Art & science | mental health
Should emergency nurses attempt to meet patients’ spiritual needs? Leanne Watkins offers a reflective case study in which the intervention of a chaplain helped a woman with mental health problems deal with self-harm Correspondence [email protected] Leanne Watkins is an emergency nurse at Wye Valley NHS Trust, Hereford Date submitted May 27 2014 Date accepted August 11 2014 Peer review This article has been subject to double-blind review and has been checked using antiplagiarism software Author guidelines rcnpublishing.com/r/en-authorguidelines
Abstract Research suggests there is a positive correlation between addressing some patients’ spiritual needs and the outcomes of their care. This article describes a case study in which a patient with mental health problems who frequently re-attended an emergency department (ED) sought spiritual support from a hospital chaplain. The patient was referred to a charitable organisation that offers spiritual care and her re-attendance at the ED has become less frequent. Keywords Spiritual needs, hospital chaplain, frequent attenders MUCH HAS been written about physical, social and psychological approaches to the care of patients in emergency departments (EDs), but little has been written about addressing these patients’ spiritual needs. Spiritual care may be particularly relevant to the care of people who frequently re-attend EDs. Many of these patients have poor health (Murphy et al 1999), some have mental health problems and others misuse alcohol or drugs (Moore et al 2009). A range of evidence-based strategies, including drawing up individualised care plans, arranging follow-up appointments and ensuring there is regular communication between care providers, have been devised to manage each of these patient groups (Skinner et al 2009). However, no strategy to address the spiritual needs of such patients has been developed, even though there is evidence that spiritual care can reduce anxiety and ‘disturbance’ in patients with mental health problems (Harlow 2008). In a recent publication on mental health care and EDs, the Department of Health (DH) (2014) discusses
36 October 2014 | Volume 22 | Number 6
three interrelated issues: over-long waits for assessment, lack of support for people with mental health problems and a tendency for staff to treat patients who self-harm as a low priority. The DH (2014) makes clear that patients who self-harm should be offered physical, psychological and social needs assessments, as recommended by the National Institute for Health and Care Excellence (NICE) (2013). However, neither the DH (2014) nor NICE (2013) recommend that patients are given spiritual needs assessments. As Cook et al (2012) have found, the spiritual needs of patients with mental health problems are often overlooked, yet one of the DH’s (2014) aims is to improve patients’ mental wellbeing. It should be noted that, when people have health problems or crises that lead them to present at EDs, their attitudes towards spirituality often change (Mowat 2011). It follows that, to provide holistic care, emergency nurses should address patients’ changing spiritual needs. Dudhwala (2005) and McManus (2006) state that the spiritual needs of patients should be continuously reassessed as their life circumstances change. The reflective case study opposite concerns a woman with mental health problems who frequently re-attended an ED after episodes of self harm. It shows how her frequent re-attendance was reduced after she had sought spiritual care, first from a hospital chaplain and then from a charitable organisation. The patient’s re-attendance rate has since reduced.
Spiritual needs Spirituality means different things to different people, especially in multi-faith countries such as the UK, and some nurses may be confused about EMERGENCY NURSE
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what it means in practice. It should be noted that spirituality is not necessarily associated with specific religions or belief systems, and people with spiritual needs are not necessarily religious. As the British Medical Association (2014) points out, front line services are being stretched to breaking point and ED staff struggling to manage their workloads may feel overwhelmed by the inclusion of spiritual needs assessments in the care they offer patients. But, where appropriate and with the consent of the individuals concerned, it is important that they take time to address patients’ spiritual needs (Dudhwala 2005). As Folland (2005) and Speck (2005) have noted, there is a positive correlation between addressing such needs and meeting clinical outcomes. Furthermore, if nurses meet patients’ spiritual needs, they may be able to reduce re-attendance and thereby reduce their workloads. To help nurses reflect on spirituality in nursing care, the Royal College of Nursing (RCN) (2011) has issued a pocket guide on the subject. The guide defines spiritual care as that which ‘recognises and responds to the needs of the human spirit when faced with trauma, ill health or sadness’. These needs may be for ‘meaning, self-worth, self-expression, faith support, rites or prayer or sacrament, or simply a sensitive listener’. Spiritual care begins, the guide says, with ‘encouraging human contact in compassionate relationship, and moves in whatever direction need requires’ (RCN 2011). The guide is divided into sections, of which one presents examples of the questions nurses could ask patients when assessing whether they want spiritual care (RCN 2011): ■■ ‘Do you have a way of making sense of the things that happen to you?’ ■■ ‘What sources of support/help do you look to when life is difficult?’
