Authors

Ronit Elk, Ph.D.a, Eric J. Hall, MDivb, Cristy DeGregory, Ph.D., RNa, Dennis Graham Ph.D., RN, ANP-BCc, Brian P. Hughes, BCC, MDiv, MSb

a College of Nursing
University of South Carolina; 1601 Greene Street, Columbia, SC 29208

b HealthCare Chaplaincy Network Spiritual Care Association; 65 Broadway, 12th Floor, New York, NY 10006-2503

c Barbara H. Hagan School of Nursing Molloy College; 1000 Hempstead Avenue, Rockville Centre, NY 11571-5002

Abstract

Spiritual care has been recognized as part of holistic nursing care, in promoting health and well-being. The purpose of this article is to describe: (1) The state of the science in terms of the positive clinical impact when spiritual care is provided to patients by healthcare providers. (2) Ways in which, despite lack of training, nurses can provide spiritual care by screening for spiritual needs and preferences, referring patients for spiritual assessment, and providing a range of spiritual care. (3) Methods by which nurses can determine spiritual distress and intervene effectively. (4) Spiritual self-care for nurses. Conclusions: Although the provision of spiritual care by nurses has been strongly recommended, lack of such training as part of the nursing curriculum, has resulted in lack of competence and expertise in providing such care. Despite this, there are many aspects of spiritual care that nurses are able to provide. Not providing spiritual support to patients is neglecting an important opportunity to improve patient care. The significant gap in research into methods for developing spiritual care competencies in nursing students must be addressed.

Spirituality in Healthcare

Spirituality has increasingly become more central throughout healthcare. The World Health Organization determined that a person’s health care needs include physical, mental, social and spiritual well-being (World Health Organization., 2007). On a National Inpatient Priority Index of patient satisfaction, assessing over one million patients, emotional and spiritual needs ranked second (Clark, Drain, & Malone, 2003; McClung, Grossoehme, & Jacobson, 2006). Despite this, spirituality is often considered tangential to clinical care and not offered to patients, especially those with serious illness (Astrow, Wexler, Texeira, He, & Sulmasy, 2007; T. A. Balboni et al., 2007; Daaleman, Kuckelman Cobb, & Frey, 2001; Ehman, Ott, Short, Ciampa, & Hansen-Flaschen, 1999) regardless of national guidelines for quality end of life care including attending to patients’ religious and spiritual needs (“Clinical Practice Guidelines for Quality Palliative Care; Christina Puchalski et al., 2009). In considering holistic nursing care, organizations such as The North American Nursing Diagnosis Association International (formerly NANDA) (NANDA, 2014) have recognized the importance of spiritual and religious care in promoting health and well-being.

Defining spirituality: Defining spirituality is complex. A recent international interdisciplinary expert panel arrived at this consensus definition: “Spirituality is a dynamic and intrinsic aspect of humanity through which persons seek ultimate meaning, purpose and transcendence, and experience relationship to self, family, others, community, society, nature, and the significant or sacred. Spirituality is expressed through beliefs, values, traditions and practices” (C. M. Puchalski, Vitillo, Hull, & Reller, 2014). Spirituality is often confused with religion. They are not the same. Religion is defined as “a subset of spirituality, encompassing a system of beliefs and {Citation}practices observed by a community, supported by rituals that acknowledge, worship, communicate with, or approach the sacred, the divine, God (in Western cultures), or ultimate truth, reality, or nirvana (in Eastern cultures) (Koenig, 2008). Religion may be a way in which people express their spirituality, but it is not the only way. Religion is more focused on systems or social institutions of people who share beliefs or values (Emblen, 1992).

Importance of Spiritual Care delivered to patients by healthcare providers: Studies have examined the importance of spirituality/religion. For example, a multi-institutional study with advanced cancer patients found that 88% considered religion important to them (T. A. Balboni et al., 2007). However, 72% reported that their spiritual needs were minimally or not supported at all by the healthcare system. Another study of cancer patients (Pearce, Coan, Herndon, Koenig, & Abernethy, 2012) found 91% of patients reported having spiritual needs, and 67% wanted their healthcare providers to provide this spiritual care. In a study of chronic kidney disease patients (Davison & Jhangri, 2010) 69% of patients reported at least one spiritual need. Although patients and family do not usually expect in-depth spiritual care from nurses, studies show there is an expectation for empathy and compassion (Sinclair et al., 2017). Cancer patients and their family were asked what spiritual care they wanted from their nurses. Responses included a desire for quiet time or space, nurses listening to their spiritual concerns, assistance with religious practice, and arranging for a chaplain visit (Taylor & Mamier, 2005).

