Chapter 16 1. Discuss themes of spirituality 2. Examine the FICA (Faith and Belief: Importance, Community, and Address in Care) tool for taking a spiritual history 3. Discuss strategies to nurture the spirit 4. Identify nursing interventions to meet the spiritual needs of the client and family 5. Describe behaviors that the nurse can use to adopt a hopeful perspective and offer hope 6. Review a spiritual assessment tool for use in a clinical setting 7. Discuss the role of the nurse in helping the client find meaning in illness 8. Participate in exercises to build skills in meeting spiritual needs in health Spirituality comes from a Latin word meaning “breath of life” (Brillhart, 2005, p. 31). The concept of spirituality is elusive because it is “heart” language not “head” language and is hard to put into words (Carson and Koenig, 2008). Donnelly and Cook (1989) reflect that “to be spiritual is to be connected—to the inner self, to others, or to a transcendent being or energy.” Spirituality in practice is “to demonstrate a unique capacity for love, joy, caring, compassion, and for finding meaning in life’s difficult experience.” Nurses’ spiritual interventions “reflect the human traits of caring, love, honesty, wisdom, and imagination . . . a belief in a higher power, higher existence, or a guiding spirit . . . something outside the self and beyond the individual nurse or patient” (Dossey, 1998b, p. 47). Spirituality includes “unconditional love, trust, forgiveness, hope, and imagination . . . a sense of awe and wonder regarding life” (Brillhart, 2005, p. 31). In a study measuring the attributes of caring relationships created by nurse practitioners, spiritual expression proved to be a significant factor (Thomas et al, 2004). The use of a spiritually based complementary group intervention with U.S. combat veterans experiencing symptoms of posttraumatic stress disorder (PTSD) from the wars in Iraq and Afghanistan showed promising results (Bormann et al, 2008). Spirituality is good science . . . Over 250 studies now show that religious practice—the specific religion doesn’t seem to matter—is correlated with greater health and increased longevity . . . some say that clinicians have no business taking on the role of spiritual guide . . . but we are not being asked to become spiritual counselors. We’re being asked to integrate a holistic approach and extend love, compassion, and empathy . . . the bedrock upon which nursing has always rested. (Dossey, 1998a, p. 37) Harold Koenig, MD, at Duke University’s Center for the Study of Religion/Spirituality and Health, reports on the results of over 70 data-based, peer-reviewed published papers. Findings show that people who attend religious services on a regular basis have better health outcomes, have stronger immune systems, have lower stress, and recover from hip fractures and open-heart surgeries more quickly than do less religious people. Elders with religious faith seem to be better protected from cardiovascular disease and cancer (Koenig, 1999). Spirituality has been shown to be an important variable in quality of life in persons living with human immunodeficiency virus infection (Tuck et al, 2001). In a study of persons with spinal cord injury, life satisfaction increased as spirituality increased (Brillhart, 2005). Exploring meaning in life and prayer has been associated with increased psychological well-being in breast cancer survivors (Meraviglia, 2006). Spirituality has been part of the vision of nursing since the time of Florence Nightingale (Calabria and Macrae, 1994). From his continued review of the literature and research, Koenig concludes: “Addressing spiritual issues in clinical practice can bring back life into our profession and, for many of our patients, can help them regain their lives by finding hope, meaning, and healing” (2007, p. 232). The goal of practicing spiritually sensitive care is to support clients in the search for meaning and solace without injecting our own opinions or values (Lackey, 2009). Erickson and colleagues (1983) believe that human beings are holistic with multiple interacting subsystems. “Permeating all subsystems are the inherent bases . . . which include the genetic and spiritual drive” (p. 44). Our “spiritual drive starts before our biophysical existence, continues through our lifetime, and culminates during transformation. It is always present, and pervades our subsystems even though we may not be consciously aware of it. It inspires us to search for our Life Purpose” (Erickson, 2006, p. 8). As nurses, every interaction we share with our clients allows us to nurture and facilitate the client’s spiritual essence and drive. Through this sharing of experiences, moments, and events the nurse and client journey together to gain a better understanding of and to work toward their Life Purpose or Reason for Being (Erickson, 2006, p. 8). In this chapter, we will explore the concept of spirituality, a notion that may be feared or ignored by healthcare professionals, perhaps because it reminds us of the fallibility of science in healing (Donnelly and Cook, 1989). It is this spiritual connection that is the essence of being present with clients in moments of tragedy where the seeds of personal triumph are