Chapter 12. The Spiritual Dimension in Nursing Care
■ describes what is meant by spirituality and spiritual wellbeing;
■ illustrates how matters of the spirit and spiritual wellbeing have been presented in nursing literature;
■ highlights the spiritual needs of persons with dementia and the contribution that nursing care can make to their spiritual wellbeing; and
■ draws attention to the importance of preparation for effective involvement in the spiritual dimension of nursing care.
Within nursing, there is a growing interest in the role of the spiritual dimension as an important component of healing. The spiritual, together with the physical, the emotional, the social, and the psychological are integral to being human. Matters of the spirit are often of major importance when illness and other undesirable life transitions occur. At such times, added importance surrounds questions concerning one’s identity, the meaning of life, one’s relatedness to others, and the purposes suffering can serve. The search for peace of mind and the importance of hope (which are part of the human experience throughout life) now have added relevance.
This chapter provides an introduction to spirituality, especially as it relates to people who are ill, from a nursing perspective. The importance of seeking to define the meanings given to spirituality and the distinction that needs to be made between spirituality and religiosity preface a brief exploration of the spiritual dimension for persons with dementia. The extent to which nurses have a shared responsibility in addressing the spiritual concerns of dementia patients and how this might be approached are also considered. Using the example of dementia is relevant given the large numbers of Australians living with the illness, or caring for someone who does.
In nursing practice, interest in the spiritual continues to grow. The hospice movement has been a major contributor to this development (Barnum 1996, Chandler 1999), as has been a deepening commitment to holistic nursing. Both these influences have encouraged an exploration of the spiritual dimension as it relates to those who are ill and/or dying, and those who love them. Two other major contributors to the growing interest in the spiritual domain have been the New Age movement, with its links to Eastern spiritualities (Confoy 2002, Heelas 1996, Tacey 1997), and those areas of alternative medicines that include meditation and prayer (Brown-Saltzman 1997, Dossey 1993). All these contributors have led to an increased recognition amongst nurses of the importance of spiritual care as an important component of person-centred care (Carson 1989, Hutchison 1997, Sims 1987).
The current emphasis on the spiritual is not a religion-inspired phenomenon. In reality, the widespread acknowledgment that the spiritual is an area of life that has needs and potentials for health and wellbeing has come at a time when the Christian religion is in numerical decline in much of the Western world and its influence on the thought patterns of our day is greatly diminished. Confoy (2002) argued that there is widespread dissatisfaction with organised religions in answering spiritual concerns in today’s world. Clearly, then, we need to look beyond today’s religious institutions to understand the growing interest in the spiritual as an integral part of personcentred nursing care. Perhaps the scientific approach to health, life, death and what lies beyond, which has long maintained dominance in health care, is now becoming more open to the possibility that the spiritual may offer a supplementary contributor to human wellbeing.
The person and spiritual wellbeing
Human beings, who are body–mind–spirit entities, have five dimensions with needs specific to each dimension:
1. the physical—with needs, for example, for food and fluids;
2. the social—with needs, for example, to relate, to love and be loved, to experience mutuality and friendship;
3. the emotional—with needs, for example, to experience and express feelings;
4. the psychological—with needs, for example, of security, comfort, safety; and
5. the spiritual—with needs to find a sense of purpose and meaning, hope, and peace of mind.
Spirit can be viewed as the central core of a person’s being. When the spirit is healthy and whole, the flow of energy, or spiritual wellbeing, is integrated into the whole person so that the other dimensions of the person, the physical, social, emotional and psychological, are all enriched. Shamy (1997) claimed that the spiritual embraces the essence of what it means to be human, integrating and holding together the physical, psychological and social dimensions of life. Emotions, too, are profoundly influenced by the condition of a person’s spirit. Anecdotal evidence has highlighted that it is not uncommon for those who have achieved inner peace and hope in a relationship of trust with others, to have an awareness of wholeness and healing even when there is no cure for physical aliments or when serious disabilities cause ongoing major difficulties to their lives.
Spiritual wellbeing, then, can be an integrating power for the person who is aware of his/her individual identity, not in isolation from but in relationship with others. This person is able to affirm life in its fullness within him/herself, in relationships with others, and in harmony with the environment and whoever or whatever is that person’s highest good.
What is meant by spirituality?
The spiritual is an integral part of being a person. In its broadest sense, spirituality is the manifestation of the human spirit, just as physiology is one manifestation of the body (Laukhuf & Werner 1998). The inner spirit of a person has needs, just as the person’s body and mind does. There are diseases of the spirit, just as there are of the body. The spiritual is that dimension of a person that prompts questions like these:
• Does my life have meaning?
