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| Michelle Wensley is the acting Assistant Director of Nursing, Research and Special Projects at St. Vincent's Hospital Sydney. |
Nurses may be aware that patients have spiritual needs, but in many cases are unable to respond to these needs. This may result from an inadequacy in nurse education that does not prepare nurses to provide spiritual care. In addition, spiritual care is seen as part of the psychosocial assessment or in the domain of the pastoral care workers. In reality though, nurses are in the best position to deliver this important aspect of nursing care, particularly when caring for the patient with a life-threatening illness. Nurses learn early to become good listeners and communicators. By helping patients express their beliefs and by staying with them during the events of their illness, they are providing spiritual care. The challenge for nurses is to embrace holism and a holistic view of life and self and then convey this into caring for others.
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Nurses strive to incorporate holistic care that includes spiritual care into their nursing practice. The concept of providing spiritual care is derived from nursing theory, that states humans are biological-psychological-spiritual beings. Although nursing has recognised that patients have spiritual needs, the practice of spiritual care by nurses is often infrequent and an underutilised facet of care. This may be due to the assumption by many nurses that this domain should be dealt with by pastoral care workers. In reality, however, it is the nurse who is ideally placed to comfort and support the patient in spiritual distress, particularly those suffering a life-threatening illness. These patients are often more concerned with issues of a spiritual, rather than a physical nature. Thomas (1993: 12) believes these patients are not so afraid of death, as they are of being left alone, and describes the very act of maintaining a bond with the patient in distress as an extension of 'unconditional love'. As nurses we cannot prevent death from occurring, but we can accompany the patient some of the way just by staying, watching and being there.
The term 'spirituality' is derived from the Latin word 'spirare' meaning 'to breathe life', expressing one's values and beliefs about self, humanity, life and God. In defining spirituality, much of the literature equates spirituality with religion.
Labum (1988: 314) broadly defines spirituality as 'that which inspires in one the desire to transcend the realm of the material', which Labum believes can be interpreted as a reference to religion and deeper philosophies that contemplate the meaning of life. This explanation is reinforced by a strong belief among nurses that the only patients with spiritual issues are those who articulate using such words as 'God', 'church' and 'heaven'. While religious life and experience are a significant part of one's spirituality, other parts must not be overlooked, particularly those that search for meaning, hope or love. Some spiritual issues are raised in anger and disbelief, e.g. 'Why did God pick me?', 'I don't deserve this end; I've lived a good life'. The nurse is there to support the patient and not to defend God and can quietly acknowledge; therefore, 'Yes, I don't understand either'.
To many, spirituality is a journey, a discovery, a response to life, a search for ultimate meaning, an engagement in relationships, becoming whole in holiness, developing capacity in faith, hope and love. Religion may or may not be part of one's spirituality. Murray and Zenter (1989: 259) describe spirituality as:
... a quality that goes beyond religious affiliation, that strives for inspirations, reverence awe, meaning and purpose, even in those who do not believe in God. The spiritual dimension tries to be in harmony with the universe, strives for answers about the infinite, and comes into focus when the person faces emotional stress, physical illness or death.
Milne (1984) interprets spirituality from a pastoral perspective, referring to the 'vital expression of a person's total being, the wholeness of the spirit'. This wholeness is also inextricably entwined in the concept of holistic nursing, in which the patient is allowed to deal with their situation in a wholeness of spirit. Other definitions of spirituality encompass 'the radical truth of things', 'a sacred journey' and 'a life relationship with mystery, higher power, god or the universe' (Narayanasamay, 1993: 197). Spirituality embraces the needs of the believers and the nonbelievers; therefore, it is not confined within a religious context. Transcendence, writes Conrad (1985: 416), is integral to spirituality and focus on spiritual values that can sustain an individual as the physical body deteriorates.
Nurses are easily accepted into the patient's initial sphere during the course of their illness and should be able to address spiritual issues comfortably. As Jacik (1989: 278) writes, this spiritual care can take the form of Scripture reading, prayer or reassuring the patient that God is listening, loving and caring. Besides the significance of active listening and being present, spiritual support may also take the form of sitting with the patient during a religious ritual, joining in prayer, reading or providing inspirational literature. In addition, Thomas (1993: 16) adds meditation, guided imagery, art and music or calling a long-lost friend as important aspects of spiritual care.
Conrad (1985: 419) believes when providing spiritual care to the patient, the nurse must be comfortable in spiritual matters, have good communication skills and be able to demonstrate empathy. An opportune time to assess the patient's individual spirituality is during the nursing assessment and subsequent documentation on the nursing care plan. Conrad cites Stoll (1985: 20) who outlines four effective interviewing techniques in four areas: the person's concept of God or deity, the source of strength and hope for the person, the significance of religious practices and rituals to the person, and what the person believes is the relationship between his or her spiritual belief and their state of health.
