There has been heightened interest in spirituality in the past few decades. Many in society are disillusioned with the cultural pressure to be over-busy, succeed by being the best and seek pleasure in materialism (Brown 2012). Such lifestyles may lead to gross inequality, and more people are questioning whether such a highly competitive and individualistic way of living is good for them (Wilkinson and Pickett 2009). These lifestyles may also lead to burnout, relationship breakdowns and a deep sense of the meaninglessness of life. Rohr (2003) suggests that the individualistic nature of society adversely affects the ability of people to ﬁnd a sense of peace or purpose.
Spirituality is a way of ﬁnding hope, meaning and purpose in a frenetic world. It is especially important when individuals feel vulnerable, for example when facing illness and crisis, whether as a patient or a nurse.
Good practice indicates that spirituality should be integrated into nursing care (Nursing and Midwifery Council (NMC) 2009, International Council of Nurses (ICN) 2012). McSherry (2011) states that not engaging with spirituality in nursing care ‘may be detrimental to the provision of high quality nursing care’. The NMC (2010) asks that nurses offer holistic approaches to care, which take into account spiritual needs to ensure a comprehensive care plan is developed. Holistic care encompasses the fundamentals of spirituality by establishing a compassionate relationship with patients. NHS Education for Scotland (2009) suggests that spiritual care should ‘move in whatever direction is needed’. However, for many nurses there is confusion between spirituality and religion, ambivalence and anxiety about spirituality, and difﬁculty in knowing how to integrate spirituality into nursing care. Exploring spirituality with patients may help them ﬁnd hope and meaning during times of illness and crisis. Nurses themselves might also ﬁnd that spirituality helps them to ﬁnd meaning and purpose in their work.
Deﬁning spirituality can be difﬁcult and at times it may seem like a nebulous concept (Coyle 2002, D’ Souza 2007, Gilbert 2006). Contemporary discussion papers and empirical studies in the nursing literature offer contradictory deﬁnitions of spirituality and use a plethora of terms such as spiritual care, spiritual dimensions, spiritual behaviour, spiritual needs and spiritual assessment, which may not be deﬁned adequately (Maddox 2001, Stranahan 2001, Hubbell et al 2006, Helming 2009). Many deﬁnitions of spirituality include the concept of providing meaning, hope and purpose to an individual (Narayanasamy 2002, 2004, Cook 2004), while other deﬁnitions conﬂate spirituality with religion (Koenig et al 2001, 2004, Stranahan 2001, Monroe et al 2003, Hubbell et al 2006).
Clarke (2009) comments that diluting the concept of spirituality can make it vague and over-inclusive. In contrast, Swinton and Pattinson (2010) suggest that vagueness in deﬁning spirituality can provide strength and value. However, there is a concern that an over-inclusive deﬁnition might become cumbersome and difﬁcult to put into practice. If nurses fail to embrace the concept of spirituality in their practice, they may also fail to develop the deep interpersonal and compassionate connection with patients that is central to nursing care (Clarke 2013). Milligan (2011) reminds us that spirituality is unique to each individual and that nurses should listen to patients to determine what is important to them.
A simple deﬁnition from the nursing literature suggests that ‘spirituality is deﬁned as the essence of being and it gives meaning and purpose to our existence’ (Narayanasamy 2004). An expanded deﬁnition states that ‘spirituality is a distinctive, potentially creative and universal dimension of human experience arising both within the inner subjective experience of individuals and within communities, social groups and traditions. It may be experienced as a relationship with that which is intimately “inner”, immanent and personal within the self and others, and/or as a relationship with that which is wholly “other”, transcendent and beyond the self. It is experienced as being of fundamental or ultimate importance and is thus concerned with meaning and purpose in life, truth and values’ (Cook 2004).
Since spirituality is unique to the individual (Milligan 2011), keeping deﬁnitions ﬂexible and vague may enable it to be understood better in practice (Swinton and Pattison 2010). Considering and responding to whatever gives patients hope, meaning and purpose in life will ensure spiritual needs are addressed in practice.
