From the earliest associations of nursing with religious orders to the emerging field of parish nursing, nurses, especially oncology nurses, have recognized the importance of spirituality in health and healing. Assessment of spirituality beyond knowing the patient’s denominational affiliation is now considered an expected aspect of care in health care facilities accredited by The Joint Commission (TJC) (LaPierre, 2003, Staten, 2003).
Spirituality refers to the experiences and expressions of one’s spirit in a unique and dynamic process that reflects faith in God or a supreme being; connectedness with oneself, others, nature, or God; and integration of the dimensions of mind, body, and spirit (Meraviglia, 1999& 2004). The definitions and classifications established by the North American Nursing Diagnosis Association (NANDA) include three diagnoses related to spirituality: spiritual distress was introduced in 1978; readiness for enhanced spiritual well-being was accepted in 1994; and risk for spiritual distress was included in 1998.
An adult diagnosed with a terminal or life-threatening illness, such as cancer, is at risk for spiritual distress. NANDA defines spiritual distress as “the impaired ability to experience and integrate meaning and purpose in life through… connectedness with self, others, art, music, literature, nature, or a power greater than oneself” (NANDA, 2005). Spiritual distress is also referred to in the literature as spiritual pain, spiritual suffering, and spiritual disequilibrium. A recent analysis of the concept identifies negative consequences of spiritual distress as a false sense of hope, increased somatic complaints and symptom distress, harm to oneself, and suicide (Ackley & Ladwig, 2006; Villagomeza, 2005).
People with cancer who express feelings of impaired meaning and purpose in life, peace, or faith are experiencing spiritual distress. Additional characteristics of spiritual distress include feelings of anger, guilt, and ineffective coping with life events, such as the diagnosis and treatment of cancer (Head & Faul, 2005; NANDA, 2005; Villagomeza, 2005). O’Brien (2003) described other characteristics of spiritual distress as a deep sense of hurt from being separated from God or power greater than oneself, a sense of personal inadequacy before God and humanity; and a pervasive condition of loneliness of the spirit. The presence of these feelings in a person with cancer indicates spiritual distress and warrants a thorough assessment for evidence of negative consequences such as loneliness, social isolation, hopelessness, anxiety, and depression.
Three additional NANDA diagnoses have been added for religiosity, an important component of the care of a person with spiritual distress (NANDA, 2005). NANDA (2005) defines religiosity as “the reliance on beliefs and/or participation in the rituals of a particular faith tradition.” The three nursing diagnoses are readiness for enhanced religiosity, risk for impaired religiosity, and impaired religiosity. The oncology nurse needs to differentiate between spiritual distress and impaired religiosity to determine the best plan of care.
RISK PROFILE
Clinical and research findings have identified the following risk factors for the development of spiritual distress in people with cancer (Head & Faul, 2005; NANDA, 2005; Villagomeza, 2005):
• Diagnosis and/or treatment of advanced or recurring cancer.
• Alterations in the usual social support network.
• Conditions that interfere with the person’s ability to participate in spiritual or religious practices (e.g., institutionalization, physical impairment).
• Events that lead to the questioning of one’s faith.
• Verbalization of interpersonal or emotional suffering.
• Development of cognitive impairment (e.g., confusion, dementia).
• Depression
PROFESSIONAL ASSESSMENT CRITERIA (PAC)
The following assessment criteria indicate spiritual distress and warrant a thorough spiritual assessment (Villagomeza, 2005; McClain-Jacobson et al., 2004; Murray et al., 2004):
• Inability to participate in spiritual or religious practices.
• Expression of frustration, fear, hurt, or doubt.
• Feelings of loneliness and isolation.
• Expression of lack of hope or of feeling that life is not worthwhile.
• Feelings of losing control.
• Verbalization of questions about faith or loss of faith.
• Expression of emotional suffering, such as lack of meaning, guilt, or anger.
• Evidence of anxiety and/or depression.
• Desire for hastened death.
• Suicide ideation.
A guide for assessing spiritual distress is the Brief Assessment of Spiritual Resources and Concerns (Gaskamp et al., 2004). This brief guide is an open-ended interview that helps the nurse determine whether the person is unable to practice spiritual rituals, desires spiritual rituals or support, is questioning his or her faith or experiencing a loss of faith, or expressing suffering, loss of hope, lack of meaning, or the need to find meaning in the midst of suffering (Box 44-1). The questions that make up the assessment open a conversation about spirituality between the nurse and patient and provide for further exploration of spiritual concerns and resources. If the person is cognitively impaired, information may be obtained from a family member or caregiver on the importance of spirituality and rituals, membership in a faith community, and beliefs that might affect health care decisions. Additional spirituality assessment tools are described in Box 44-2.
BOX 44-1
BRIEF ASSESSMENT OF SPIRITUAL RESOURCES AND CONCERNS
Instructions: Use the following questions as an interview guide with the person with cancer (or the caregiver if the person is unable to communicate).
• Does your religion/spirituality provide comfort or serve as a source of stress? (Ask the person to explain in what ways spirituality is a comfort or stressor.)