■■ ‘Would you like to see someone who can help you?’ ■■ ‘Would you like to see someone who can help you talk or think through the impact of this illness or life event? You don’t have to be religious to talk to them.’ HM Government’s (2014) Mental Health Crisis Care Concordat states that some patients’ spiritual problems are factors in their mental health crises, which suggests that they would welcome spiritual needs assessments and, in some cases, referral to hospital chaplains.
Chaplaincy NHS chaplaincy guidelines (Leith 2003), which are due to be updated this year, include a great deal of useful information about chaplaincy services, and how these can support staff and patients. The guidelines also describe best practice in spirituality in nursing care and could inform the implementation of such care in EDs. They may also prompt ED managers to introduce and audit chaplaincy volunteers, who are trained and contracted members of chaplaincies, and who can offer their services in support of spiritual care. Chaplaincy volunteers have many different roles in healthcare services, from helping to transport patients to collective acts of worship to simply listening to, and empathising with, visitors. They can be especially useful in busy EDs and make a valuable contribution to spiritual care provision in healthcare services (Mowat 2008). Members of an ED chaplaincy visitor team at St Peters Hospital, Chertsey, Surrey, talk to, and run errands for, patients, their friends and families. They have gained the confidence of staff, and try to ease the strain for patients and relatives during long waits. They also refer people to different forms of spiritual care at their request (Leith 2003).
Case study A 26-year-old woman attended the emergency department (ED) after an incident of self-harm. She had attended the ED before and was known to staff. After she had been triaged and treated, she was referred to a mental health crisis team for assessment. While waiting in a cubicle to be assessed, she noticed a poster provided by the hospital chaplaincy team on the cubicle wall. She asked staff if she could speak with a chaplain and this was organised. Staff noticed immediately the patient appeared less EMERGENCY NURSE
anxious when in the presence of the chaplain, while other patients and staff on duty reported that the chaplain had calmed the situation. At the chaplain’s recommendation, the patient self‑referred to a charitable organisation called Mercy Ministries UK after she had been discharged from the mental health crisis team. The patient was helped to address the root causes of her distress and, as a result, has no longer felt a need to re-attend the ED. October 2014 | Volume 22 | Number 6 37
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Art & science | mental health Many patients and relatives find attending EDs a distressing experience, and chaplaincy volunteers can help ease their anxiety and reduce stress among staff. Their involvement in patient care improves patients’ experience of health care, and could reduce the re-attendance rate and number of complaints. The kind of work chaplaincy volunteers do can be similar to that of Street Pastors, a group of trained volunteers who patrol the streets of cities in the UK and offer practical help to people who need it (Issac and Davies 2009). The Street Pastors initiative is run by churches in partnership with local governments and police, and ED managers could find out if there are similar projects in their areas. Like all services offered by the NHS, hospital chaplaincy is affected by cutbacks, and many hospital chaplains work part time and rely on teams of chaplaincy volunteers. Many UK trusts are discussing whether hospital chaplains should be retained (Tanner 2014), even though their services have been described as beneficial and irreplaceable (Kelly 2012).
Recommendations The reflective case study described above led the author to reflect on the provision of spiritual care in EDs, particularly to patients with mental health problems and those who are frequent attenders, and to make three specific recommendations: ■■ Hospital chaplains could be included in multidisciplinary teams to offer patients who consent to their involvement more support. Chaplaincy volunteers can help care professionals provide more care in hospitals and communities (Folland 2005).
■■ Staff in EDs should receive training in spiritual care, perhaps in workshops led by hospital chaplains, to increase their knowledge and confidence in this area. Managers could consider the benefits of starting or continuing to work with chaplaincy volunteers in their departments. ■■ Examples of good practice in this area should be collated, and further research of spiritual care in EDs and the work of hospital chaplains should be undertaken (Speck 2005). The results of such research would expand the evidence base of this important but neglected area of patient care, and could lead to the development of new approaches to patient management (Cruz et al 2011).
