Journal of Religion and Health, Vol. 25, No. 2, Summer 1986
Theological Foundations for Spiritual Care J O H N N. B R I T T A I N A B S T R A C T " Five theological tenets are described which may undergird the integration of religious awareness and spiritual care into nursing curricula. The five all emphasize addressing the articulated needs of the patient within the context of the nursing process. These tenets, while Wesleyan in emphasis, suggest ways in which any nurse may engage in the common ministry of all Christians without usurping the role of clergy or chaplains.
Introduction During the 1984-85 academic year an a t t e m p t was made to integrate an awareness of religious needs and possibilities for spiritual care into the Associate Degree Nursing Curriculum of Wesley College, Dover, Delaware. The approach was built upon five theological tenets which, while Methodist in orientation, we believe may have wider applicability. These five are (1) the wholistic understaneling of persons found in the Judeo-Christian heritage; the characteristically Wesleyan tenets of (2) Arminianism and (3) Sanctification; (4) the Pauline teaching of "Godly Grief," particularly as it pertains to the redemptive nature of suffering; and (5) the recognition and exercising of Spiritual Gifts and Spiritual Fruits within the Christian community.
A wholistic understanding ofpersonhood The Old Testament portrays the human person as an animated whole. Particularly in the account of creation, the first person is depicted as a being animated by the breath of God. In this reference (Genesis 2:7) the first man becomes a living nephesh. While this term elsewhere m a y mean simply "breath," as in J o b 41:21, it here carries the meaning of an enspirited whole, and elsewhere is simply rendered as "person."~ The translation "soul," which has sometimes been used, introduces a dichotomy that is not to be found in the Hebrew. While not usually rendered as "person" in English, the Greek psyche also often means exactly that. Such linguistic considerations lead to the realization that in neither the Old nor the New Testaments is a person portrayed as a combination of soul and flesh as two fundamentally different principles. Rather, "The Hebrews conceived man as an animated body, the Greeks conceived him as an incarnated John N. Brittain, D. Min., is Director of the University Chapel Fellowship at the University of South Florida in Tampa. This article is a revision of a chapter of Dr. Brittain's doctoral dissertation from St. Mary's Seminary and University. 107
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spirit. ''2 In the pastoral approach to health care, this understanding has obvious significance, for it demands a broadened awareness of the affective and spiritual as well as the physical component of care. 3 It can be argued t h a t Jesus' a t t i t u d e toward health, particularly as demons tr ated in the healing ministry recorded in the gospels, was a direct out grow t h of the Old T e s t am e nt understanding of personhood. Morton Kelsey points out t h a t in at least this respect Jesus was more materialistic than other great religious leaders. 4 Whether one regards it positively or negatively, it can hardly be denied t h a t Jesus spent a great amount of time and energy dealing with the physical as well as the spiritual needs of persons. In his book Jesus the Magician, Morton Smith presents an interpretation of the work of Jesus t h a t would be rejected by m a n y Christians, but t hat emphasizes the wholistic n atu r e of Jesus' work. He p o r t r a y s physical healing as the key to understanding Jesus' popularity and success. Thus the rest of the tradition about Jesus can be understood if we begin with the miracles, but the miracles cannot be understood if we begin with a purely didactic tradition . . . . Teachers of the Law were not, in this period, made over into miracle workers. Neither were the authors of apocalyptic prophecies; we have a dozen, and their authors are wholly anonymous. But a miracle worker could easily come to be thought a prophet and an authority on the Law. ~ While it has become traditional to speak of Hippocrates as the " F a t h e r of Medicine," in m a n y ways it is the ministry to the sick of Jesus of Nazareth t h a t has provided the model for the development of much of the Western tradition of health care. Some t ype of health care has always existed, but even s tan d ar d nonreligious t e x t s in nursing point out, " T h e first continuity in the history of nursing began with Christianity. ''~ This continuity was provided primarily by Jesus' wholistic approach to the needs of people. His way of living reflected a deep concern, compassion, and recognition of human worth. His remarkable deeds evoked a new concept of the innate dignity of each person . . . . Instead of "saying the word" and healing the sick, Christ gave individual attention to the needs by touching, anointing and taking by the hand. The parable of the Good Samaritan emphasized the urgency of caring for anyone in need. 7 This dedication to the needs of the whole person is found not only in ancient times, but in the roots of the modern nursing m ovem ent in the work of Pastor Theodor Fliedner both in Kaiserwerth, Germany, and Pittsburgh, and Pastor William Augustus Muhlenberg in New York City. An appreciation for the total needs of persons was one of the hallmarks of the Methodist revival in England and America. The earliest Methodists at Lincoln College, Oxford, visited the asylum and prison. As the revival moved into the coal fields, schools and infirmaries were set up. John Wesley, who recorded numerous healings t hr ough prayer in his widely-read Journal, also wrote Primitive Physick, or an Easy and Natural Method of Curing Most
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D i s e a s e s in 1747, a work t h a t went through more than fifty editions and
reprints and was still in print over a century later, s Following Wesley's example, the early American Methodist circuit riders frequently became adept in folk medicine and functioned as physicians for m a n y of their remote charges. Wesley's own position is made clear by a reflection in his J o u r n a l : Reflecting today on the case of a poor woman who had continual pain in her stomach, I could not but remark the inexcusable negligence of most physicians in cases of this nature. They prescribe drug upon drug, without knowing a jot of the matter concerning the root of the disorder. And without knowing this they cannot cure, though they can murder, the patient. Whence came this woman's pain (which she would never have told had she never been questioned about it)? From fretting for the death of her son. And what availed medicines while that fretting continued? Why, then, do not all physicians consider how far bodily disorders are caused or influenced by the mind, and in those cases which are utterly out of their sphere call in the assistance of a minister; as ministers, when they find the mind disordered by the body, call in the assistance of a physician? But why are these cases out of their sphere? Because they know not God. 9 Wesley's position sounds somewhat progressive today, because in the intervening 225 years the wholistic view of h u m a n i t y has gone out of vogue and only recently staged a comeback. The nineteenth-century European emphasis on dialectical materialism influenced m a n y of the liberal theologies. '~ Methodists, among others, increasingly adopted a philosophical framework which separated the sacred from the secular and the spiritual from the physical." The deaconess movement was still alive in Wesleyan circles, and the "social gospel" movement resulted in the founding of hospitals and orphanages, but often without the kind of wholistic theological underpinning found in Wesley. Following World War II, some attitudes began to change. In 1948 the United States Government sponsored a massive study of heart disease in Framingham, Massachusetts. That study concluded, among other things, t h a t there was no connection between heart disease and stress. The common understanding resulting from such studies was t h a t disease was something " o u t there" that attacked the human body without regard for other facets of the total person, an outlook ably refuted by James J. Lynch in his important work T h e B r o k e n H e a r t . 12 Treatment was often approached with the attitude of a "repair job," not unlike what might be carried out on a piece of machinery. The spiritual, emotional, and economic impacts of illness were sometimes overlooked, sometimes deliberately ruled out as being irrelevant. In 1962, for example, a study group of the United Lutheran Church cautioned against the church becoming involved in what today would be called wholistic medicine. 13 It is noteworthy that it was within the medical community t h a t a multidisciplinary approach to healing began to re-emerge. In the late 1950s and early 1960s some American physicians and researchers began to react against the conclusions of the Framingham s t u d y and to recognize important connections between emotions, beliefs, and physical well-being. Particularly
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within nursing education, there has been a dramatic shift toward a wholistic approach to patient care, so much so that one of the most widely-used texts in nursing fundamentals contrasts the wholistic and biomedical approaches to health care and chooses the former in its presentations. 14 In wholistic nursing considerable importance is given to factors such as the environment of the patient, his or her state of mind, emotional well-being, and social relationships. Illness is no longer viewed as something outside the self that suddenly intrudes, but as part of a wellness spectrum that is affected by many factors. Superficially, it would appear that things have come full circle, with modern health care systems at least approximating the attitude of Jesus and the early church. It becomes apparent at the pastoral level, however, that there are really significant differences. For John Wesley, for example, it was clear that the spirit that gives life comes from God. In one form or another there would have been agreement among the Christian leaders in medicine and nursing that " M a n ' s chief end is to glorify God, and to enjoy him forever." Today it is possible to support the concept of wholistic nursing while overlooking or specifically denying the relevance of a transcendental dimension to human affairs. In an article contending that religious belief is a cause rather than a potential cure of illness, one author argues that when religious language is used with regard to ill persons it is, "purely to move the discussion into the realm of non-reality, thereby setting the stage for the entry of the clergy and other vested-interest religionists. ''15 Since it is no longer taken for granted that the spiritual dimension has validity, it becomes essential for those who lay claim to such a view to manifest a spirit of helping and caring, rather than to posture themselves in any way that suggests special privilege. Wesley College's official philosophy states its conviction that "Education is an intellectual response to a loving God." It is therefore appropriate that this institution reaffirm that its understanding of the wholeness of persons is far more than that of a complex being which can be affected by a variety of causes. Rather, we understand the enspiriting of humanity somehow to reflect the divine character: we are made in the image of God. (Genesis 1:26} This understanding and affirmation have at least three direct consequences for a nursing program: they suggest that those who prepare to give service to others can understand themselves better by deepening their own relationship with God; they suggest that those they serve can be aided b y being helped in their relationship with God; and they suggest the importance of care for all, since all persons are created with the divine spirit and in the image of God. Involved, then, is self-knowledge, a willingness and ability to enable others to gain self-knowledge, and a noncritical acceptance of the path others take on their spiritual pilgrimage. At the pastoral level this necessitates a real understanding of the wholistic nature of persons and an integration of these concepts into the understanding of the total nursing process, so that the spiritual component is not perceived as an auxiliary enterprise simply "tacked on" for insufficient or even spurious reasons. Writing of a church-based health clinic in Kingston, Jamaica, Ezra E. H. Griffith, M.D., has described problems encountered in attempts to integrate
