Sunday December 17th 2017

Higher education

Learning what it means to provide spiritual care

Providing spiritual care may seem as ethereal as the term implies. It doesn’t truly lend itself to a checklist and can even be difficult for some nurses to define. But addressing patients’ spiritual needs is a critical component of multidimensional nursing care, and there are plenty of opportunities to meet those needs within health care, say RN experts.

“Nurses interact with individuals and their families across the lifespan, and these individuals may experience significant challenges throughout their life, such as a tragic accident, loss of a pregnancy, a chronic, serious illness or other such events,” said Sally Welsh, MSN, RN, NEA-BC, chief executive officer of the Hospice and Palliative Nurses Association, an organizational affiliate of the American Nurses Association. So it’s important for nurses in all settings and roles to be able to have discussions about spiritual needs with patients and families.

But there are challenges and misconceptions.

After co-workers at the Cleveland Clinic expressed feeling ill-prepared to provide spiritual care to their patients, Christina Canfield, MSN, CCRN-E, ACNS-BC, Debi Taylor, RN, and their colleagues embarked on a study to gain greater insight from frontline nurses on this aspect of care. They specifically explored how critical care nurses define spirituality, their comfort in providing spiritual care and their perceived need for education on this dimension of care. Their research appears in the American Journal of Critical Care published by the American Association of Critical-Care Nurses, an organizational affiliate of ANA.

What they discovered, in part, was that the term “spirituality” was highly subjective, meaning nurses did not share a common definition. And while all nurses reported that people did not need to be religious to be spiritual, the majority referenced religion as a way to express spirituality.

Further, 75 percent of the 30 critical care nurses who participated in this qualitative study expressed having some level of comfort in providing spiritual care to critically ill patients typically around issues such as end of life and feelings of guilt or hope.

“Yet nurses are hesitant to initiate a conversation about a patient’s spiritual needs, and worry that they will come across as pushing their own religion on patients,” said Taylor, an AACN member. “And what surprised me was that nurses were providing spiritual care and not even realizing it.”

Understanding spirituality

Both undergraduate and graduate students learn about spiritual assessment and care in their nursing programs — generally as part of content about culturally competent care, Welsh noted.

“And new nurses have knowledge and some basic skills regarding patient assessment and therapeutic communication,” she said. “However, [comfort with] conversations that deal with such existential issues as spirituality and the meaning of one’s life are usually developed over time.”

Alyson Breisch, MSN, RN-BC, primary author of “Faith Community Nursing: Scope and Standards of Practice,” added, “Nurses come out of their educational [programs] knowing that spiritual care is part of whole-person care. But for a number of reasons, they don’t feel comfortable discussing it with patients. They worry about saying the wrong thing so they don’t do anything.

“Even if nurses have the intention, they may not know the best way to open a conversation [about spiritual needs] so they can develop a plan of care. And sometimes, they may not see it as a priority because of time constraints with physical care.”

The Joint Commission and other agencies require hospital personnel to conduct spiritual assessments of their patients.  But there is no standard on what that assessment should entail, so it can lead to cursory questions about religious designations and beliefs.

And some hospital administrations see spiritual care as something that solely falls under pastoral care and not part of nurses’ healing practice, said Canfield, an AACN member.

So once they completed their study interviews, the Cleveland Clinic nurses realized that having a working definition for spirituality for nurses was key, especially as a starting point for assessing and interacting with patients effectively on this component of care. They ultimately defined spirituality as the part of a person that gives meaning and purpose to one’s life. They further described it as a “belief in a higher power that may inspire hope, provide resolution and transcend physical and conscious constraints.”

In its updated 2010 position statement promoting spiritual care as an essential aspect of hospice and palliative care practice, HPNA also views spirituality as “the aspect of humanity that refers to the way individuals seek and express meaning and purpose.”

And again, while religious beliefs and rituals may be part of spirituality for some patients, it is much broader.

Putting it into practice

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Before nurses assess their patients’ spiritual needs, it’s critical that they examine their own views, perceptions and experiences, so they can ensure they are providing culturally congruent care, said Breisch, a North Carolina Nurses Association member. That said, when Breisch speaks to other nurses about spiritual care, they often ask whether it is appropriate to pray with a patient.