Find out more Mercy Ministries UK offers support to people of any age, gender or religion who have life‑controlling issues, such as self-harm, depression, addiction, eating disorders and abuse in all its forms. The charity, which is funded by donations, runs a 24-hour telephone helpline, and offers a six-month free residential programme in West Yorkshire for women aged between 18 and 28 who are sympathetic to the organisation’s Christian approach. Mercy Ministries UK plans to open another residential programme in the south of England. Further information is available at www.mercyministries.co.uk More information about street pastors at Wye Valley NHS Trust is available from tinyurl.com/p5xnaah Up to 20 copies of Spirituality in Nursing Care, can be ordered from RCN Direct, at 0845 772 6100
Online archive For related information, visit our online archive and search using the keywords Conflict of interest None declared Acknowledgement The author would like to thank consultant nurse and senior lecturer in emergency care at the University of the West of England Rebecca Hoskins, the team running the Principles of Emergency care course at the university,and the chaplaincy team and volunteers at Wye Valley NHS Trust, Hereford, for their help and encouragement
References British Medical Association (2014) ‘NHS is starting to buckle,’ warns BMA. News, Views, Analysis. tinyurl.com/kn2d4cg (Last accessed: September 15 2014). Cook C, Breckon J, Jay C et al (2012) Pathway to accommodate patients’ spiritual needs. Nursing Management. 19, 2, 33-37. Cruz D, Pearson A, Saini P et al (2011) Emergency department contact prior to suicide in mental health patients. Emergency Medicine Journal. doi:10.1136/emj.2009.081869 Department of Health (2014) Closing the Gap: Priorities for Essential Change in Mental Health. DH, London. Dudhwala Y (2005) Winning the lottery. Nursing Management. 12, 6, 14-15. Folland M (2005) Hope for the future. Nursing Management. 12, 6, 16-21.
Harlow W (2008) Meeting Spiritual Needs on an Acute Mental Health Admission Ward: National Institute for Health and Care Excellence Shared Learning Database. tinyurl.com/oypugoz (Last accessed: September 9 2014). HM Government (2014) Mental Health Crisis Care Concordat: Improving Outcomes for People Experiencing Mental Health Crisis. tinyurl.com/lxltbyp (Last accessed: September 9 2014). Issac L, Davies R (2009) Street Pastors. Kingsway Communications, Eastbourne, East Sussex. Kelly E (2012) The development of healthcare chaplaincy. Expository Times. 123, 10, 469-478. Leith B (2003) NHS Chaplaincy: Meeting the Religious and Spiritual Needs of Patients and Staff. tinyurl.com/olvcqtr (Last accessed: September 11 2014).
38 October 2014 | Volume 22 | Number 6
McManus J (2006) Spirituality and health. Nursing Management. 13, 6, 24-27.
emergency department over a year period. Emergency Medicine Journal. 16, 6, 425-427.
Moore L, Deehan A, Seed P et al (2009) Characteristics of frequent attenders in an emergency department: analysis of a one-year attendance data. Emergency Medicine Journal. 26, 4, 263-267.
National Institute for Health and Care Excellence (2013) Quality Standard for Self-Harm. tinyurl.com/p92dkzj (Last accessed: September 9 2014).
Mowat H (2008) The Potential for Efficacy of Healthcare Chaplaincy and Spiritual Care Provision in the NHS (UK): A Scoping of Recent Research. tinyurl.com/pmky85p (Last accessed: September 9 2014).
Royal College of Nursing (2011) Spirituality in Nursing Care: A Pocket Guide. RCN, London. Skinner J, Carter L, Haxton C (2009) Case management of patients who frequently present to a Scottish emergency department. Emergency Medicine Journal. 26, 2, 103-105.
Mowat H (2011) Defining the Spiritual. tinyurl.com/ntflxlt (Last accessed: September 9 2014).
Speck P (2005) The evidence base for spiritual care. Nursing Management. 12, 6, 28-31.
Murphy A, Leonard C, Plunkett P et al (1999) Characteristics of attenders and their attendances at an urban accident and
Tanner B (2014) Fears that Hereford County Hospital chaplain service will be cut. Hereford Times. tinyurl.com/olmpar9 (Last accessed: September 9 2014).