planted. This discussion is not based on religious denomination but on the spiritual path to finding personal meaning and to helping the patient and family find meaning in illness and suffering (Travelbee, 1970). This chapter helps you recognize opportunities to introduce clients and families to the idea that we learn lessons from life’s difficulties and that we find meaning in life by sharing these life lessons as part of our legacy. Nagai-Jacobson and Burkhardt (1989) review general themes that emerge in the literature that broaden the concept of spirituality. They found that spirituality has the following characteristics: • It is a broader concept than religion. • It involves a personal quest for meaning and purpose in life. • It relates to the inner essence of a person. • It is a sense of harmonious interconnectedness with self, others, nature, and an Ultimate Other. Discussions of spirituality in nursing suggest that interactions between nurses and their clients involve the spirituality of both and that this relationship can transform them all in the search for a meaning in life. The nature of such client–nurse relationships is sacred. It is a walk on holy ground as two people meet at what Newman (1989) calls choice points presented by health crises. These choice points or events are “opportunities to experience more fully the reality of the patterns of our lives.” These are times when former ways of coping and relating to life no longer work. When a person is confronted with disability, new ways of existing, of behaving, and of finding meaning are necessary. A woman whose husband was experiencing the deterioration of Alzheimer’s disease, for example, found her own health affected by the strain of being a caregiver. Unable to drive or visit with friends, she befriended a wild, stray cat who was reluctant to make physical contact. Over time, the mother cat brought her kittens to the woman. Feeding these kittens and playing with them gave this woman’s life a purpose and some joy in the midst of the suffering she was sharing with her husband. “God sent me this cat,” she said. “We needed each other.” She slowed down and stayed focused in the present. A qualitative research study of opportunities for enhanced spirituality in well adults revealed six themes: connectedness, relationships with “self, others, nature, the universe, or a higher power”; beliefs, such as a belief in God or in good versus bad; inner motivating factors, guides for behavior and attitude; divine providence, belief in a higher power; understanding the Mystery, looking for meaning and purpose in life; and walking through, using our inner resources on life’s journey (Cavendish et al, 2000). The researchers concluded that nurses need to be more aware of the significance of life events in clients’ lives to make accurate nursing diagnoses and to intervene in meaningful ways. Support of clients’ coping strategies, inner resources, and beliefs, and an understanding of spirituality that allows nurses to foster even small changes in the spiritual aspect of their clients’ lives, can have a significant impact (Cavendish et al, 2000). A documented spiritual history is mandated by The Joint Commission (TJC) for clients who are admitted for care in an acute care hospital or nursing home and those seen through a home health agency (Koenig, 2007). Beginning this conversation opens a dialogue about spiritual issues and gives the client permission to talk about spirituality with you (Koenig, 2007). The acronym FICA stands for Faith and Belief: Importance, Community, and Address in Care, a tool developed by Christina M. Puchalski, MD, founder and director of the George Washington Institute for Spirituality and Health (Box 16-1). This brief tool is a good way to begin to incorporate spiritual assessment in your work. A more detailed assessment can be found later in this chapter (see Box 16-7). A single question concerning spiritual history can be, “Do you have any spiritual needs or concerns related to your health?” Sometimes the initiation of even this short history is met with the response that the client has no interest in religion or spirituality and does not use these for coping with illness. At this point, you can take a different tack and ask about other ways the client is coping—what gives meaning and purpose in the face of illness, what social supports are useful, and what cultural beliefs may influence the treatment of illness. This gets at the essence of the spiritual history (Koenig, 2007, pp. 44–45). Life is a journey. Peck (1998) suggests that we must appreciate the fact that life is complex. This means to “abandon the urge to simplify everything, to look for easy answers, and to begin to think multi-dimensionally, to stay in the mystery and paradoxes of life.” Those who would simplify nursing practice would teach students how to do “things”—treatments, techniques, procedures. How easy it would be if the quality of nursing care could be quantified by how accurately or quickly procedures could be performed. Consider that “the essence of nursing is not doing . . . but being open to whatever arises in the interaction with the client. It is being fully present with an unconditional acceptance of the client’s experience” (Newman, 