Narayanasamay (1993: 196) supports Conrad's claim and posits there is concern within nursing that spiritual care of the patients is inadequate and suggests this is due to the lack of sufficient educational preparation of nurses in the provision of holistic nursing care. Jacik (1989: 276) agrees and adds that nurses can only adequately provide the spiritual care if they have examined their own beliefs and discovered how the truths and religious principles have guided their own lives. Fitzgerald (1987: 15) offers the motto 'know thyself' to any nurse who wishes to be more comfortable with spiritual matters. The challenge, adds Jacik (1987: 15), is to listen for the call for wholeness and embrace holism and a holistic view of life and self and then convey this into caring for others. One must be able to face the reality of one's own mortality, believe that they can help another die well by realising human life is temporary and human beings are mortal, and accept life as transient. If the spiritual care is inept, the patient is left on their own to struggle with their spiritual needs.
Hamner (1991: 3) also expresses concern that spiritual needs are not necessarily included in the nursing assessment, despite the fact that nurses take great pride in delivering holistic care. Many nurses believe spirituality is intertwined with the psychosocial dimensions. However, Piles (1990: 37) explains that the psychosocial dimension involves man's relationship to himself, others or to his environment, while the spiritual dimension deals with man's relationship to a higher being, or God, depending on how the person wishes to define it. Many nurses have never been exposed to, questioned the relevance of, or indeed, investigated, the spiritual needs of their patients.
However, despite not having had a formal introduction to the concept of spirituality, nurses have spent many hours holding a dying patient's hand, and reassuring them that they will not die alone. Spiritual support is essential to the holistic care of any patient. Although Fitzgerald (1987: 14) emphasises that the dying patient does not have special spiritual needs, those with a life-threatening illness are more conscious of time and may feel an urgency to look at life more deeply. Spiritual support can foster richness of meaning, hope, love and satisfaction in their final days of living. Labun (1988: 316) reinforces this view, by stating patients who are facing death or crisis, encounter intense spiritual events described as a 'near death experience'. According to Mackenzie (1992: 44), people who have experienced near-death become more spiritual, love people in a totally different way, retain a deep sense of God and a spiritual hunger to discover how best to live life in the future.
Spiritual healing, states Thomas (1993: 3), occurs when we attempt to meet the following spiritual needs: the search for meaning and transcendence; the sense of forgiveness both given and received; the maintenance of hope and the sustenance of love and relationships. The nurse can provide spiritual care by attempting to provide some meaning in experiences that are lived as meaningless, or appear as meaningless. Fitzgerald (1987: 15) believes nurses are privileged to be allowed to witness the vulnerability of another's death. Spiritual care of the dying heightens our awareness, promotes understanding and assists us to overcome hurdles in our search for meaning. Pain, death and suffering can be given meaning by guiding the dying to ask of themselves 'now that I am dying, what am I going to do about it?'
The dying patient may sometimes experience guilt and anxiety as they consider unfulfilled expectations or acts of omission towards others. The sense of guilt can be relieved by merely talking with someone who cares. Thomas (1993: 11) states that by providing this opportunity for reconciliation, our awareness of human nature as vulnerable, limited, imperfect and humble, is heightened. The patient will realise acceptance of self and others regardless of past mistakes and their spiritual pain will be eased.
Hope, says Aristotle, is a waking dream. As nurses, we become the source of spiritual hope for the dying patient by ensuring freedom of pain, a good night's sleep, a nice hot bath and at all times emphasising that there is always something, no matter how small, to look forward to. This provides a powerful barrier against despair, and the patient can be assured they will not die alone. Cassidy (1988: 5) interprets the spirituality of caring:
The spirituality of those who care for the dying must be the spirituality of the companion, of the friend who walks alongside, helping, sharing, and sometimes just sitting empty-handed, when we would rather run away. It is the spirituality of presence, of being alongside, watchful, available of being there... we who would be a companion to the dying therefore must enter into their darkness, go with them at least part of the way, along their lonely and frightening road... enter into the suffering and share in some small way their pain, confusion and desolation.
Spiritual support is essential to the total nursing care of the dying patient. They should not die without meaning, guilt-ridden, lonely or suffer feelings of hopelessness when being cared for by nurses. The dying patient does not expect theological answers to all their questions, but rather a comforting supportive listener. Despite a lack of formal educational preparation. on spirituality, nurses learn early to become good listeners, and can rely on their own skills in communication to provide specific spiritual interventions. Because of their clinical practice and lived experience, nurses are able to give total, quality care. The nurse is able to help patients express their beliefs, and by staying with them during the events of terminal illness, the nurse provides spiritual care. The simple act of being there is, in many ways, the hardest part.
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