EMERGENCY NURSE
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Should emergency nurses attempt to meet patients’ spiritual needs? Leanne Watkins offers a reflective case study in which the intervention of a chaplain helped a woman with mental health problems deal with self-harm Correspondence [email protected] Leanne Watkins is an emergency nurse at Wye Valley NHS Trust, Hereford Date submitted May 27 2014 Date accepted August 11 2014 Peer review This article has been subject to double-blind review and has been checked using antiplagiarism software Author guidelines rcnpublishing.com/r/en-authorguidelines
Abstract Research suggests there is a positive correlation between addressing some patients’ spiritual needs and the outcomes of their care. This article describes a case study in which a patient with mental health problems who frequently re-attended an emergency department (ED) sought spiritual support from a hospital chaplain. The patient was referred to a charitable organisation that offers spiritual care and her re-attendance at the ED has become less frequent. Keywords Spiritual needs, hospital chaplain, frequent attenders MUCH HAS been written about physical, social and psychological approaches to the care of patients in emergency departments (EDs), but little has been written about addressing these patients’ spiritual needs. Spiritual care may be particularly relevant to the care of people who frequently re-attend EDs. Many of these patients have poor health (Murphy et al 1999), some have mental health problems and others misuse alcohol or drugs (Moore et al 2009). A range of evidence-based strategies, including drawing up individualised care plans, arranging follow-up appointments and ensuring there is regular communication between care providers, have been devised to manage each of these patient groups (Skinner et al 2009). However, no strategy to address the spiritual needs of such patients has been developed, even though there is evidence that spiritual care can reduce anxiety and ‘disturbance’ in patients with mental health problems (Harlow 2008). In a recent publication on mental health care and EDs, the Department of Health (DH) (2014) discusses
36 October 2014 | Volume 22 | Number 6
three interrelated issues: over-long waits for assessment, lack of support for people with mental health problems and a tendency for staff to treat patients who self-harm as a low priority. The DH (2014) makes clear that patients who self-harm should be offered physical, psychological and social needs assessments, as recommended by the National Institute for Health and Care Excellence (NICE) (2013). However, neither the DH (2014) nor NICE (2013) recommend that patients are given spiritual needs assessments. As Cook et al (2012) have found, the spiritual needs of patients with mental health problems are often overlooked, yet one of the DH’s (2014) aims is to improve patients’ mental wellbeing. It should be noted that, when people have health problems or crises that lead them to present at EDs, their attitudes towards spirituality often change (Mowat 2011). It follows that, to provide holistic care, emergency nurses should address patients’ changing spiritual needs. Dudhwala (2005) and McManus (2006) state that the spiritual needs of patients should be continuously reassessed as their life circumstances change. The reflective case study opposite concerns a woman with mental health problems who frequently re-attended an ED after episodes of self harm. It shows how her frequent re-attendance was reduced after she had sought spiritual care, first from a hospital chaplain and then from a charitable organisation. The patient’s re-attendance rate has since reduced.
Spiritual needs Spirituality means different things to different people, especially in multi-faith countries such as the UK, and some nurses may be confused about EMERGENCY NURSE
Downloaded from RCNi.com by ${individualUser.displayName} on Aug 26, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
what it means in practice. It should be noted that spirituality is not necessarily associated with specific religions or belief systems, and people with spiritual needs are not necessarily religious. As the British Medical Association (2014) points out, front line services are being stretched to breaking point and ED staff struggling to manage their workloads may feel overwhelmed by the inclusion of spiritual needs assessments in the care they offer patients. But, where appropriate and with the consent of the individuals concerned, it is important that they take time to address patients’ spiritual needs (Dudhwala 2005). As Folland (2005) and Speck (2005) have noted, there is a positive correlation between addressing such needs and meeting clinical outcomes. Furthermore, if nurses meet patients’ spiritual needs, they may be able to reduce re-attendance and thereby reduce their workloads. To help nurses reflect on spirituality in nursing care, the Royal College of Nursing (RCN) (2011) has issued a pocket guide on the subject. The guide defines spiritual care as that which ‘recognises and responds to the needs of the human spirit when faced with trauma, ill health or sadness’. These needs may be for ‘meaning, self-worth, self-expression, faith support, rites or prayer or sacrament, or simply a sensitive listener’. Spiritual care begins, the guide says, with ‘encouraging human contact in compassionate relationship, and moves in whatever direction need requires’ (RCN 2011). The guide is divided into sections, of which one presents examples of the questions nurses could ask patients when assessing whether they want spiritual care (RCN 2011): ■■ ‘Do you have a way of making sense of the things that happen to you?’ ■■ ‘What sources of support/help do you look to when life is difficult?’
