Narayanasamy (1999) has suggested a model for actioning spirituality and spiritual care education and training, called ASSET, which uses experiential learning and student centred learning to develop nurses' communication and counselling skills. Shih et al (2001) have undertaken an empirical validation of a teaching programme on spiritual care in Taiwan which indicates that nurses require four levels of help in:

1. clarifying theoretical concepts of spiritual care;
2. in providing a culturally bonded spiritual care plan;
3. in self-disclosure of the nurse's personal value system and spiritual needs; and
4. in clarifying the symbolic meaning and impact of religious rituals.

The issues however are broader than just those of education and training and may in part be attributable to the historical and socio-political development of nursing and health care systems. If one looks at the evolution of nursing since the 1970's one can see that role intensification and specialisation have drawn nursing further towards the scientific paradigm. Concepts of Clinical Governance, evidence-based practice, quality control, effectiveness and efficiency indicators focus our attention on specific measurable outcomes of care that are cost effective. The artistic side of nursing that was once considered to be the essential element of our caring role has assumed a lesser importance. I would also suggest that procedural approaches that help nurses to define, label, diagnose and prescribe spiritual care make a number of assumptions about our relationship with the patient/client. For example, not all of our patients and clients will wish to discuss their spirituality or indeed have spiritual needs during an illness episode. The problem with the checklist approach to spiritual care, is that it gives the nurse "power over" their patient/client who is potentially reduced to a shopping list of problems that need to be "fixed".

My own research and work in the field demonstrates that nurses need to be aware of and comfortable with their own spirituality before they are able to provide for the spiritual needs of their patients and clients. Groups of patients, nurses, health professionals and clergy that I have worked with in the UK, Europe and Australasia talk about the importance of feeling valued as human beings and report to feeling a sense of "connectedness" when they share common experiences, thoughts, feelings and values and beliefs. Connectedness with each other and with our patients/clients aids our healing and recovery. Indeed healing is an experiential, energy-requiring process in which space is created through a caring relationship in a process of expanding consciousness and results in a sense of wholeness, integration, balance and transformation (Myss 1996).

It is tempting to shape our spirituality to fit the organization we work for. While it is appropriate to change parts of our value systems after education and thought, we can't remain at peace in an organization that conflicts with our true self. A dispirited workplace can manifest itself in low morale, high turnover, burnout, frequent stress-related illness, and rising absenteeism. This is evidenced by the increasing problems associated with nurse recruitment and retention, with hospitals relying more heavily on a global workforce to fill their ever-growing vacancy lists. While empowerment has been a popular business practice, and has for the most part been successful in bringing more shared power into organizations, applying such spiritual principles as trust and cooperation to the workplace takes empowerment to another level. Spirituality goes beyond empowerment. It's not just giving people decision-making authority; it's allowing people to live their values at work.

LeTourneau (2000), a physician, writes about the grief health professionals are experiencing over the loss of the traditional culture of care giving. If we are to help nurses find their passion and the qualities that drew them to the profession then we need to:

• Create healing environments, foster adaptability and creativity, and give caregivers better involvement in their practice and connection to their patients.
• Become key players in helping the organization to serve the community and its members. Spirituality needs to be reflected in our mission and values and demonstrated by making decisions based on those values.

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