Defining Spiritual Well Being and Spiritual Distress: NANDA-International defines these as follows: Readiness for enhanced spiritual well-being: “A pattern of experiencing and integrating meaning and purpose in life through connectedness with self, others, art, music, literature, nature, and/or a power greater than oneself, which can be strengthened” (Diagnoses, N. N., 2003a) Spiritual distress: “a state of suffering related to the impaired ability to experience meaning in life through connections with self, others, the world, or a superior being” (Caldeira & Vieira, 2012), and at risk for spiritual distress: “vulnerable to an impaired ability to experience and integrate meaning and purpose in life through connectedness within self, literature, nature, and/or a power greater than oneself, which may compromise health”(Diagnoses, N. N., 2003b)

Clinical Impact of Providing Spiritual Care: Studies have found a strong positive relationship between spirituality/religiosity and health and well-being. For many medically ill or mental health patients, spirituality/religiosity may provide coping resources, enhance pain management, improve surgical outcomes, protect against depression, and reduce risk of substance abuse and suicide (Larson & Larson, 2003). Patients with cancer (M. J. Balboni et al., 2014; Phelps et al., 2012) identified the benefits of spiritual care as supporting their emotional well-being, improving their quality of life, and strengthening relationships with providers. Providing spiritual care also positively impacts patient satisfaction with care provided in a hospital or clinic. Family members who received spiritual care reported this was a key factor associated with their increased satisfaction with care in the ICU. In another study of over 9,000 patients, chaplains visits increased the willingness of patients to recommend the hospital (Marin et al., 2015). In a Press Ganey study of over 2 million patients, the single most unmet need in terms of patient satisfaction with care received in the hospital is the staff addressing the patient’s emotional and spiritual needs (Williams, Aimee, 2003) . When staff addressed spiritual/religious concerns of internal medicine patients, they were more likely to rate their care at the highest level on multiple measures of patient satisfaction (Williams, Meltzer, Arora, Chung, & Curlin, 2011). Alternately, patients whose spiritual needs were unmet gave lower ratings of both quality of care and satisfaction with care (Astrow et al., 2007).

On the other end of the continuum, studies examining patients’ spiritual distress find correlative negative impacts on health. For example, among palliative care unit patients (Hui et al., 2011), 44% experienced spiritual distress, and those patients were more likely to also experience depression and pain. Among hematopoietic cell transplant patients, 27% of patients experienced some form of spiritual struggle, and these patients were more likely to be depressed and have poorer quality of life (King et al., 2017). A study of end of life cancer patients (T. Balboni et al., 2011) with unmet spiritual needs found they were less likely to receive a week or more of hospice care, and more likely to die in the ICU. End of life care costs were also higher when patients reported their spiritual needs were unsupported. A seminal study (Phelps et al., 2012) found when spiritual care was offered appropriately and sensitively, it could significantly enrich the patient’s emotional well-being and patient-provider relationships.

The Role of Nursing in Spiritual Care: Within the nursing literature, interest in spirituality has increased exponentially in the last several decades. For example, on the research site PubMed, in the decade 1982-1991 there were only seven articles addressing ‘spirituality & nursing,’ and three ‘religious & nursing’. While in 2001-2011, there were 401 of the former, and 491 of the latter (Reinert & Koenig, 2013). Studies find that nurses wish to provide spiritual care but there are barriers that prevent this. For example, The Religion and Spiritualty in Cancer Study (M. J. Balboni et al., 2014) found that most nurses (74%) had the desire to provide spiritual care; however, 40% felt they provided such care less often than desired. Within the same study, 85% of nurses believed spiritual care would have a positive impact on the patients (Phelps et al., 2012). Several other studies have found that nurses consider spirituality to be very important in patient care (Chandramohan & Bhagwan, 2016).