■■ ‘Would you like to see someone who can help you?’ ■■ ‘Would you like to see someone who can help you talk or think through the impact of this illness or life event? You don’t have to be religious to talk to them.’ HM Government’s (2014) Mental Health Crisis Care Concordat states that some patients’ spiritual problems are factors in their mental health crises, which suggests that they would welcome spiritual needs assessments and, in some cases, referral to hospital chaplains.
Chaplaincy NHS chaplaincy guidelines (Leith 2003), which are due to be updated this year, include a great deal of useful information about chaplaincy services, and how these can support staff and patients. The guidelines also describe best practice in spirituality in nursing care and could inform the implementation of such care in EDs. They may also prompt ED managers to introduce and audit chaplaincy volunteers, who are trained and contracted members of chaplaincies, and who can offer their services in support of spiritual care. Chaplaincy volunteers have many different roles in healthcare services, from helping to transport patients to collective acts of worship to simply listening to, and empathising with, visitors. They can be especially useful in busy EDs and make a valuable contribution to spiritual care provision in healthcare services (Mowat 2008). Members of an ED chaplaincy visitor team at St Peters Hospital, Chertsey, Surrey, talk to, and run errands for, patients, their friends and families. They have gained the confidence of staff, and try to ease the strain for patients and relatives during long waits. They also refer people to different forms of spiritual care at their request (Leith 2003).
Case study A 26-year-old woman attended the emergency department (ED) after an incident of self-harm. She had attended the ED before and was known to staff. After she had been triaged and treated, she was referred to a mental health crisis team for assessment. While waiting in a cubicle to be assessed, she noticed a poster provided by the hospital chaplaincy team on the cubicle wall. She asked staff if she could speak with a chaplain and this was organised. Staff noticed immediately the patient appeared less EMERGENCY NURSE
anxious when in the presence of the chaplain, while other patients and staff on duty reported that the chaplain had calmed the situation. At the chaplain’s recommendation, the patient self‑referred to a charitable organisation called Mercy Ministries UK after she had been discharged from the mental health crisis team. The patient was helped to address the root causes of her distress and, as a result, has no longer felt a need to re-attend the ED. October 2014 | Volume 22 | Number 6 37
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Art & science | mental health Many patients and relatives find attending EDs a distressing experience, and chaplaincy volunteers can help ease their anxiety and reduce stress among staff. Their involvement in patient care improves patients’ experience of health care, and could reduce the re-attendance rate and number of complaints. The kind of work chaplaincy volunteers do can be similar to that of Street Pastors, a group of trained volunteers who patrol the streets of cities in the UK and offer practical help to people who need it (Issac and Davies 2009). The Street Pastors initiative is run by churches in partnership with local governments and police, and ED managers could find out if there are similar projects in their areas. Like all services offered by the NHS, hospital chaplaincy is affected by cutbacks, and many hospital chaplains work part time and rely on teams of chaplaincy volunteers. Many UK trusts are discussing whether hospital chaplains should be retained (Tanner 2014), even though their services have been described as beneficial and irreplaceable (Kelly 2012).
Recommendations The reflective case study described above led the author to reflect on the provision of spiritual care in EDs, particularly to patients with mental health problems and those who are frequent attenders, and to make three specific recommendations: ■■ Hospital chaplains could be included in multidisciplinary teams to offer patients who consent to their involvement more support. Chaplaincy volunteers can help care professionals provide more care in hospitals and communities (Folland 2005).
■■ Staff in EDs should receive training in spiritual care, perhaps in workshops led by hospital chaplains, to increase their knowledge and confidence in this area. Managers could consider the benefits of starting or continuing to work with chaplaincy volunteers in their departments. ■■ Examples of good practice in this area should be collated, and further research of spiritual care in EDs and the work of hospital chaplains should be undertaken (Speck 2005). The results of such research would expand the evidence base of this important but neglected area of patient care, and could lead to the development of new approaches to patient management (Cruz et al 2011).