Religion and spirituality
Religion and spirituality are distinct, though for some individuals they overlap. The Oxford Dictionaries (2015) give the primary deﬁnition of religion as ‘belief in… a superhuman controlling power, especially a personal god or gods’. Wattis and Curran (2006), writing in a healthcare context, suggested that religion is connected with the beliefs and rituals found in many faiths and is often associated with power structures. These authors also include in their deﬁnition of religion the means people use to relate to God, for example prayer. There may be some overlap between spirituality and religion; some people will view their faith as the core of their spirituality. However, many would assert that you can be spiritual without being religious, or religious without being spiritual (Cook et al 2010).
A good starting point for being sensitive to the spiritual needs of patients is to be aware of our own approach to spirituality. 2
Spirituality in nursing care
There may be differences in conceptualising spirituality, but professional standards expect nurses to pay attention to the spiritual needs of patients (NMC 2009, 2010, ICN 2012).
McSherry and Jamieson (2011) undertook a UK survey of nurses’ perceptions of spirituality and spiritual care in 2010, with 4,054 respondents. The authors found that nurses struggled to conceptualise spirituality even though they recognised it as being important to their patients. Almost 93% of the nurses’ surveyed believed spiritual care should be addressed, but only 5. 3% (213) felt able to meet the spiritual needs of patients all the time. Many more (3,688) believed they could sometimes address spiritual needs. However, it was not clear how they would do this, and lack of training in this area was evident.
A survey of university teachers in healthcare professions found that, while around 90% (26/29) of respondents agreed or agreed strongly that spiritual values were relevant to their subject area, and more than half (17/29) thought them integral to teaching and learning, only 17% (5/29) agreed it was integrated into their curricula (Prentis et al 2014). Being clear about what spirituality means can make it easier to address this subject with patients. Including spirituality in the nursing curriculum ensures nurses have the opportunity to explore what it is and how to address it in practice.
Spirituality’s connection with hope, meaning and purpose in life, beliefs and values is important in nursing practice. It helps to meet the need to promote a person-centred approach: ‘The key to providing spiritual care is to understand what spirituality means to the person you are caring for’ (Gordon et al 2011). A person-centred approach is the most effective approach in a multicultural, multifaith society where some people think ‘science has disproved God’ and ﬁnd their meaning and purpose outside religion, while others continue to do so through religious faith.
In a personal communication dated September 25 2014, Janice Jones, senior lecturer at the University of Huddersﬁeld’s School of Human and Health Sciences, concluded that it was easier to describe spiritually competent practice in occupational therapy than to deﬁne spirituality. We have paraphrased her description with permission so that it can be applied to spiritually competent practice in nursing and other healthcare professions: spiritually competent practice engages a person as a unique spiritual being, in ways which will provide them with a sense of meaning and purpose, connecting or reconnecting with a community where they experience a sense of wellbeing, addressing suffering and developing coping strategies to improve their quality of life. This includes the practitioner accepting a person’s beliefs and values, whether they are religious in foundation or not, and practising with cultural competency.
Illness, especially if life-threatening or disabling, may challenge the understanding that patients have developed about the meaning and purpose of their lives (Puchalski 2001). Serious illnesses often involve losses, including loss of income, abilities and role. They may even result in a feeling of loss of meaning and purpose and the need to adjust life goals. One function of the spiritually competent nurse is to recognise these challenges and support patients in responding to them. Many studies have shown that spirituality is fundamental for patients in helping them regain hope, meaning and purpose in the midst of illness (Ellis et al 1999, Koenig et al 2001, Ellis and Campbell 2004, Koenig 2004, Burkhardt 2007, D’ Souza 2007).
Assessing spiritual needs in nursing practice
Nurses strive to practise holistic care when faced with those coping with illness, pain, distress, vulnerability and death. Illness and admission to hospital often lead patients to consider the meaning and purpose of their own lives (Puchalski 2001). Patients often ask deeply spiritual questions and invite nurses into their questioning: ‘Why me?’, ‘What does this mean?’, ‘How can I deal with this?’ These questions provide an opening to explore spiritual needs; our responses can help patients ﬁnd a sense of meaning and purpose during their illness.
There is growing evidence that addressing spirituality improves a patient’s comfort levels emotionally and physically and has a positive effect on their response to illness and treatments (Koenig 2004). Conversely, neglecting to deal with spiritual issues may expose a patient to additional suffering.