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services catering to spiritual, psychological, and orthodox medical needs of clients. In spite of sharing a facility and a philosophy of treating the whole person, the clinic under study failed to integrate the kinds of practice offered. Griffith observed t h a t a religious ritual, which marked the opening of the clinic the two nights a week it was in operation, was meant to be attended by the entire staff and serve, among other functions, to build community. In fact, the service was rarely attended by physicians and commonly missed by other technical staff, so t h a t it remained the domain of the lay religious workers. Without the attendance of the medical personnel, these services tended to focus on the laying-on-of-hands and prayers for miraculous healing. In the medical subdivision of the clinic it was found t h a t the physicians performed standard clinical practice with no reference to any healing mode other than clinical, including counseling, although a number of cases were reported to the physicians t h a t could have benefited from counseling or group support. The counseling subdivision was the least used and, for the most part, was perceived as a place for " m a d " persons. 16 In spite of an apparently adequate philosophical base and a dedication t h a t required both financial support and risk on the part of the sponsoring church, Griffith concluded that the clinic was characterized primarily by missed opportunities. The orthodox medical practitioners saw all the patients in this sample. Yet a significant percentage of the patients' psychological problems either were not detected or were elicited and then ignored. Certainly, few of the patients were referred to the psychological counselors. In addition, personnel in the medical and psychological sectors had serious reservations about the . . . prayer partners. 17 Many general lessons can be drawn from this situation, which is not unlike the experience in m a n y American hospitals where social work and pastoral care components, if present, are not fully accepted and integrated into health care programs. This denotes both a lack of understanding and a lack of acceptance of any function except that of orthodox medical care. These observations suggest a twin danger for our enterprise. On the one hand, it would be easy for spiritual care to become an entity unto itself, separated from and even antagonistic to the main function of the nursing professional, as it has with some splinter groups. On the other hand, the Christian nurse or pastoral care worker m a y become simply an " a m a t e u r doctor," imitating the physician and using clinical jargon in an a t t e m p t to be accepted. Neither is appropriate. It is imperative, rather, to develop strategies for acknowledging and nurturing the spiritual dimension in both patient and nurse. In the health care setting this dimension most often manifests itself in issues of self-worth, doubt, values, and grief. This end m a y be accomplished not only by the nurse respecting the special competence of the pastoral counselor or chaplain, but also by the nurse developing a deeper awareness of those areas where he or she, as nurse, m a y offer spiritual help and allow the patient to use the spiritual resources he or she already possesses.
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Arminianism
Technically, the term Arminianism refers to the system of theology t a u g h t by Professor James Arminius at the University of Leyden in the late sixteenth century. His teachings specifically denied the type of absolute and unconditional election then current in some Calvinist circles and earned him accusations of Pelagianism.18 Originally applied to John Wesley as an epithet, the term "Arminianism" was later adopted by him to signify his understanding of God's free grace and concern for every person. For m a n y later Methodists it has come to signify little more than their affirmation t h a t the primary understanding of God is one who is active in the world over against the view that God is sovereign over, and implicitly somewhat removed from, the world. 19 For our purposes, we m a y define four points commonly understood by Wesleyans to make up the essence of Methodist Arminianism with the belief t h a t they may be substantiated by the New Testament. 1. 2. 3. 4.
All have sinned. {Romans 3:23) All may be saved. {Romans 3:24) All m a y have knowledge and assurance of salvation. (I John 5:13) Any individual m a y fall from grace or "backslide"; salvation is not a guarantee of perfection.
The assertion of universal sin is not a negative one or a judgment about the " t o t a l depravity of man." It is, rather, an acknowledgment of the universal predicament of humanity. {Romans 5:12) Rather than a negative statement, it is one t h a t defines a common starting point and affirms that we are all in the same situation. It is this basic understanding t h a t opens the door to an important corollary of Methodist Arminianism: because of the basic equality of all and the common human predicament, the Christian community has a special obligation toward those who are disenfranchised and in special need of grace. Arminianism lays the groundwork for following the Lucan example of Jesus' graciousness in dealing with both the righteous and the sinner, with persons of all races and classes. In the health care system, the way in which persons with handicapping conditions or psychiatric problems, the elderly, and those unable to pay are treated will reveal our point of view. Arminianism stresses an underlying understanding of common h u m a n i t y as opposed to a segmented view of the righteous and the sinner, those worthy of help as opposed to the unworthy or those needing salvation over against the self-perfected. In a sermon on money, Wesley saw such dangers in his day: And are not they partakers of the same guilt [greed] . . . whether surgeons, apothecaries or physicians, who play with the lives or health of men, to enlarge their own gain? who purposely lengthen the pain or disease, which they are able to remove speedily? who protract the cure of their patient's body, in order to plunder his substance? 2~
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A r m i n i a n i s m opens the door for c o m m u n i c a t i o n and c o o p e r a t i o n with all who have some " k n o w l e d g e of s a l v a t i o n . " As a p r o d u c t of his times, J o h n W e s l e y saw clear theological adversaries: the Calvinists and the Papists. Yet he was r e m a r k a b l y open to all who seemed, b y the q u a l i t y of their lives, to evidence a t r u e religious experience. A f t e r a 1749 visit to Ireland, he c o m p o s e d a " L e t t e r to a R o m a n Catholic," which c o n t i n u e d to be r e p r i n t e d and circulated d u r i n g the rest of his life. A f t e r c o m m e n t i n g on the m a n y areas of a g r e e m e n t between R o m a n Catholics and " t r u e P r o t e s t a n t s , " W e s l e y wrote: Are we not thus far agreed? Let us thank God for this, and receive it as a fresh token of his love. But if God still loveth us, we ought also to love one another. We ought, without this endless jangling about opinions, to provoke one another to love and to good works. Let the points wherein we differ stand aside: here are enough wherein we agree, enough to be the ground of every Christian temper and of every Christian action. O brethren, let us not still fall out by the way. I hope to see y o u in heaven. And if I practice the religion above described, you dare not say I shall go to hell . . . . Then if we cannot as yet t h i n k alike in all things, at least we may love alike. 21 There are clear inferences for spiritual care in this A r m i n i a n perspective. First, there is no place for p r o s e l y t i n g those who h a v e their own religious beliefs or for imposing a p a r t i c u l a r viewpoint on t h o s e whose search is t a k i n g t h e m in a n o t h e r direction. Second, t h e r e is no r o o m for p r o v o k i n g p a t i e n t s or fellow workers to a n y t h i n g b u t m u t u a l support. I t is always possible, even within a given religious tradition, to find an " e n d l e s s j a n g l i n g of o p i n i o n s . " These need to be set aside in the c o n t e x t of s u p p o r t a n u r s e is called u p o n to provide. Third, t h e r e is no r o o m for s t e r e o t y p i n g . E v e n when one accepts a wholistic view of persons, t h e r e are value conflicts. Two examples of such conflicts which m a y lead to serious s t e r e o t y p i n g problems come from small c o n t e m p o r a r y religious groups. The A m i s h and M e n n o n i t e c o m m u n i t i e s were the focus of h o s t i l i t y in the late 1970s when, d u r i n g polio o u t b r e a k s in P e n n s y l v a n i a , t h e y were r e l u c t a n t to receive inoculations. This led to scorn from m a n y , including h e a l t h care professionals, who viewed t h e m as b a c k w a r d and s t u b b o r n individuals t h r e a t e n i n g the life of the whole c o m m u n i t y . Only when it b e c a m e clear t h a t t h e y were n o t o p p o s e d to inoculations per se, b u t only to u n n e c e s s a r y medical t r e a t m e n t , was t h e impasse resolved: the p r e v e n t i v e t r e a t m e n t was seen as n e c e s s a r y and was undertaken. 22 A n o t h e r group t h a t is the focus of r e c u r r e n t h o s t i l i t y is the J e h o v a h ' s Witnesses who, because of their v e r y literal i n t e r p r e t a t i o n of the Scriptures, absolutely refuse to accept blood t r a n s f u s i o n s . A c c o r d i n g to H o r a c e H e r b s m a n , M.D., m a n y p h y s i c i a n s h a v e such s t r o n g feelings a g a i n s t this sect t h a t t h e y h a v e a d o p t e d one of two tactics: a t t e m p t i n g to convince J e h o v a h ' s W i t n e s s p a t i e n t s t h a t their religious r e s e r v a t i o n s a b o u t blood t r a n s f u s i o n s are misdirected, or d e m a n d i n g the signing of a legal waiver before even e m e r g e n c y t r e a t m e n t is considered. H e views the first as philosophically questionable,