1989). Perhaps we can think of life not as a series of problems to be solved but rather as a mystery to unravel. To be a nurse is to be given a sacred trust. Clients and families come to us fearfully in their darkest hours, in the face of their own mortality, or, at the time of childbirth, in the face of the wonder of creation. Burkhardt and Nagai-Jacobson (1994) speak of a “reawakening spirit in nursing practice.” To have the ability to stay connected to the experience of another, you must pay attention to nurturing your own spirit. Moore (1998) speaks of living artfully as a necessity for the care of the soul or spirit. To do so, he suggests the following: • Pause—the opposite of being busy—stop, reflect, savor the moment, experience wonder at the things around you, be still. • Take time for self, people, relationships, and things—living creatures, too! To take time for relationships, even difficult ones, deepens our understanding and appreciation. • Be mindful of, or pay attention to, what is happening all around you so that you recognize the need to stop and focus on this moment rather than thinking about the past or the future. But how can you slow down, considering the demands of nursing? Other chapters in this volume address methods such as relaxation techniques and meditation. Practicing these techniques helps you to be in touch with your own spirit and helps you to be centered. The process of centering helps you focus on this moment. Remember the value of rest, of time to do nothing, and of playful leisure time. Focusing on the moment can mean slowing down to really enjoy the taste and texture and smells of the food you eat, taking time to stroke the fur of a cat or dog, listening to the sound of birds singing, enjoying music rather than using it for background noise, stroking the hair of a child, listening to another person without offering an opinion, hugging a friend, and listening to laughter and joining in. In a series of community classes for cancer patients and their families, one man said that cancer had changed his focus from “working for a living to the art of living.” These simple suggestions are mindful activities. They are what clients tell us they do to stay connected to life in tough times. For them, these are the things that make life worthwhile. Nurses reported spiritual renewal practicing mindfulness and other spiritual self-care processes such as meditation, time in nature, yoga, and music in retreats as part of a study to support nurses’ spirituality (Bay et al, 2010). Perhaps such activities can replenish your energy to do your life’s work. Communication is more than verbal and nonverbal behavior. The ability to stay present in the moment requires conscious effort, which is sometimes a struggle. When you feel overwhelmed, take time to return to being still and paying attention to the gifts of the senses. When you are frightened, remember the lyrics, “when you are troubled and cannot sleep. Just count your blessings instead of sheep.” Emmons (2007) discusses results of gratitude research. Study participants who kept a weekly gratitude journal exercised with more regularity, had fewer physical complaints, felt better about their lives, and were more optimistic than the control group who kept journals about neutral events. Participants who kept a daily gratitude journal were more likely to offer emotional support to someone else. People who are grateful are more likely to believe in an interconnectedness of all life and demonstrate a commitment to others. Consider starting your own gratitude journal, writing a few words each day about the things for which you are grateful or just spend a few moments before you go to sleep to say thank you for the things for which you are grateful or for the people and things in your life that you appreciate. Reflect on this mnemonic for fear when you are afraid and in spiritual distress. FEAR is: Offering simple strategies that work for you may be useful for your clients. Spiritual care is not separate from all other aspects of nursing care. In Watson’s conceptual model of nursing, spirituality is central. “The human spirit is regarded as the most powerful force in human existence and the source behind striving for self-transcendence through spiritual evolutions and the achievement of inner harmony. Nurses practicing within this framework promote harmony of body, mind, and spirit, regardless of the external health problem, age, or life circumstance of the person” (Touchy, 2001). Caring in nursing requires intention, relationship, and actions (Touchy, 2001). Spiritual care is how you do what you do. It is an attitude, an openness, to the shared experience of the human condition. When you assist a patient with morning care, when you offer a bedpan or a urinal, when you take a temperature, when you bathe a person who has soiled himself—these ordinary tasks, when done mindfully, provide spiritual care. In a book on spiritual fulfillment in everyday life, Fields and colleagues (1984) talk about performing simple daily tasks as a way to get in touch with the natural cycles of life and death. When searching for meaning, a client may have a need to explore spiritual and psychological issues and to talk about religious feelings or the lack