Find out more Mercy Ministries UK offers support to people of any age, gender or religion who have life‑controlling issues, such as self-harm, depression, addiction, eating disorders and abuse in all its forms. The charity, which is funded by donations, runs a 24-hour telephone helpline, and offers a six-month free residential programme in West Yorkshire for women aged between 18 and 28 who are sympathetic to the organisation’s Christian approach. Mercy Ministries UK plans to open another residential programme in the south of England. Further information is available at www.mercyministries.co.uk More information about street pastors at Wye Valley NHS Trust is available from tinyurl.com/p5xnaah Up to 20 copies of Spirituality in Nursing Care, can be ordered from RCN Direct, at 0845 772 6100
Online archive For related information, visit our online archive and search using the keywords Conflict of interest None declared Acknowledgement The author would like to thank consultant nurse and senior lecturer in emergency care at the University of the West of England Rebecca Hoskins, the team running the Principles of Emergency care course at the university,and the chaplaincy team and volunteers at Wye Valley NHS Trust, Hereford, for their help and encouragement
References British Medical Association (2014) ‘NHS is starting to buckle,’ warns BMA. News, Views, Analysis. tinyurl.com/kn2d4cg (Last accessed: September 15 2014). Cook C, Breckon J, Jay C et al (2012) Pathway to accommodate patients’ spiritual needs. Nursing Management. 19, 2, 33-37. Cruz D, Pearson A, Saini P et al (2011) Emergency department contact prior to suicide in mental health patients. Emergency Medicine Journal. doi:10.1136/emj.2009.081869 Department of Health (2014) Closing the Gap: Priorities for Essential Change in Mental Health. DH, London. Dudhwala Y (2005) Winning the lottery. Nursing Management. 12, 6, 14-15. Folland M (2005) Hope for the future. Nursing Management. 12, 6, 16-21.
Harlow W (2008) Meeting Spiritual Needs on an Acute Mental Health Admission Ward: National Institute for Health and Care Excellence Shared Learning Database. tinyurl.com/oypugoz (Last accessed: September 9 2014). HM Government (2014) Mental Health Crisis Care Concordat: Improving Outcomes for People Experiencing Mental Health Crisis. tinyurl.com/lxltbyp (Last accessed: September 9 2014). Issac L, Davies R (2009) Street Pastors. Kingsway Communications, Eastbourne, East Sussex. Kelly E (2012) The development of healthcare chaplaincy. Expository Times. 123, 10, 469-478. Leith B (2003) NHS Chaplaincy: Meeting the Religious and Spiritual Needs of Patients and Staff. tinyurl.com/olvcqtr (Last accessed: September 11 2014).
38 October 2014 | Volume 22 | Number 6
McManus J (2006) Spirituality and health. Nursing Management. 13, 6, 24-27.
emergency department over a year period. Emergency Medicine Journal. 16, 6, 425-427.
Moore L, Deehan A, Seed P et al (2009) Characteristics of frequent attenders in an emergency department: analysis of a one-year attendance data. Emergency Medicine Journal. 26, 4, 263-267.
National Institute for Health and Care Excellence (2013) Quality Standard for Self-Harm. tinyurl.com/p92dkzj (Last accessed: September 9 2014).
Mowat H (2008) The Potential for Efficacy of Healthcare Chaplaincy and Spiritual Care Provision in the NHS (UK): A Scoping of Recent Research. tinyurl.com/pmky85p (Last accessed: September 9 2014).
Royal College of Nursing (2011) Spirituality in Nursing Care: A Pocket Guide. RCN, London. Skinner J, Carter L, Haxton C (2009) Case management of patients who frequently present to a Scottish emergency department. Emergency Medicine Journal. 26, 2, 103-105.
Mowat H (2011) Defining the Spiritual. tinyurl.com/ntflxlt (Last accessed: September 9 2014).
Speck P (2005) The evidence base for spiritual care. Nursing Management. 12, 6, 28-31.
Murphy A, Leonard C, Plunkett P et al (1999) Characteristics of attenders and their attendances at an urban accident and
Tanner B (2014) Fears that Hereford County Hospital chaplain service will be cut. Hereford Times. tinyurl.com/olmpar9 (Last accessed: September 9 2014).
EMERGENCY NURSE
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