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since it requires the p a t i e n t to c o m p r o m i s e his or her u n d e r s t a n d i n g of G o d at a t i m e of p o t e n t i a l spiritual need; the second is legal intimidation. W r i t i n g as a physician, Dr. H e r b s m a n ' s c o n t e n t i o n is t h a t there are m a n y a l t e r n a t i v e protocols to blood t r a n s f u s i o n available for the t r e a t m e n t of J e h o v a h ' s Witness p a t i e n t s which are overlooked or ignored because of the physicians' inclination to dismiss the i m p o r t a n c e of their religious scruples. 23 B o t h of these illustrations u n d e r s c o r e the need to view all persons as equals in need of the same grace and the same consideration. The final c o m m o n t h r u s t of A r m i n i a n i s m is the traditional W e s l e y a n concern for " b a c k s l i d i n g " : the affirmation t h a t salvation is not a p e r m a n e n t s t a t e once a t t a i n e d b u t one t h a t requires c o n s t a n t a t t e n t i o n . In the c o n t e x t of the n u r s i n g process it is, therefore, not acceptable simply to m a k e n o t e of a p a t i e n t ' s denomination. Nor is it sufficient to rely on the c o m m o n practice of r e f e r r i n g only t h o s e who h a v e no c h u r c h affiliation to the p a s t o r a l care departm e n t as if c h u r c h affiliation s o m e h o w g u a r a n t e e s spiritual health. This p a r t of Arminianism, while easily m i s u n d e r s t o o d as pessimistic and negative, is a call for c o n s t a n t n u r t u r e and care. The practical implications of A r m i n i a n i s m seem clear. First, it requires equal physical and spiritual care for all with a deliberate bias t o w a r d the poor and disenfranchised. 24Second, it c o m m a n d s an a p p r o a c h where the focus is the p a t i e n t ' s beliefs r a t h e r t h a n the nurse's. The p r i m a r y t a s k is to discover and use the faith resources already at work in the individual. This requires t h a t the care-givers be aware of and secure in their own religious position. The nurse must be self-confident, not anxious or confused about her own relationship to God. Her ideas may not coincide with those of the patient but under no circumstances should she try to convert the patient to her way of thinking. 25 Third, p a t i e n t s should not be left to their own resources simply because t h e y indicate a church relationship or use religious language. N o t all religious terminology, beliefs, or ideation are healthy. We are on a pilgrimage, not at a destination, and need c o n s t a n t e n c o u r a g e m e n t and help along the way.
Sanctification One of J o h n W e s l e y ' s favorite t h e m e s was the relationship of faith and life often found u n d e r the M e t h o d i s t rubrics of " h o l y living," " h o l i n e s s , " "sanctification," or " C h r i s t i a n P e r f e c t i o n . " What is religion then? It is easy to answer, if we consult the oracles of God. Accounting to these, it lies in one single point: it is neither more nor less than love. It is love which "is the fulfilling of the law, the end of the commandment." Religion is the love of God and our neighbour; that is, every man under heaven. 26
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During his lifetime Wesley often complained t h a t the Catholics and Calvinists alike set standards of Christian living too high, so t h a t t h e y would be attainable only in " g l o r y . " His detractors complained t h a t Wesley's standards were too low and fostered delusions of grandeur and self-righteousness. 27 Today, jus t as then, there are problems with Wesleyan nomenclature. Some groups use the term "holiness" to denote a kind of ecstatic worship t h a t Wesley would have condemned as " e n t h u s i a s m " ; others claim "perfect i on" in an arrogant manner. As a result, m a n y c o n t e m p o r a r y Methodists shy away from this language. Nonetheless, it denotes the ongoing work of the Holy Spirit in the life of the believer in a way t h a t is not only scriptural, but essential to grasping the traditional Methodist concern with "practical p i e t y . " For Wesley, "holiness" was always understood in terms of the twin dimensions of internal holiness {love of G o d and neighbor} and external holiness {love of God and neighbor). 2s It states firmly the conviction t h a t religion is not a m a t t e r of dogma separated from the real world, nor promise m eant to be fulfilled only in the next life. Neither is it a m a t t e r of "pulling one's self up by the b o o t s t r a p s . " Real Christianity is an intermingling of internal and external holiness. The importance of the Methodist doctrine of Sanctification for nursing is practically self-evident: not only is it desirable, but it is affirmed as possible truly to live the qualities needed in spiritual care. Spiritual nurt ure and care can thus be given, even as the nurse attends to the more " r o u t i n e " or " n e c e s s a r y " duties, since spiritual care is delivered as much by who one is as by what one says. Care is expressed in nursing by tending to another, being with him, assisting him, giving heed to his responses, and guarding him from danger--and doing this with compassion as opposed to tolerance, with tenderness as opposed to a sense of duty, and with respect as opposed to obligation. 29 In co n tem por ar y nursing training, particularly in psychiatric nursing, emphasis is placed on the therapeutic use of self or the offering of self. 3~Since the Wesleyan position stresses t ha t positive behavioral characteristics m a y be forged out of a personal, growing relationship with God, the use of self carries the o p p o r t u n i t y for spiritual nurture. As the nurse grows in his or her own spiritual awareness, it is possible for him or her to incarnate the spiritual qualities the patient requires, so t h a t the patient m a y appropriate t h e m in his or her own way. When the client cannot trust, the nurse can be faithful, be consistent, and follow through on commitments and time schedules. When the client is in turmoil and confusion, the nurse can demonstrate calmness and stability. When the client does not feel loved and accepted, the nurse can love and accept the client. When the client cannot feel forgiven, the nurse can show forgiveness and acceptance. When the client feels hopeless, the nurse can offer hope. 31
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Godly grief Nowhere does the therapeutic use of self become more crucial than in helping persons confront and deal with grief, not only in facing death but with regard to the necessity to change lifestyle as a result of illness or aging. It is widely recognized t h a t grief is a process rather than an event and that the ability to pass through several somewhat predictable, although not invariable, stages of grief can be positively correlated with recovery. 32 From a theological perspective we are reminded by Paul t h a t grief in itself is neither good nor bad: it m a y be Godly grief t h a t results in some kind of amendment of life or changed attitude; or it m a y be a negative force t h a t leads to depression or even, quite literally, death. For Godly grief produces a repentance that leads to salvation and brings no regret, But worldly grief produces death. (II Corinthians 7:10) Eugene Peterson has pointed out, "The biblical revelation neither explains nor eliminates suffering. It shows, rather, God entering into the life of suffering humanity, accepting and sharing the suffering. ''33 Taking her cue from Viktor Frankl's logotherapy, Sr. Corita Dickinson has argued that it is the search for meaning t h a t determines a person's perspective in situations of suffering and loss. If whatever we are doing is meaningless to us, we are desperately unhappy; but if whatever we are suffering has some meaning, we can be at peace. 34This search for God within illness and suffering, not as stern judge using the illness as a bully pulpit from which to chastise the sufferer, but as fellow sufferer, offers the opportunity for finding meaning and growth even in grief, rather than simply coping with a necessary evil. One of the differences between theology and technology is that the former is concerned not only with what is but with what it means. 35 From the biblical viewpoint one meaning of grief is that we may enter into the experience of God whose love for the world and overtures to humanity have often been frustrated and caused Him grief. God is not perceived as a " G o d of the Gaps" injected from the outside into situations where He really does not fit; He is rather already present waiting to be discovered within the depths of emotion. The helper who has experienced Sanctification, who has been aware of God's presence in him- or herself and/or others in a variety of life situations can be present with a person going through the grief process in a way that will enable t h a t person to sense God's presence in it. Understanding grief within the larger context of Sanctification encourages two things, both of which have been pointed out by Eugene Peterson from a totally different perspective. 3~ First, it encourages grievers to organize their grief within the context of their own lives and, one hopes, within the context of the faith community. The latter could take the form of biblical narratives, the lives of saints, or oral tradition from the local community. This examination of grief in context encourages the appreciation of the significance of every detail
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of life and reflects the stance of faith t h a t God is ready to meet us in every aspect of life. It encourages entry into, rather than escape from, life. Second, by placing suffering in its life context, it allows it to take its place, ominous as it may be, among other things. Suffering is never all there is, and the grieving process should not permit it to become an obsession. The therapeutic use of self in spiritual care uses techniques t h a t are common to other kinds of helping. In the case of grieving, appropriate interventions would be support, awareness of the patient's needs, empathy, and nonjudgmental understanding. 3v If they are to be effective in transforming worldly grief into Godly grief, however( these or any techniques need to be supported by the affirmation t h a t it is possible to encounter God in the process. What Hans Kting has recently written regarding eternal life m a y be paraphrased with regard to grief. 38 The immediate question anyone asks, particularly within the utilitarian mind-set of health care, is, "Does belief in God make grief easier?" The honest answer is, "No, belief in God does not necessarily make it easier to face suffering or pass through the stages of grief." The further question, if it is asked, is, "Does it make any difference?" Here the answer is, "Yes." For an experience of the sanctifying presence of God within the context of grief provides us with the opportunity to assent to suffering in a way t h a t affirms that "there is nothing in all creation t h a t can separate us from God's love. ''39 Whatever the root cause, it is clear t h a t suffering and grief are part of the fabric of life. A flight from suffering is therefore a flight from life? ~Conversely, the affirmation of suffering with hope is part of our great "Yes" to life and to God. 41 The nurse can provide a companionship t h a t incarnates God's love and supports this process of affirmation. Daniel Simundson has described two levels at which the Bible addresses suffering: the intellectual level and the survival level. 42The intellectual level deals with the great whys: why there is suffering in the world and why it comes to some but not all. For any final resolution of the issue of suffering, this level needs to be addressed, but it is best handled at times when there is some breathing space for reflection. The survival level provides support and comfort for the sufferer. While it may not provide the final integrating answer, the survival approach bridges those times when suffering so preoccupies patients t h a t they can think of little else. One could say t h a t the error of Job's counselors was t h a t they moved too quickly from the survival level to the intellectual level, imposing ideological answers of their own to Job's questions. (Job 2:13) The nurse, by virtue of his or her short-term crisis-dominated relationship with m a n y patients, will largely deal at the survival level, utilizing the therapeutic use of self, encouraging and enabling the patient to move to the intellectual level.