• Is there some power or being beyond what I can see?
• What are the perceptions that I have about life that influence my values?
From a nursing perspective, it is also important to consider why peace of mind, hope, and a sense of belonging appear to be important to human wellbeing and how these states of being can be obtained and retained. In my practice, I have noted that when a person feels ‘together’ and at peace within, then major transitions and undesirable experiences are not only survived, but can even become growth experiences. In a slightly different vein, it is interesting to consider what it is about some people that cause others in their presence to experience remarkable tranquility and a rekindling of hope.
Reed (1992) described spirituality as a person’s capacity for self-transcendence, which allows that person to experience connectedness inter-personally, intra-personally, and trans-personally. It is also a personal, individual value system about the way people approach and view their life, in relationship with others and in the face of life’s upheavals, changes, setbacks and opportunities. It is constantly evolving, developing, and perhaps contracting. At different stages in life, the focus may shift from one area of the spiritual domain to another. Thus, in the early years of life, the focus may tend to be on the search to establish one’s own identity; in later years, more attention may be directed to such questions as ‘Have I achieved my life goals? What are my hopes for the years that remain?’
While some writers are hesitant about attempting a definition of the spiritual, since it is an individual matter and has a mystical element to it, there have been numerous attempts at seeking to define the meaning of spirituality especially as it relates to nursing and other health care workers. Definitions of spirituality include the following: seeks meaning (May 1982); connectedness to self, others and a higher being (Burkhardt & Nagai-Jacobson 2002); focus to our living and loving (Confoy 2002); and is present in all individuals as a relationship with a transcendent God or supreme reality and is manifested as inner peace and strength (Narayanasamy 1999).
Human spirituality and wellbeing
Who one is, one’s ‘self’, refers to our perceptions of who we are, which we are able to assess through relationships with others, the environment, and with ‘the other’ (however understood). In relationships, for example, we are often confronted with the best and worst in ourselves, sometimes in the form of direct feedback from those we relate to. Growing out of this process is the formation and shaping of a personal sense of identity. Being sure of one’s identity is of particular importance at various stages in life’s journey; for example, when separating from parents, when engaging in deep reciprocal relationships, when facing major transitions, when experiencing dramatic losses or when confronted by life-threatening illnesses.
For each individual there is a need to have some purpose to live in order to perceive a satisfying and fulfilling life. The acquired meanings and purpose that we give to our lives may be challenged when we encounter tragedy, losses and changes beyond our control in our lives. It is during these times that we may examine what is beyond the self, others and the environment, beyond all that we have known and seek some higher power to be able to vision its meaning in a new light. We may well seek to understand the nature of this other, this power, force, mind, spirit, or god and how to transcend our worldly reality.
The spirit seeks to integrate values and to espouse special qualities. It is aware of the importance to the self of hope and of being at peace within one’s self and with others. It recognises a responsibility of care for the environment and the importance of helping others to experience justice, and the opportunity to experience holistic wellbeing. The spirit also seeks to nurture and sustain both self and others by engaging fully in life, through creative activities, and through the embracing of beauty, truth, and the majesty of the universe. The spirit treasures moments of transcendence and mystery.
Religion and spirituality
As noted earlier in this chapter, spirituality is not synonymous with religion or belief in a god, but is something much broader. Laukhuf & Werner (1998, p 61) explain this distinction:
Religion is the service and adoration of God or a god expressed in forms of worship. Religion refers to the external formalised system of beliefs whereas spirituality is concerned with a personal interpretation of life and the inner resource of people.
Spirituality is a dimension of and has importance in the lives of persons of all cultures, of all faiths, and of no faiths. Religion as distinct from spirituality is more about systems of practice and beliefs, rituals and community engagement. Religion can provide a platform for the expression of one’s spirituality, but religious beliefs and practices can also discourage a development of the spiritual dimension (Dyson, Cobb & Forman 1997). This can occur when religious beliefs become blinding dogma, and rituals are blindly followed without a continuing focus on the key spiritual messages underpinning such beliefs and practices.
In formal religious practices, such as prayer, meditation, worship, compassionate and charitable behaviours, many do, however, discover that these expressions of their religiosity are vital ways for the ongoing development of their spirit life. Likewise, it is through religious beliefs about a god and the person’s relationship to this ‘other’ and to the special persons in their world that many religious practitioners discover wholeness, health, and a rich life.