When people are unwell, they may signal their desire to discuss spiritual issues. Being responsive and sensitive to these signals may enable helpful conversations on spiritual issues to occur. It is also important to consider how spiritual issues can be approached if the patient does not raise them directly. A sensitive and individualised approach is indicated. A questionnaire is not necessarily an effective way to approach discussion of spiritual issues, but some questions may be useful to initiate the discussion. The following are suggestions from the authors’ practical experience: ‘How has this illness affected you… your relationships and your activities? Has your illness raised any special concerns for you? Has it caused you to question things that you previously took for granted? What has helped or might help you to cope? What has being ill meant to you? How has it affected your family? How has it affected your work?’ It is best to avoid questions beginning with ‘ Why’ as these are often perceived as critical or as attributing blame. Questions such as ‘What is behind that?’ can serve the same purpose in a less threatening way.
The discussion should result in a dialogue about how the patient can be best supported in addressing their identi ﬁed needs. The results of this discussion can then be included in the care plan.
Discussion of spiritual issues requires a degree of cultural competency and an ability to discern what is important to people. Patients may have a different set of values, different hopes and expectations, and different ideas about the meaning and purpose of life from one’s own. Often, an effective way to approach this is to let patients tell their own story and to listen empathetically, providing suitable prompts to give patients an opportunity to discuss what their illness means to them and to understand how it may be disrupting their sense of purpose in life.
Competencies in spiritual care
It may also be helpful to consider speciﬁc healthcare professional competencies, such as those contained in the Marie Curie Cancer Care (2003) self-assessment tool on spiritual and religious care. Most Marie Curie competencies are generic and might be expected of any healthcare professional. These competencies may be grouped into the categories of knowledge, skills and action; the six competencies that apply most directly to spirituality are included in Box 3. The ﬁrst, second and fourth of the competencies in Box 3 have been addressed earlier in this article, the third will depend on local circumstances, while the ﬁfth and sixth follow logically from the other competencies and are discussed below. 4
Resources for integrating spirituality in practice and barriers to integration
Nurses should assess the resources needed to practise in a spiritually competent manner. These resources may be summarised as:
Development and education.
System and organisational resources.
The most important resources are the personal qualities of the nurse and their development and education in achieving spiritual competency. Systems of care that encourage holistic aspects and which allow nurses time to develop rapport with patients are also essential. McSherry (2011) identiﬁed that integrating spiritual care involved those personal qualities of care instilled in nurses during their training. These include offering care, being kind and compassionate, listening and being cheerful (McSherry and Jamieson 2013).
Nurses should provide supportive relationships for people who may be going through a period of perplexity and pain, as theytry to understand what their illness means for them and those around them (McSherry and Jamieson 2013). Integrating spirituality into care is not laborious or complicated. For many nurses, the means of doing so is already integralto their practice, yet they may not conceptualisethese actions as spiritual competence.
Monroe et al (2003) and Helming (2009) suggest that one difﬁculty in addressing spirituality may be the daily demand of achieving targets, leaving little time for holistic care. With reduced numbers of nurses in practiceand increased pressures on time, there is often limited time to talk to patients. Essential care is frequently provided by healthcare assistants in many areas. However, it is often during the provision of essential care, for example washing a patient, making their beds or helping them eat, that nurses are able to develop a relationship with the patient and spend time listening to their concerns. Nurses and others working in health care need to consider how they can ﬁnd time to integrate spirituality within the limitations imposed by present-day systems of care. Systems that dehumanise care should be identiﬁed and changed.
Qualitative ﬁndings from a recent study of healthcare educators revealed that teachers understood spirituality in the context of the importance of self, personhood, being, direction, meaning and purpose in life. They also conceived spirituality as practical, affecting how people lived and acted towards each other and the outside world. Their strategies for addressing spirituality in education involved using particular contexts, such as palliative care and ethical issues, where spiritual values were considered particularly relevant (Prentis et al 2014).
Speciﬁc methods of teaching that encouraged self-awareness, reﬂective learning, sharing, modelling and an emphasis on empathy and compassion helped to open up the spiritual side of nursing, as did the use of narratives, discussion and poetry. However, these methods were time-consuming. The main theme to emerge from the study was that personal values should not be imposed on nursing students, just as a nurse’s personal values should not be imposed on patients (Prentis et al 2014).