Spiritual gifts and spiritual fruits Four positions have been examined thus far: the wholistic nature of persons as spiritual beings; the traditional Wesleyan doctrine of Arminianism; the
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Methodist teachings of Sanctification; and the position that in and through grief one can encounter God, that grief need not be worldly grief but may be Godly grief. One can accept these four tenets and their implications for health care and still ask, " B u t is it the nurse's role to be concerned about such matters? Will he or she not be competing with others whose main interest and responsibility is the spiritual? Are not these things better left to the pastoral care team or the visiting minister?" One superficial but important answer to these questions is that in many smaller hospitals there is no pastoral care team, and the system by which local ministers are notified of hospitalized parishioners is so loose that one often wonders if the very concept of the "visiting minister" has any validity. Many Wesley College graduates work in such facilities. At this level, then, a flippant answer would be, "The nurse needs to do it because no one else does." There is, however, a more profound level of understanding, building on the concepts so far presented. In John Wesley's teachings about Sanctification, holiness of living, and Christian Perfection, he stressed the importance of the ordinary Fruits of the Spirit for all Christians (Galatians 5:22f.) in conjunction with the extraordinary Gifts of the Spirit which are given to some for particular tasks within the Church. (I Corinthians 12:4f.p 3 These and similar teachings have been the focus of great attention in the past fifteen years as some categories traditionally associated only with small Holiness sects have been integrated into the mainline churches. One of the results of this has been some lack of clarity. In particular, there has been so much concern with extraordinary Gifts of the Spirit, such as speaking in tongues or miraculous healing, that the more ordinary gifts, which form the backbone for the doctrines of Sanctification and Christian Perfection, have been ignored or underestimated. 44 Some authors, who should know better, have even implied that Wesley did not know the difference between the Spiritual Gifts, enumerated by Paul in places like I Corinthians 12, and Spiritual Fruits, such as those mentioned in Galatians 5. 4~ While it is true that Wesley's terminology is not that of the Revised Standard Version, a reading of his thought makes it clear that he had this distinction in mind. 46 The distinction is simply this: Gifts of the Spirit are those special endowments that are provided individuals in order to accomplish certain vocations within the church. The Spiritual Gift of healing (I Corinthians 12:9), for example, could be interpreted to include the particular abilities with which some especially good nurses are endowed. Spiritual Fruits, on the other hand, are those manifestations of the Holy Spirit such as love, gentleness, and selfcontrol (Galatians 5:23) with which all Christians are equipped for the living of a life within the reign of God. (Galatians 5:21) One would not necessarily expect the nurse to exhibit the same Spiritual Gifts as a pastoral care worker, but one can expect the nurse to be sympathetic with, if not a personal possessor of, the characteristics of the Spiritual Fruits. In fact, owing to availability and involvement with the patient in ways that break down normal resistance and barriers {assistance with bathing or elimination}, the nurse may be in a better position to exhibit patience and self-control in a meaningful way than the floor chaplain or visiting minister.
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In 1968, Ruth Piepgras, writing in the American Journal of Nursing, posed some questions about nurses being involved in meeting patients' spiritual needs. 47 They remain critical questions. By addressing some of them, the theological positions put forth in this essay m a y be summarized, and the distinction between Spiritual Gifts and Spiritual Fruits m a y be further explicated. " B y what authority can a nurse undertake the spiritual guidance of a patient? I s n ' t it better to avoid taking a stand?" Because we are dealing with a wholistic approach to persons, we realize t h a t it is impossible not to take a stand with regard to spiritual needs. A t t e m p t s to avoid them are often interpreted either as hostility or a feeling t h a t spiritual and emotional needs are unimportant. Some statement about this component of the human person will be made one way or another. " I s it permissible to interfere in a private personal area of the human spirit? Will interference lead a nurse to impose her own point of view or, worse yet, her own confusion?" Interference is not advocated or acceptable according to the understandings we have outlined. The primary goal is to allow the patients to use the spiritual resources they already have, if any, or to discover meaning in the circumstance in which they find themselves. The Spiritual Fruits of love, joy, and patience can be manifested in empathy and non-judgmental understanding. Interference may well result if the nurse a t t e m p t s to exercise some specific gift such as didactic teaching or evangelization. There m a y be individuals with such gifts that they will exercise elsewhere, but t h a t will not be appropriate for them to use as nurses. " I s n ' t a nurse exceeding her ability when she discusses religious questions with the patient who is entrusted to her care and who trusts her?" He or she well may be. It is important to distinguish between the kind of spiritual care with which we have been primarily concerned and specifically religious matters in the sectarian sense. The nurse m a y support the patients' desire to deepen their relationship with God and be supportive of the patients' requests for prayer. At the point at which a Roman Catholic patient asks the Baptist nurse for aid in remembering the rosary, or at which the Pentecostal patient asks the Presbyterian nurse for a certain kind of spontaneous prayer, there should be no a t t e m p t at hollow compliance. It is possible, however, to be supportive and to seek appropriate help, perhaps from another nurse on the unit who will be comfortable in meeting the specific request. The discussion of religious questions, if it means debating the doctrines of differing or even competing churches, is not a part of spiritual care and violates the basic tenet of Arminianism mentioned earlier. 48 If it means a sharing of beliefs or meaningful experiences in a non-judgmental manner, it can be most valid and helpful. The question is a difficult one because it is a good one. Is a nurse exceeding his or her ability? That is an individual question that must be answered in each specific situation. " W o n ' t the nurse be competing with the clergy in a function t h a t is rightfully theirs?" Not if the nurse is involved in the area of Spiritual Fruits which enable the common ministry of all Christians. The clergy or commissioned lay workers have a particular vocation, generally recognized by a certain
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denomination and, more often than not, tied up with the promotion of that denomination's point of view. It m a y be appropriate on occasion for the visiting minister to exhort the patients to reaffirm their beliefs and remind them how members of their particular communion regard illness or suffering. It would be wholly inappropriate for the nurse to try to convert the patient to his or her point of view through similar exhortations. Sacramental and liturgical matters are the province of the official religious worker. For many Protestants an informal reading of the Bible and prayer time have special meaning because they are with the "Preacher." Verna Carson writes of the possibilities open to a nurse who is recognized as a "pray-er," 49one who is open to spiritual matters. A "pray-er" does not necessarily compete with the clergy, but is open to the spiritual dimension in his or her own way. It is when some general theological base is lacking and when the distinction between Spiritual Gifts and Spiritual Fruits has not been thought through that problems arise. "Witnessing" may be substituted for non-judgmental understanding; doctrinaire tracts may be placed on trays in an attempt to "do something." In many Protestant churches the only model the believer has for ministry or spiritual care is that of the pulpiteer; so exhortations that might be acceptable in a general context from the pulpit are used in a manner that is less than sensitive or helpful.
Conclusion The nurse can meet the spiritual needs of patients by applying the five theological tenets stated above. An awareness of the wholistic nature of persons m a y lead to an openness to and support of the spiritual dimension of the patient's life. Arminianism encourages focusing on the patient's beliefs and using the faith resources already at work in the individual. The practical bent of Wesleyan theology encourages the nurse to incarnate the qualities that make for spiritual health, entering into the experiences of suffering and grief in ways that enhance the redemptive possibilities for the patient. All of these goals m a y be achieved by exercising the ordinary Spiritual Fruits available to all without interfering with the patient's beliefs or usurping the role of the clergy.