of them. The client is not asking for advice or opinions but a time to talk about feelings and to express doubts, fears, and anguish. Even clients with strong religious beliefs may need encouragement in crisis. You can support a client with religious beliefs by encouraging prayer or meditation (Narayanasamy, 2004). Consider the role of spirituality, religion, and culture in healthcare beliefs. Participants in a study of spiritual practices in the self-management of diabetes in African Americans used prayer, reading the Bible, listening to Christian radio and television programs, church attendance, and testimonies from people with diabetes (Casarez et al, 2010). Perhaps a selection of scripture, a morning prayer, or a testimony of success about the use of spiritual practices in making better food choices is a “nudge” to make better food choices or take a walk that day, ways to get us to think before we choose (Donnelly, 2010; Thaler and Sustein, 2008). Clients can be very vulnerable and not comfortable sharing sensitive information such as their belief system. It is important to respect the individual’s freedom of choice about a personal belief system and not to try to persuade or encourage a patient to adopt your personal point of view (Buswell et al, 2006). Spiritual needs may be greater during times of illness and a separation from routine comforting spiritual or religious practices can be a source of stress. The spiritual history and spiritual assessment may provide information that helps in mutual problem solving to find ways to meet these needs (Delgado, 2007). “Spiritual care begins with presence. . . . In essence, the presence of love we bring to any situation is the basic way we integrate spirituality into care” (Burkhardt and Nagai-Jacobson, 2002). Presence is “a conscious act of being fully present—body, mind, emotions, and spirit—to another person” (McKivergin and Daubenmire, 1994). It is about how we do the things we do, who we are, and how we are with one another. Each moment is new. Each moment is different. In the chapter on empathy, you read about the highest level of empathy, in which you recognize the other’s humanity and personhood regardless of the illness, its circumstance, or its stigma. You understand that we are all connected. Consider for a moment: can you view all of your work as sacred and feel that you are standing on holy ground day by day? (O’Brien, 1999). In the accompanying Moments of Connection, one nurse is fully present with a novice nurse and her client, sharing her own convictions. She responded “as whole being to whole being, using all of her . . . resources of body, mind, emotions, and spirit” (McKivergin and Daubenmire, 1994). This response was brief. Spiritual care does not take extra time. It is a part of all you do. In a national study of more than 2000 Americans, about 75% of those responding report they pray to prevent illness and 22% report they pray to alleviate a medical condition with a high degree of perceived helpfulness (McCaffrey, 2004). Prayer “is an intimate conversation between us and God”; it is “an expression of spirit that is a fundamental way of connection with our inner self and the Sacred Source” (Burkhardt and Nagai-Jacobson, 2002); it is “an expression of the spirit . . . a deep human instinct that flows from the core of one’s being where the longing for and awareness of one’s connectedness with the source of life are blended . . . [and] represents a longed for communion or communication with God or the Absolute” (Dossey and Keegan, 2008). Prayer as a nursing intervention—praying with a client, praying aloud in the presence of a client, offering time of silence for prayer, fostering a supportive environment for prayer, or praying in your own quiet time—is based on an assessment of the spiritual needs of a client. Praying at the end of a time with a client or praying prematurely may be seen as dismissive, a way to escape after the content of an interaction has been emotional, of cutting off conversation (Bayfront Medical Center, 2002). Consider the use of prayer in the middle of a visit, which allows time for the client to respond emotionally to the prayer if appropriate. See the thoughts on prayer listed in Box 16-2. Box 16-2 Thoughts on Prayer • Not everyone is receptive to or believes in prayer. • Clients may offer cues that they are open to prayer by verbal references or the presence of inspirational or religious reading material or religious objects. • Prayer may help the client with feelings of isolation. • It is appropriate to ask the client if he or she would like a prayer and for what. • Prayer can express what the clients would pray if they were able. • Prayer may be a brief, simple statement of the client’s hopes, fears, and needs and God’s ability to be with the client in difficult times. • Prayer for the greatest good for all involved is an inclusive prayer.
Spirituality
Definition of spirituality
Themes of spirituality
Fica—taking a spiritual history
The essence of the spiritual history
The nurse as a spiritual person and caregiver
Spiritual care begins with the nurse
Meeting the spiritual needs of the client
Being fully present
Offering prayer
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Spirituality