Other studies emphasise concerns about not imposing one’s values on others, and a fear of projecting one’s beliefs onto a patient, which is considered ethically unacceptable (Ellis et al 2002, Monroe et al 2003, Ellis and Campbell 2004). Many will recall the nurse who was suspended after offering to pray for a patient (BBC News 2009). This may have further increased nurses’ reticence to explore spirituality, for fear of being accused of proselytising. However, spirituality should not be viewed as an invitation to share one’s faith, nor an attempt to convert patients to a speci ﬁc religious belief. The latter is in breach of nurses’ code of conduct (NMC 2015). A spiritual approach involves following patients’ leads when they ask nurses to connect with them and to help them ﬁnd hope, meaning and purpose in their suffering. 5
An emphasis on evidence-based nursing has led educators to focus on technical and measurable factors. In Western culture, scientiﬁc and economic knowledge is often privileged over more intuitive ways of knowing, perhaps based on narrative, poetry and common humanity. This is reﬂected by virtually all (28/29) participants in the small-scale study by Prentis et al (2014), who responded that ‘intellect is more important than spirituality’.
Yet there is good scienti ﬁc evidence, often based on qualitative research, for the importance of factors such as empathy, compassion, person-centred care and integrity. The emphasis on measurable facts followed the great divide between science and the humanities that occurred in the Enlightenment. Not all cultures share this split, and this should be borne in mind when supporting people from those cultures.
Other factors, such as the dominant political, economic and organisational cultures, may affect the ability of nurses to offer good spiritual care. Examples include the tendency for care to be fragmented, for patients to be moved around in hospital and sometimes sent home early because of pressure for beds to be vacated, and for ‘industrialised’ models of care, based on short-term contracts using personnel with minimum training.
Research indicates that patients want nurses to discuss spirituality with them (Ellis et al 2002, Ellis and Campbell 2004). Moreover, nurses say that spirituality is important in their work (Stranahan 2001, McSherry and Jamieson 2011, 2013). The literature suggests that listening attentively for patient cues leads naturally to discussions on spirituality (Ellis and Campbell 2004, Helming 2009). An open, accepting and compassionate attitude makes it easier for patients to share their concerns. Nurses can help by fostering a positive attitude to spirituality, recognising that patients want to discuss spiritual issues and understanding that spirituality is important in recovery.
Ellis and Campbell (2004) report that patients would not begin to talk about their spiritual needs unless they felt honoured and respected. Further, patients believed that neglecting to address their spiritual needs would adversely affect the healing process. Clinicians who integrate spirituality into their practice appear to be those who are aware of their own spirituality and listen to patient cues (Treloar 2000, Stranahan 2001, Ellis et al 2002, Hubbell et al 2006). Treloar (2000) suggests that the breadth and depth of the spiritual care offered reﬂects the nurse’s own spiritual maturity.
Holistic practice is important. McSherry and Jamieson (2011, 2013) found that spirituality for many nurses is a fundamental and integral aspect of holistic nursing, which embraces what gives patients hope, meaning and purpose. Spirituality ﬁnds its place in the biopsychosocial model of practice.
Nurses should develop their conﬁdence in integrating spirituality. Many feel they are only sometimes able to meet their patients’ spiritual needs (McSherry 2011). However, a clearer understanding of spirituality in education and practice leads to increased recognition that some of the ways of integrating spirituality are already part of nurses’ core practice. This may, in turn, lead to increased conﬁdence in integrating spirituality into their practice; Box 4 shows some ways this can be achieved.
This article has considered what is meant by spirituality and spiritually competent practice in nursing and health care. A narrative example of spiritual care has been provided and factors that encourage or discourage spiritually competent nursing have been discussed. As with other healthcare professions, nursing has its own sense of meaning and purpose and its own values. These professional values underpin nurses’ ethics, while a sense of purpose can sustain us as nurses and make us more resilient in difﬁcult times. Conceptualising spirituality for yourself and considering how to integrate it into your practice will lead to a more holistic way of caring, an increased therapeutic connection with patients and improvements in recovery. Nurses who integrate spirituality into their practice may also re-engage with the meaning and purpose of their work.
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