References 1. Burrows, M., An Outline of Biblical Theology. Philadelphia, The Westminster Press, 1946, p. 135. 2. McKenzie, J.L., Dictionary of the Bible. Milwaukee, The Bruce Publishing Company, 1965, p. 539. 3. Dickinson, C., "The Search for Spiritual Meaning," Amer. J. Nursing, October 1975, 75, 1790. 4. Kelsey, M.T., Healing and Christianity. New York, Harper and Row, 1973, p. 53. 5. Smith, M., Jesus the Magician. San Francisco, Harper and Row, 1978, p. 16. 6. Ellis, J.R., and Hartley, C.L., Nursing in Today's World. Philadelphia, J. B. Lippincott Company, 1980, p. 14. 7. Dolan, J.A., Nursing In Society. Philadelphia, W.B. Saunders, 1978, p. 43. 8. Kelsey, op. cit., p. 233. 9. Wesley, J. In Burtner, R.W., and Chiles, R.E., A Compend of Wesley's Theology. New York, Abingdon, 1954, p. 245.
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10. Ki]ng, H., EternaILife? Garden City, New York, Doubleday, 1984, p. 23. 11. Kelsey, o19. cit., p. 27. 12. Lynch, J.J., The Broken Heart: The Medical Consequences of Loneliness. New York, Basic Books, 1977, p. 23. 13. Kelsey, o19. cit., p. 26. 14. Wolff, L.; Weitzel, M.; Zornow, R.; and Zsohar, H., Fundamentals of Nursing, 7th ed. Philadelphia, J.B. Lippincott, 1983, p. 118. 15. Graves, C.C., "Religion: Cause or Cure?" Perspectives in Psychiatric Care, 1983, 21 27, 37-38. 16. Griffith, E.E.H., "The Significance of Ritual in a Church-Based Healing Model," Amer. J. Psychiatry, May 1983,140 568-572. 17. Ibid., 570. 18. Simpson, M., ed., Cyclopedia of Methodism. Philadelphia, Everts and Stewart, 1878, pp. 53-54. 19. Outler, A.C., ed.,John Wesley. New York, Oxford University Press, 1964, p. 478. 20. Wesley, In Burtner and Chiles, op. cit., p. 242. 21. . In Outler, ed.,John Wesley, o19. cit., p. 478. 22. Darocy, C., "Religious Considerations in Patient Care," J. Practical Nursing, December 1979, 18-21, 31. 23. Herbsman, H., "Treating the Jehovah's Witness," Emergency Medicine, January 15, 1980, 75-76. 24. Fish, S., and Shelly, J.A., Spiritual Care: The Nurse's Role. Downer's Grove, Illinois, InterVarsity, 1983, p. 30. 25. Piepgras, R., "The Other Dimension: Spiritual Help," Amer. J. Nursing, December 1968, 68 2613. 26. Wesley, J. In Outler, Albert C., Theology in the Wesleyan Spirit. Nashville, Tidings, 1975, p. 83. 27. Outler, ed.,John Wesley, o19. cit., p. 283. 28. - - , Theology in the Wesleyan Spirit, p. 72. 29. Dickinson, op. cit., p. 1790. 30. Manfreda, M.L., and Krampitz, S.D., Psychiatric Nursing. Philadelphia, F.A. Davis Company, 1977, pp. 253-259. 31. Shelly, J.A.; John, S.D.; et al., Spiritual Dimensions of Mental Health. Downers Grove, Illinois, InterVarsity, 1983, p. 87. 32. Wolff et al., op. cit. pp. 772-776. 33. Peterson, E.H., Five Smooth Stones for Pastoral Work. Atlanta, John Knox Press, 1980, pp. 93-94. 34. Dickinson, o19. cit. p. 1790. 35. Studer, J.N., "Toward a Theology of Healing," J. Religion and Health, 1982, 21, 4,286. 36. Peterson, op. cit., pp. 99-101. 37. Dickinson, op. cit., p. 1792. 38. K~ng, op. cit., pp. 230-234. 39. Soelle, D., Suffering. Philadelphia, Fortress Press, 1975, p. 103. 40. Ibid., p. 88. 41. Ibid., p. 108. 42. Simundson, D.J., Faith Under Fire. Minneapolis, Augsburg Publishing House, 1980, pp. 144-151. 43. Wesley. In Burtner and Chiles, op. cir., pp. 102-104. 44. Outler, Theology in the Wesleyan Spirit, op. cit., p. 78. 45. Kinghorn, K.C., Gifts of the Spirit. Nashville, Abingdon, 1976, p. 16. 46. As these t h o u g h t s were being organized, a student presented a concern that has become increasingly common in recent years: he had been in a service where it was asserted t h a t anyone who did not speak in tongues was not a true believer. There was then an opportunity for those in attendance to go forward, be slain in the spirit, and speak in tongues. He was troubled since his Nazarene background was at variance with what he had experienced. As a Nazarene with Wesleyan background, it was not hard to discuss the difference between Spiritual Fruits and Gifts and to distinguish between Christian Sanctification and "Enthusiasm." 47. Piepgras, o19. cit., p. 2611. 48. See my discussion of Arminianism earlier in this paper. 49. Carson, V., "Meeting the Spiritual Needs of Hospitalized Psychiatric Patients," Perspectives in Psychiatric Care, 1980,18, 20.
Theological Foundations for Spiritual Care J O H N N. B R I T T A I N A B S T R A C T " Five theological tenets are described which may undergird the integration of religious awareness and spiritual care into nursing curricula. The five all emphasize addressing the articulated needs of the patient within the context of the nursing process. These tenets, while Wesleyan in emphasis, suggest ways in which any nurse may engage in the common ministry of all Christians without usurping the role of clergy or chaplains.
Introduction During the 1984-85 academic year an a t t e m p t was made to integrate an awareness of religious needs and possibilities for spiritual care into the Associate Degree Nursing Curriculum of Wesley College, Dover, Delaware. The approach was built upon five theological tenets which, while Methodist in orientation, we believe may have wider applicability. These five are (1) the wholistic understaneling of persons found in the Judeo-Christian heritage; the characteristically Wesleyan tenets of (2) Arminianism and (3) Sanctification; (4) the Pauline teaching of "Godly Grief," particularly as it pertains to the redemptive nature of suffering; and (5) the recognition and exercising of Spiritual Gifts and Spiritual Fruits within the Christian community.