• Do you have any religious or spiritual beliefs that might conflict with health care or affect health care decisions? (Ask the person to identify any conflicts.)
• Do you belong to a supportive church, congregation, or faith community? (Ask the person how the faith community is supportive.)
• Do you have any practices or rituals that help you express your spiritual or religious beliefs? (Ask the person to identify or describe these practices.)
• Do you have any spiritual needs you would like someone to address? (Ask the person what those needs are and if referral to a spiritual professional is desired.)
• How can we (health care providers) help you with your spiritual needs or concerns?
Modified from Meyer, C. (2003). How effectively are nurse educators preparing students to provide spiritual care? Nurse Educator, 28(4):185-190; and Koenig, H. G. (2002). Spirituality in patient care: Why, how, when, what? Philadelphia: Templeton Foundation Press.
BOX 44-2
SPIRITUAL ASSESSMENT TOOLS
Four Basic Content Areas for a Spiritual History (Koenig, 2002)
• Religion or spirituality as a way to cope with illness, or a source of stress.
• Member of supportive spiritual community.
• Spiritual concerns or questions.
• Spiritual beliefs that might influence health care.
Five Categories for Assessing Spiritual Needs (LaPierre, 2003)
• Capacity to love and be loved.
• Search for meaning, purpose, truth, and balance.
• Performing spiritual practices or rituals.
• Experience of transcendence, awe, or fear.
• Evil as the experience of the opposite of how spirituality is usually defined.
• Religion/spirituality as comfort or cause of stress.
• Beliefs that might conflict with medical care or affect medical decisions.
• Membership in a supportive community.
• Spiritual needs someone should address.
• Practices that help express spiritual beliefs.
Spiritual Assessments Required in All Settings (Staten, 2003)
• What provides the patient with strength and hope.
• The patient’s use of prayer.
• How the patient expresses spirituality.
• The patient’s philosophy of life.
• Spiritual or religious support desired.
• Name of a spiritual professional.
• Meaning of suffering.
• Meaning of dying.
• Spiritual goals.
• Role of place of worship in the patient’s life.
• How faith helps in coping with illness.
• What keeps the patient going day to day.
• What helps the patient get through the health care experience.
• How illness has affected the patient’s and family’s life.
Spiritual Assessment Approaches (Post et al., 2000) *
*The author notes that none of these approaches has undergone rigorous psychometric testing.
• HOPE: Sources of hope; role of organized religion; personal spirituality and practices; effects on care and decision making.
• FICA: Faith and beliefs; importance of spirituality in one’s life; spiritual community support; how the person wants spirituality addressed.
• SPIRIT: Spiritual belief system; personal spirituality; integration with spiritual community; ritualized practices and restrictions; implications for care; terminal events planning.
• Single question history: “What role does spirituality or religion play in your life?”
Dimensions of Assessment (Taylor, 2002)
• Experience of God or Transcendence.
• Spirit-enhancing practices or rituals.
• Involvement in a spiritual community.
• Sense of meaning.
• Connectedness to self and others, giving and receiving love.
• Sources of hope and strength.
• Links between spirituality and health.
Topics for a Spiritual Assessment Interview (Wilkinson, 2001)
• Religious practices: What practices are important and how illness has interfered with religious practices.
• Faith: Whether faith is important and helpful; what the health care provider can do to help older adults carry out their faith.
• Referral to spiritual professional desired.
• Concept of “God” or power greater than oneself.
• Purpose and meaning in life.
• Sources of hope and strength.
• Religious practices and rituals.
• Perception of connection between health and spiritual beliefs.
• Fear of loneliness, solitude, or alienation.
From Koenig, H. G. (2002). Spirituality in patient care: Why, how, when, and what. Philadelphia: Templeton Press; LaPierre, L. L. (2003). JCAHO safeguards spiritual care. Holistic Nursing Practice, 17(4):219; Meyer, C. L. (2003). How effectively are nurse educators preparing students to provide spiritual care? Nurse Educator, 28(4):185-190; Post, S. G. (2000). Physicians and patient spirituality: Professional boundaries, competency, and ethics. Annals of Internal Medicine, 132, 578-583. Staten, P. (2003). Spiritual assessment required in all settings. Hospital Peer Review, 28(4):55-57. Retrieved November 20, 2005, from www.galenet.galegroup.com; Taylor, E. J. (2002). Spiritual care: Nursing theory, research, and practice. Upper Saddle River, NJ: Prentice Hall; and Wilkinson, J. M. (2001). Nursing process and critical thinking. (3rd ed.). Upper Saddle River, NJ: Prentice Hall.
NURSING CARE AND TREATMENT
Providing spiritual care involves the interpersonal dimension and requires strong communication skills. Nurses need to be aware of their own spiritual histories and beliefs, because their spirituality always affects the care given to patients. Specific guidelines for ethical spiritual care include respecting the patient’s spiritual needs and practices while maintaining the nurse’s integrity. Expertise in spiritual care comes through self-awareness, education, practice, and sensitivity to others’ spiritual needs.
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