Barriers for nurses providing such care have also been identified. The barrier most strongly cited by nurses was a lack of private space (M. J. Balboni et al., 2014). Inadequate or lack of training was another common reason (both in the US and internationally) (Ali, Wattis, & Snowden, 2015; M. J. Balboni et al., 2013; Blanchard, Dunlap, & Fitchett, 2012; Daaleman & Nease, 1994; Ruder, 2013), as was “not my professional role”, and power inequity with the patient. Feeling underequipped to provide spiritual care has also been found in other studies (Selby, Seccaraccia, Huth, Kurppa, & Fitch, 2017). Lack of training has been reported in many other studies, both in the US and in other countries (Ali et al., 2015; M. J. Balboni et al., 2013; Blanchard et al., 2012; Daaleman & Nease, 1994; Ruder, 2013). In a study of nurses’ perceptions of spiritual care (Ruder, 2013) researchers found that Nurses who had received spiritual care training as part of their basic nursing curriculum, and had been taught to incorporate spiritual care into the planning and delivery of care, felt more competent and prepared to address spiritual issues (Ruder, 2013).

Recognizing How Nurses Can Provide Spiritual Care: How, then, can nurses provide spiritual care? Step 1: Recognizing what constitutes appropriate spiritual care: In the Religion and Spirituality Cancer Study (Phelps et al., 2012), the most comprehensive study on this issue, the appropriate delivery of spiritual care was defined by physicians, nurses and patients as a very important aspect of spiritual care. Appropriate spiritual care included: (a) assessing the patient’s spiritual needs, (b) referring to clergy/chaplains as needed, and (c) supporting the patient’s spiritual beliefs and needs, individualizing the spiritual care to the patient, and not proselytizing. This includes ensuring that spiritual care is voluntary for both patients and providers. Step 2: Knowing what spiritual care all nurses, even those untrained in spiritual care, can provide: There is a wide range of spiritual care that all nurses can provide. These include (a) spiritual screening or spiritual history, (b) referral for spiritual care, and (c) providing a range of basic spiritual care.

(a) Spiritual Screening and Spiritual History for Spiritual Preferences and Needs: The first tool to providing well-integrated spiritual care is that of assessment of the patient’s spiritual needs. This includes three forms of screening: a spiritual screen, spiritual history and spiritual assessment. Depending on the institution the nurse works in, she or another team member will conduct one or more of these.

(i) Conducting a Spiritual screen: This is a tool of just a few questions that helps identify the patient’s spiritual preferences and identify any distress in order to refer them to a chaplain. One such tool is the Spiritual Struggle Screening Protocol (Fitchett & Risk, 2009):

(ii) Conducting a Spiritual History: This is a more in-depth tool, usually administered by an advanced care nurse practitioner or physician, that assess the religious/spiritual background of the patient and determines what type of support is potentially most helpful. This conversation just takes a few moments, and may uncover important issues that could benefit from referral to a chaplain (Phelps et al., 2012). This assessment also opens the door to the patient and the assessor discussing the spiritual and religious aspects of illness. Several spiritual history tools have been developed, including the HOPE (Anandarajah & Hight, 2001) and SPIRIT (Maugans, 1996), but FICA (Faith, Importance, Community, Address in Care) (C. Puchalski & Romer, 2000) is the tool that has become one of the most widely used (C. Puchalski & Romer, 2000).

(b) Referring the Patient for a Spiritual Assessment: This is a process that should only be completed by a spiritual care specialist such as a chaplain. It is a conversation where the patient is listened to, the spiritual needs evaluated and requires specific expertise and time (Bowden, J., Murphy, P., & Peery, B, 2016). The spiritual assessment helps articulate not only spiritual needs and resources, but develops a spiritual care plan and desired contributing outcomes. This assessment is always communicated in the patient’s chart, but depending on the specific institution, may end up in the “ancillary notes” which unfortunately is rarely read by healthcare staff. It is therefore important for the nurse to know where this is filed and review it as it may have direct impact on the care of the patient.