A wholistic understanding ofpersonhood The Old Testament portrays the human person as an animated whole. Particularly in the account of creation, the first person is depicted as a being animated by the breath of God. In this reference (Genesis 2:7) the first man becomes a living nephesh. While this term elsewhere m a y mean simply "breath," as in J o b 41:21, it here carries the meaning of an enspirited whole, and elsewhere is simply rendered as "person."~ The translation "soul," which has sometimes been used, introduces a dichotomy that is not to be found in the Hebrew. While not usually rendered as "person" in English, the Greek psyche also often means exactly that. Such linguistic considerations lead to the realization that in neither the Old nor the New Testaments is a person portrayed as a combination of soul and flesh as two fundamentally different principles. Rather, "The Hebrews conceived man as an animated body, the Greeks conceived him as an incarnated John N. Brittain, D. Min., is Director of the University Chapel Fellowship at the University of South Florida in Tampa. This article is a revision of a chapter of Dr. Brittain's doctoral dissertation from St. Mary's Seminary and University. 107
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spirit. ''2 In the pastoral approach to health care, this understanding has obvious significance, for it demands a broadened awareness of the affective and spiritual as well as the physical component of care. 3 It can be argued t h a t Jesus' a t t i t u d e toward health, particularly as demons tr ated in the healing ministry recorded in the gospels, was a direct out grow t h of the Old T e s t am e nt understanding of personhood. Morton Kelsey points out t h a t in at least this respect Jesus was more materialistic than other great religious leaders. 4 Whether one regards it positively or negatively, it can hardly be denied t h a t Jesus spent a great amount of time and energy dealing with the physical as well as the spiritual needs of persons. In his book Jesus the Magician, Morton Smith presents an interpretation of the work of Jesus t h a t would be rejected by m a n y Christians, but t hat emphasizes the wholistic n atu r e of Jesus' work. He p o r t r a y s physical healing as the key to understanding Jesus' popularity and success. Thus the rest of the tradition about Jesus can be understood if we begin with the miracles, but the miracles cannot be understood if we begin with a purely didactic tradition . . . . Teachers of the Law were not, in this period, made over into miracle workers. Neither were the authors of apocalyptic prophecies; we have a dozen, and their authors are wholly anonymous. But a miracle worker could easily come to be thought a prophet and an authority on the Law. ~ While it has become traditional to speak of Hippocrates as the " F a t h e r of Medicine," in m a n y ways it is the ministry to the sick of Jesus of Nazareth t h a t has provided the model for the development of much of the Western tradition of health care. Some t ype of health care has always existed, but even s tan d ar d nonreligious t e x t s in nursing point out, " T h e first continuity in the history of nursing began with Christianity. ''~ This continuity was provided primarily by Jesus' wholistic approach to the needs of people. His way of living reflected a deep concern, compassion, and recognition of human worth. His remarkable deeds evoked a new concept of the innate dignity of each person . . . . Instead of "saying the word" and healing the sick, Christ gave individual attention to the needs by touching, anointing and taking by the hand. The parable of the Good Samaritan emphasized the urgency of caring for anyone in need. 7 This dedication to the needs of the whole person is found not only in ancient times, but in the roots of the modern nursing m ovem ent in the work of Pastor Theodor Fliedner both in Kaiserwerth, Germany, and Pittsburgh, and Pastor William Augustus Muhlenberg in New York City. An appreciation for the total needs of persons was one of the hallmarks of the Methodist revival in England and America. The earliest Methodists at Lincoln College, Oxford, visited the asylum and prison. As the revival moved into the coal fields, schools and infirmaries were set up. John Wesley, who recorded numerous healings t hr ough prayer in his widely-read Journal, also wrote Primitive Physick, or an Easy and Natural Method of Curing Most
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D i s e a s e s in 1747, a work t h a t went through more than fifty editions and
reprints and was still in print over a century later, s Following Wesley's example, the early American Methodist circuit riders frequently became adept in folk medicine and functioned as physicians for m a n y of their remote charges. Wesley's own position is made clear by a reflection in his J o u r n a l : Reflecting today on the case of a poor woman who had continual pain in her stomach, I could not but remark the inexcusable negligence of most physicians in cases of this nature. They prescribe drug upon drug, without knowing a jot of the matter concerning the root of the disorder. And without knowing this they cannot cure, though they can murder, the patient. Whence came this woman's pain (which she would never have told had she never been questioned about it)? From fretting for the death of her son. And what availed medicines while that fretting continued? Why, then, do not all physicians consider how far bodily disorders are caused or influenced by the mind, and in those cases which are utterly out of their sphere call in the assistance of a minister; as ministers, when they find the mind disordered by the body, call in the assistance of a physician? But why are these cases out of their sphere? Because they know not God. 9 Wesley's position sounds somewhat progressive today, because in the intervening 225 years the wholistic view of h u m a n i t y has gone out of vogue and only recently staged a comeback. The nineteenth-century European emphasis on dialectical materialism influenced m a n y of the liberal theologies. '~ Methodists, among others, increasingly adopted a philosophical framework which separated the sacred from the secular and the spiritual from the physical." The deaconess movement was still alive in Wesleyan circles, and the "social gospel" movement resulted in the founding of hospitals and orphanages, but often without the kind of wholistic theological underpinning found in Wesley. Following World War II, some attitudes began to change. In 1948 the United States Government sponsored a massive study of heart disease in Framingham, Massachusetts. That study concluded, among other things, t h a t there was no connection between heart disease and stress. The common understanding resulting from such studies was t h a t disease was something " o u t there" that attacked the human body without regard for other facets of the total person, an outlook ably refuted by James J. Lynch in his important work T h e B r o k e n H e a r t . 12 Treatment was often approached with the attitude of a "repair job," not unlike what might be carried out on a piece of machinery. The spiritual, emotional, and economic impacts of illness were sometimes overlooked, sometimes deliberately ruled out as being irrelevant. In 1962, for example, a study group of the United Lutheran Church cautioned against the church becoming involved in what today would be called wholistic medicine. 13 It is noteworthy that it was within the medical community t h a t a multidisciplinary approach to healing began to re-emerge. In the late 1950s and early 1960s some American physicians and researchers began to react against the conclusions of the Framingham s t u d y and to recognize important connections between emotions, beliefs, and physical well-being. Particularly
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within nursing education, there has been a dramatic shift toward a wholistic approach to patient care, so much so that one of the most widely-used texts in nursing fundamentals contrasts the wholistic and biomedical approaches to health care and chooses the former in its presentations. 14 In wholistic nursing considerable importance is given to factors such as the environment of the patient, his or her state of mind, emotional well-being, and social relationships. Illness is no longer viewed as something outside the self that suddenly intrudes, but as part of a wellness spectrum that is affected by many factors. Superficially, it would appear that things have come full circle, with modern health care systems at least approximating the attitude of Jesus and the early church. It becomes apparent at the pastoral level, however, that there are really significant differences. For John Wesley, for example, it was clear that the spirit that gives life comes from God. In one form or another there would have been agreement among the Christian leaders in medicine and nursing that " M a n ' s chief end is to glorify God, and to enjoy him forever." Today it is possible to support the concept of wholistic nursing while overlooking or specifically denying the relevance of a transcendental dimension to human affairs. In an article contending that religious belief is a cause rather than a potential cure of illness, one author argues that when religious language is used with regard to ill persons it is, "purely to move the discussion into the realm of non-reality, thereby setting the stage for the entry of the clergy and other vested-interest religionists. ''15 Since it is no longer taken for granted that the spiritual dimension has validity, it becomes essential for those who lay claim to such a view to manifest a spirit of helping and caring, rather than to posture themselves in any way that suggests special privilege. Wesley College's official philosophy states its conviction that "Education is an intellectual response to a loving God." It is therefore appropriate that this institution reaffirm that its understanding of the wholeness of persons is far more than that of a complex being which can be affected by a variety of causes. Rather, we understand the enspiriting of humanity somehow to reflect the divine character: we are made in the image of God. (Genesis 1:26} This understanding and affirmation have at least three direct consequences for a nursing program: they suggest that those who prepare to give service to others can understand themselves better by deepening their own relationship with God; they suggest that those they serve can be aided b y being helped in their relationship with God; and they suggest the importance of care for all, since all persons are created with the divine spirit and in the image of God. Involved, then, is self-knowledge, a willingness and ability to enable others to gain self-knowledge, and a noncritical acceptance of the path others take on their spiritual pilgrimage. At the pastoral level this necessitates a real understanding of the wholistic nature of persons and an integration of these concepts into the understanding of the total nursing process, so that the spiritual component is not perceived as an auxiliary enterprise simply "tacked on" for insufficient or even spurious reasons. Writing of a church-based health clinic in Kingston, Jamaica, Ezra E. H. Griffith, M.D., has described problems encountered in attempts to integrate
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services catering to spiritual, psychological, and orthodox medical needs of clients. In spite of sharing a facility and a philosophy of treating the whole person, the clinic under study failed to integrate the kinds of practice offered. Griffith observed t h a t a religious ritual, which marked the opening of the clinic the two nights a week it was in operation, was meant to be attended by the entire staff and serve, among other functions, to build community. In fact, the service was rarely attended by physicians and commonly missed by other technical staff, so t h a t it remained the domain of the lay religious workers. Without the attendance of the medical personnel, these services tended to focus on the laying-on-of-hands and prayers for miraculous healing. In the medical subdivision of the clinic it was found t h a t the physicians performed standard clinical practice with no reference to any healing mode other than clinical, including counseling, although a number of cases were reported to the physicians t h a t could have benefited from counseling or group support. The counseling subdivision was the least used and, for the most part, was perceived as a place for " m a d " persons. 16 In spite of an apparently adequate philosophical base and a dedication t h a t required both financial support and risk on the part of the sponsoring church, Griffith concluded that the clinic was characterized primarily by missed opportunities. The orthodox medical practitioners saw all the patients in this sample. Yet a significant percentage of the patients' psychological problems either were not detected or were elicited and then ignored. Certainly, few of the patients were referred to the psychological counselors. In addition, personnel in the medical and psychological sectors had serious reservations about the . . . prayer partners. 17 Many general lessons can be drawn from this situation, which is not unlike the experience in m a n y American hospitals where social work and pastoral care components, if present, are not fully accepted and integrated into health care programs. This denotes both a lack of understanding and a lack of acceptance of any function except that of orthodox medical care. These observations suggest a twin danger for our enterprise. On the one hand, it would be easy for spiritual care to become an entity unto itself, separated from and even antagonistic to the main function of the nursing professional, as it has with some splinter groups. On the other hand, the Christian nurse or pastoral care worker m a y become simply an " a m a t e u r doctor," imitating the physician and using clinical jargon in an a t t e m p t to be accepted. Neither is appropriate. It is imperative, rather, to develop strategies for acknowledging and nurturing the spiritual dimension in both patient and nurse. In the health care setting this dimension most often manifests itself in issues of self-worth, doubt, values, and grief. This end m a y be accomplished not only by the nurse respecting the special competence of the pastoral counselor or chaplain, but also by the nurse developing a deeper awareness of those areas where he or she, as nurse, m a y offer spiritual help and allow the patient to use the spiritual resources he or she already possesses.