“Nurses are concerned about it, but it can be a great source of comfort for patients,” Breisch said. If nurses don’t feel comfortable praying, they can listen or ensure that the patient has uninterrupted time with a hospital chaplain or their own spiritual leader.

Then there are the interactions nurses frequently have with patients that they may not think of as spiritual.

“Listening is a spiritual intervention,” Breisch said. “That can be hard to do with all the interruptions nurses experience, and nurses tend to be problem-fixers who want to ‘do’ rather than ‘be.’ But that intentional, undivided presence can make such a difference.”

Canfield noted that, in their study, nurses provided spiritual care often without recognizing it by “offering themselves as a comforting presence – through touch, through time and by listening.”

Patients can be carrying a burden – feelings of guilt, resentment or loss – that can complicate their healing, Taylor added. So simply asking patients if there is something that they want to share also is a spiritual intervention.

Other ways RNs can address spirituality are by asking patients to share what gives their life meaning, what helps them to keep going, and how nurses can support their spirituality and religion during the treatment process, Welsh said.

Another significant role for nurses is that of facilitator. They can provide patients with the tools, privacy and quiet to do their own meditation, listen to the music they prefer, engage in other expressive arts, such as poetry, and pursue reflective writing, according to Breisch. If patients find spirituality in nature, RNs can find ways to assist them in making that connection, from repositioning the bed so their patients can see outside or taking them outdoors so they can feel a breeze or the warmth of the sun on their face.

“Providing spiritual care is about seeing the patient as a person,” she said. “And instead of looking at patients by diagnoses and problems, identify and embrace their strengths, which can help them cope.

“Intuition and empathy are also a big part of spiritual care.”

Personal growth

Nurses can improve their comfort with providing spiritual care by engaging in professional development activities, as well as exploring tools and other available resources. They can also work to develop a language around spirituality and practice conversations with their colleagues about this part of care, nurse experts said.

“Sometimes when you hear others talk, you can learn what is effective and what you might be missing [when assessing and offering spiritual care],” Breisch said.

When Canfield and Taylor began interviewing nurses on this topic, they were amazed by how much nurses shared with them.

“It seemed as if nurses felt they needed permission to discuss spirituality, and our interviews gave them the opportunity they needed,” Canfield said.

Taylor noted that turnover in ICUs tends to be high, often because patient morbidity and mortality rates are high. So addressing nurses’ own spiritual needs, such as during a debriefing after a critical event, is also important and may aid with nurse retention.

“This research has changed my practice,” she said. “When I’m with a patient, I always look them in the eye, put a hand on their arm, and start to build that rapport [needed to meet their spiritual needs].”

— Susan Trossman is a writer-editor for ANA.

Resources

“Critical Care Nurses’ Perceived Need for Guidance in Addressing Spirituality in Critically Ill Patients”: May issue of the American
Journal of Critical Care at http://ajcc.aacnjournals.org/content/25/3/206.full

Link to journal home page: http://ajcc.aacnjournals.org/

HPNA Position Statement: Spiritual Care:  http://hpna.advancingexpertcare.org/wp-content/uploads/2015/08/Spiritual-Care.pdf

HPNA Palliative Nursing Manual, “Spiritual, Religious and Cultural Aspects of Care,” edited by Betty Ferrell, National Consensus Project for Quality Palliative Care. Domain 5: Spiritual, Religious and Existential Aspects of Care. National Consensus Project for Quality Palliative Care: Clinical Practice Guidelines for Quality Palliative Care, Second Edition: www.nationalconsensusproject.org

Faith Community Nursing: Scope and Standards of Practice 2nd Edition (currently being revised): www.nursesbooks.org/Main-Menu/Standards/A–G/Faith-Community-Nursing.aspx

George Washington University Spirituality and Health Online Education and Resource Center: https://smhs.gwu.edu/gwish/soerce

National Comprehensive Cancer Network – Distress Management: www.nccn.org/patients/resources/life_with_cancer/spirituality.aspx

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