(c) Providing a Range of Spiritual Care: Nurses can provide spiritual care by attending to several important spiritual elements. This includes supporting the patient’s spiritual beliefs and needs, and individualizing spiritual care to the patient. This involves explicitly communicating compassion, active listening, and supporting the patient through their health care journey. Nurses should also be sensitive to the spiritual impact of a hospitalization on the patient and family, as well as the spiritual resources that may need to be involved. This may involve coordinating with local community faith leaders, with the patient’s permission to avoid potential HIPAA violations, to provide some more in-depth spiritual support as needed. In the predominantly Christian US, it is important to recognize that not all people are Christian, and many express their spirituality through a variety of different, and even disparate, religious or spiritual means (Eric J Hall, Brian P. Hughes, & George H. Handzo, 2016). Nurses should be sensitive and show respect for how the patient’s faith tradition or spiritual believes and priorities impact care. Sometimes patients ask the nurse to pray with them. If the nurse is uncomfortable saying a prayer with a patient, she/he can make a referral to a religious leader, saying, for example, “I don’t usually pray with my patients directly. But I can call the chaplain/minister who does. I will promise to be holding you in my thoughts and heart today and throughout your journey.” If the nurse is comfortable, it is helpful to ask what specifically would the patient like the nurse to pray for. This invites clarification, communicates respect for the patient, and allows the patient to determine what, when and who is involved in the prayer, which many consider to be an intimate shared action. For patients who are not Christian, it is very important not to pray “in the name of Jesus”.

Finally, if a nurse suspects that a patient is expecting spiritual distress, there are several interventions that she/he can implement as needed. The Nursing Intervention Classification (NIC) (Nursing Interventions and Rationales, 2013) recommends that the nurse:

1. Observe client for self-esteem, self-worth, feelings of futility, or hopelessness.

2. Monitor client’s support systems.

3. Be physically present and available to help client determine religious and spiritual needs.

4. Provide protected quiet time for meditation, prayer and relaxation.

5. Help client make a list of important and unimportant values.

6. Ask how to be most helpful, then actively listen, and seek clarification.

7. If client is comfortable with touch, hold client’s hand or place hand gently on arm. Touch makes nonverbal communication more personal.

8. Help client develop and accomplish short-term goals and tasks.

9. Help client find a reason for living and be available for support.

10. Listen to client’s feelings about death. Be non-judgmental and allow time for grieving.

11. Help client develop skills to deal with illness or lifestyle changes. Include client in planning of care.

12. Provide appropriate religious materials, artifacts or music as requested.

13. Provide privacy for client to pray with others or to be read to by members of own faith.

Spirituality as Self-Care for Nurses

Many nurses enter the field out of compassion and caring for others. The difficulty arises when the nurse provides a higher level of care for those served than for him/herself. This may lead to compassion fatigue, burnout, vicarious traumatization, moral and spiritual distress. Many healthcare professionals cope with the daily stress of work by eating, drinking, exercising, sexual activity, smoking or drugs, music, yoga, art, or other outlets that function as coping strategies. Options within the spiritual and religious disciplines may also prove healthy and helpful, from the disciplines of meditation, prayer and religious ritual to the relationships many create and maintain in faith communities (Ross et al., 2014; White, 2016).

Summary Conclusions: The provision of spiritual care by nurses and physicians has been recommended by the findings of several studies (Phelps et al., 2012), and recommended by nursing organizations (NANDA 2014). Even so, challenges for nurses in providing such care include lack of training and as a result, lack of expertise. Two significant gaps lead to two key recommendations. First is the lack of training provided in spiritual care provided in the nursing curriculum. A recent systematic review of nursing education challenges (Ali et al., 2015), found very few studies focused on methods for developing spiritual care competencies in nursing students, nor on nursing educators’ perspective on how to develop such competencies in students. This is a significant gap that needs to be addressed by both researchers and educators. Second is the lack of spiritual support provided to patients, especially those with serious illness. “Physicians and nurses might be neglecting an important opportunity to improve the care of patients…” (Phelps et al., 2012 p2543). This is yet another significant concern that requires immediate attention by clinicians and nursing organizations.