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Arminianism
Technically, the term Arminianism refers to the system of theology t a u g h t by Professor James Arminius at the University of Leyden in the late sixteenth century. His teachings specifically denied the type of absolute and unconditional election then current in some Calvinist circles and earned him accusations of Pelagianism.18 Originally applied to John Wesley as an epithet, the term "Arminianism" was later adopted by him to signify his understanding of God's free grace and concern for every person. For m a n y later Methodists it has come to signify little more than their affirmation t h a t the primary understanding of God is one who is active in the world over against the view that God is sovereign over, and implicitly somewhat removed from, the world. 19 For our purposes, we m a y define four points commonly understood by Wesleyans to make up the essence of Methodist Arminianism with the belief t h a t they may be substantiated by the New Testament. 1. 2. 3. 4.
All have sinned. {Romans 3:23) All may be saved. {Romans 3:24) All m a y have knowledge and assurance of salvation. (I John 5:13) Any individual m a y fall from grace or "backslide"; salvation is not a guarantee of perfection.
The assertion of universal sin is not a negative one or a judgment about the " t o t a l depravity of man." It is, rather, an acknowledgment of the universal predicament of humanity. {Romans 5:12) Rather than a negative statement, it is one t h a t defines a common starting point and affirms that we are all in the same situation. It is this basic understanding t h a t opens the door to an important corollary of Methodist Arminianism: because of the basic equality of all and the common human predicament, the Christian community has a special obligation toward those who are disenfranchised and in special need of grace. Arminianism lays the groundwork for following the Lucan example of Jesus' graciousness in dealing with both the righteous and the sinner, with persons of all races and classes. In the health care system, the way in which persons with handicapping conditions or psychiatric problems, the elderly, and those unable to pay are treated will reveal our point of view. Arminianism stresses an underlying understanding of common h u m a n i t y as opposed to a segmented view of the righteous and the sinner, those worthy of help as opposed to the unworthy or those needing salvation over against the self-perfected. In a sermon on money, Wesley saw such dangers in his day: And are not they partakers of the same guilt [greed] . . . whether surgeons, apothecaries or physicians, who play with the lives or health of men, to enlarge their own gain? who purposely lengthen the pain or disease, which they are able to remove speedily? who protract the cure of their patient's body, in order to plunder his substance? 2~
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A r m i n i a n i s m opens the door for c o m m u n i c a t i o n and c o o p e r a t i o n with all who have some " k n o w l e d g e of s a l v a t i o n . " As a p r o d u c t of his times, J o h n W e s l e y saw clear theological adversaries: the Calvinists and the Papists. Yet he was r e m a r k a b l y open to all who seemed, b y the q u a l i t y of their lives, to evidence a t r u e religious experience. A f t e r a 1749 visit to Ireland, he c o m p o s e d a " L e t t e r to a R o m a n Catholic," which c o n t i n u e d to be r e p r i n t e d and circulated d u r i n g the rest of his life. A f t e r c o m m e n t i n g on the m a n y areas of a g r e e m e n t between R o m a n Catholics and " t r u e P r o t e s t a n t s , " W e s l e y wrote: Are we not thus far agreed? Let us thank God for this, and receive it as a fresh token of his love. But if God still loveth us, we ought also to love one another. We ought, without this endless jangling about opinions, to provoke one another to love and to good works. Let the points wherein we differ stand aside: here are enough wherein we agree, enough to be the ground of every Christian temper and of every Christian action. O brethren, let us not still fall out by the way. I hope to see y o u in heaven. And if I practice the religion above described, you dare not say I shall go to hell . . . . Then if we cannot as yet t h i n k alike in all things, at least we may love alike. 21 There are clear inferences for spiritual care in this A r m i n i a n perspective. First, there is no place for p r o s e l y t i n g those who h a v e their own religious beliefs or for imposing a p a r t i c u l a r viewpoint on t h o s e whose search is t a k i n g t h e m in a n o t h e r direction. Second, t h e r e is no r o o m for p r o v o k i n g p a t i e n t s or fellow workers to a n y t h i n g b u t m u t u a l support. I t is always possible, even within a given religious tradition, to find an " e n d l e s s j a n g l i n g of o p i n i o n s . " These need to be set aside in the c o n t e x t of s u p p o r t a n u r s e is called u p o n to provide. Third, t h e r e is no r o o m for s t e r e o t y p i n g . E v e n when one accepts a wholistic view of persons, t h e r e are value conflicts. Two examples of such conflicts which m a y lead to serious s t e r e o t y p i n g problems come from small c o n t e m p o r a r y religious groups. The A m i s h and M e n n o n i t e c o m m u n i t i e s were the focus of h o s t i l i t y in the late 1970s when, d u r i n g polio o u t b r e a k s in P e n n s y l v a n i a , t h e y were r e l u c t a n t to receive inoculations. This led to scorn from m a n y , including h e a l t h care professionals, who viewed t h e m as b a c k w a r d and s t u b b o r n individuals t h r e a t e n i n g the life of the whole c o m m u n i t y . Only when it b e c a m e clear t h a t t h e y were n o t o p p o s e d to inoculations per se, b u t only to u n n e c e s s a r y medical t r e a t m e n t , was t h e impasse resolved: the p r e v e n t i v e t r e a t m e n t was seen as n e c e s s a r y and was undertaken. 22 A n o t h e r group t h a t is the focus of r e c u r r e n t h o s t i l i t y is the J e h o v a h ' s Witnesses who, because of their v e r y literal i n t e r p r e t a t i o n of the Scriptures, absolutely refuse to accept blood t r a n s f u s i o n s . A c c o r d i n g to H o r a c e H e r b s m a n , M.D., m a n y p h y s i c i a n s h a v e such s t r o n g feelings a g a i n s t this sect t h a t t h e y h a v e a d o p t e d one of two tactics: a t t e m p t i n g to convince J e h o v a h ' s W i t n e s s p a t i e n t s t h a t their religious r e s e r v a t i o n s a b o u t blood t r a n s f u s i o n s are misdirected, or d e m a n d i n g the signing of a legal waiver before even e m e r g e n c y t r e a t m e n t is considered. H e views the first as philosophically questionable,
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since it requires the p a t i e n t to c o m p r o m i s e his or her u n d e r s t a n d i n g of G o d at a t i m e of p o t e n t i a l spiritual need; the second is legal intimidation. W r i t i n g as a physician, Dr. H e r b s m a n ' s c o n t e n t i o n is t h a t there are m a n y a l t e r n a t i v e protocols to blood t r a n s f u s i o n available for the t r e a t m e n t of J e h o v a h ' s Witness p a t i e n t s which are overlooked or ignored because of the physicians' inclination to dismiss the i m p o r t a n c e of their religious scruples. 23 B o t h of these illustrations u n d e r s c o r e the need to view all persons as equals in need of the same grace and the same consideration. The final c o m m o n t h r u s t of A r m i n i a n i s m is the traditional W e s l e y a n concern for " b a c k s l i d i n g " : the affirmation t h a t salvation is not a p e r m a n e n t s t a t e once a t t a i n e d b u t one t h a t requires c o n s t a n t a t t e n t i o n . In the c o n t e x t of the n u r s i n g process it is, therefore, not acceptable simply to m a k e n o t e of a p a t i e n t ' s denomination. Nor is it sufficient to rely on the c o m m o n practice of r e f e r r i n g only t h o s e who h a v e no c h u r c h affiliation to the p a s t o r a l care departm e n t as if c h u r c h affiliation s o m e h o w g u a r a n t e e s spiritual health. This p a r t of Arminianism, while easily m i s u n d e r s t o o d as pessimistic and negative, is a call for c o n s t a n t n u r t u r e and care. The practical implications of A r m i n i a n i s m seem clear. First, it requires equal physical and spiritual care for all with a deliberate bias t o w a r d the poor and disenfranchised. 24Second, it c o m m a n d s an a p p r o a c h where the focus is the p a t i e n t ' s beliefs r a t h e r t h a n the nurse's. The p r i m a r y t a s k is to discover and use the faith resources already at work in the individual. This requires t h a t the care-givers be aware of and secure in their own religious position. The nurse must be self-confident, not anxious or confused about her own relationship to God. Her ideas may not coincide with those of the patient but under no circumstances should she try to convert the patient to her way of thinking. 25 Third, p a t i e n t s should not be left to their own resources simply because t h e y indicate a church relationship or use religious language. N o t all religious terminology, beliefs, or ideation are healthy. We are on a pilgrimage, not at a destination, and need c o n s t a n t e n c o u r a g e m e n t and help along the way.
Sanctification One of J o h n W e s l e y ' s favorite t h e m e s was the relationship of faith and life often found u n d e r the M e t h o d i s t rubrics of " h o l y living," " h o l i n e s s , " "sanctification," or " C h r i s t i a n P e r f e c t i o n . " What is religion then? It is easy to answer, if we consult the oracles of God. Accounting to these, it lies in one single point: it is neither more nor less than love. It is love which "is the fulfilling of the law, the end of the commandment." Religion is the love of God and our neighbour; that is, every man under heaven. 26
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During his lifetime Wesley often complained t h a t the Catholics and Calvinists alike set standards of Christian living too high, so t h a t t h e y would be attainable only in " g l o r y . " His detractors complained t h a t Wesley's standards were too low and fostered delusions of grandeur and self-righteousness. 27 Today, jus t as then, there are problems with Wesleyan nomenclature. Some groups use the term "holiness" to denote a kind of ecstatic worship t h a t Wesley would have condemned as " e n t h u s i a s m " ; others claim "perfect i on" in an arrogant manner. As a result, m a n y c o n t e m p o r a r y Methodists shy away from this language. Nonetheless, it denotes the ongoing work of the Holy Spirit in the life of the believer in a way t h a t is not only scriptural, but essential to grasping the traditional Methodist concern with "practical p i e t y . " For Wesley, "holiness" was always understood in terms of the twin dimensions of internal holiness {love of G o d and neighbor} and external holiness {love of God and neighbor). 2s It states firmly the conviction t h a t religion is not a m a t t e r of dogma separated from the real world, nor promise m eant to be fulfilled only in the next life. Neither is it a m a t t e r of "pulling one's self up by the b o o t s t r a p s . " Real Christianity is an intermingling of internal and external holiness. The importance of the Methodist doctrine of Sanctification for nursing is practically self-evident: not only is it desirable, but it is affirmed as possible truly to live the qualities needed in spiritual care. Spiritual nurt ure and care can thus be given, even as the nurse attends to the more " r o u t i n e " or " n e c e s s a r y " duties, since spiritual care is delivered as much by who one is as by what one says. Care is expressed in nursing by tending to another, being with him, assisting him, giving heed to his responses, and guarding him from danger--and doing this with compassion as opposed to tolerance, with tenderness as opposed to a sense of duty, and with respect as opposed to obligation. 29 In co n tem por ar y nursing training, particularly in psychiatric nursing, emphasis is placed on the therapeutic use of self or the offering of self. 3~Since the Wesleyan position stresses t ha t positive behavioral characteristics m a y be forged out of a personal, growing relationship with God, the use of self carries the o p p o r t u n i t y for spiritual nurture. As the nurse grows in his or her own spiritual awareness, it is possible for him or her to incarnate the spiritual qualities the patient requires, so t h a t the patient m a y appropriate t h e m in his or her own way. When the client cannot trust, the nurse can be faithful, be consistent, and follow through on commitments and time schedules. When the client is in turmoil and confusion, the nurse can demonstrate calmness and stability. When the client does not feel loved and accepted, the nurse can love and accept the client. When the client cannot feel forgiven, the nurse can show forgiveness and acceptance. When the client feels hopeless, the nurse can offer hope. 31
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Godly grief Nowhere does the therapeutic use of self become more crucial than in helping persons confront and deal with grief, not only in facing death but with regard to the necessity to change lifestyle as a result of illness or aging. It is widely recognized t h a t grief is a process rather than an event and that the ability to pass through several somewhat predictable, although not invariable, stages of grief can be positively correlated with recovery. 32 From a theological perspective we are reminded by Paul t h a t grief in itself is neither good nor bad: it m a y be Godly grief t h a t results in some kind of amendment of life or changed attitude; or it m a y be a negative force t h a t leads to depression or even, quite literally, death. For Godly grief produces a repentance that leads to salvation and brings no regret, But worldly grief produces death. (II Corinthians 7:10) Eugene Peterson has pointed out, "The biblical revelation neither explains nor eliminates suffering. It shows, rather, God entering into the life of suffering humanity, accepting and sharing the suffering. ''33 Taking her cue from Viktor Frankl's logotherapy, Sr. Corita Dickinson has argued that it is the search for meaning t h a t determines a person's perspective in situations of suffering and loss. If whatever we are doing is meaningless to us, we are desperately unhappy; but if whatever we are suffering has some meaning, we can be at peace. 34This search for God within illness and suffering, not as stern judge using the illness as a bully pulpit from which to chastise the sufferer, but as fellow sufferer, offers the opportunity for finding meaning and growth even in grief, rather than simply coping with a necessary evil. One of the differences between theology and technology is that the former is concerned not only with what is but with what it means. 35 From the biblical viewpoint one meaning of grief is that we may enter into the experience of God whose love for the world and overtures to humanity have often been frustrated and caused Him grief. God is not perceived as a " G o d of the Gaps" injected from the outside into situations where He really does not fit; He is rather already present waiting to be discovered within the depths of emotion. The helper who has experienced Sanctification, who has been aware of God's presence in him- or herself and/or others in a variety of life situations can be present with a person going through the grief process in a way that will enable t h a t person to sense God's presence in it. Understanding grief within the larger context of Sanctification encourages two things, both of which have been pointed out by Eugene Peterson from a totally different perspective. 3~ First, it encourages grievers to organize their grief within the context of their own lives and, one hopes, within the context of the faith community. The latter could take the form of biblical narratives, the lives of saints, or oral tradition from the local community. This examination of grief in context encourages the appreciation of the significance of every detail
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of life and reflects the stance of faith t h a t God is ready to meet us in every aspect of life. It encourages entry into, rather than escape from, life. Second, by placing suffering in its life context, it allows it to take its place, ominous as it may be, among other things. Suffering is never all there is, and the grieving process should not permit it to become an obsession. The therapeutic use of self in spiritual care uses techniques t h a t are common to other kinds of helping. In the case of grieving, appropriate interventions would be support, awareness of the patient's needs, empathy, and nonjudgmental understanding. 3v If they are to be effective in transforming worldly grief into Godly grief, however( these or any techniques need to be supported by the affirmation t h a t it is possible to encounter God in the process. What Hans Kting has recently written regarding eternal life m a y be paraphrased with regard to grief. 38 The immediate question anyone asks, particularly within the utilitarian mind-set of health care, is, "Does belief in God make grief easier?" The honest answer is, "No, belief in God does not necessarily make it easier to face suffering or pass through the stages of grief." The further question, if it is asked, is, "Does it make any difference?" Here the answer is, "Yes." For an experience of the sanctifying presence of God within the context of grief provides us with the opportunity to assent to suffering in a way t h a t affirms that "there is nothing in all creation t h a t can separate us from God's love. ''39 Whatever the root cause, it is clear t h a t suffering and grief are part of the fabric of life. A flight from suffering is therefore a flight from life? ~Conversely, the affirmation of suffering with hope is part of our great "Yes" to life and to God. 41 The nurse can provide a companionship t h a t incarnates God's love and supports this process of affirmation. Daniel Simundson has described two levels at which the Bible addresses suffering: the intellectual level and the survival level. 42The intellectual level deals with the great whys: why there is suffering in the world and why it comes to some but not all. For any final resolution of the issue of suffering, this level needs to be addressed, but it is best handled at times when there is some breathing space for reflection. The survival level provides support and comfort for the sufferer. While it may not provide the final integrating answer, the survival approach bridges those times when suffering so preoccupies patients t h a t they can think of little else. One could say t h a t the error of Job's counselors was t h a t they moved too quickly from the survival level to the intellectual level, imposing ideological answers of their own to Job's questions. (Job 2:13) The nurse, by virtue of his or her short-term crisis-dominated relationship with m a n y patients, will largely deal at the survival level, utilizing the therapeutic use of self, encouraging and enabling the patient to move to the intellectual level.
Spiritual gifts and spiritual fruits Four positions have been examined thus far: the wholistic nature of persons as spiritual beings; the traditional Wesleyan doctrine of Arminianism; the
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Methodist teachings of Sanctification; and the position that in and through grief one can encounter God, that grief need not be worldly grief but may be Godly grief. One can accept these four tenets and their implications for health care and still ask, " B u t is it the nurse's role to be concerned about such matters? Will he or she not be competing with others whose main interest and responsibility is the spiritual? Are not these things better left to the pastoral care team or the visiting minister?" One superficial but important answer to these questions is that in many smaller hospitals there is no pastoral care team, and the system by which local ministers are notified of hospitalized parishioners is so loose that one often wonders if the very concept of the "visiting minister" has any validity. Many Wesley College graduates work in such facilities. At this level, then, a flippant answer would be, "The nurse needs to do it because no one else does." There is, however, a more profound level of understanding, building on the concepts so far presented. In John Wesley's teachings about Sanctification, holiness of living, and Christian Perfection, he stressed the importance of the ordinary Fruits of the Spirit for all Christians (Galatians 5:22f.) in conjunction with the extraordinary Gifts of the Spirit which are given to some for particular tasks within the Church. (I Corinthians 12:4f.p 3 These and similar teachings have been the focus of great attention in the past fifteen years as some categories traditionally associated only with small Holiness sects have been integrated into the mainline churches. One of the results of this has been some lack of clarity. In particular, there has been so much concern with extraordinary Gifts of the Spirit, such as speaking in tongues or miraculous healing, that the more ordinary gifts, which form the backbone for the doctrines of Sanctification and Christian Perfection, have been ignored or underestimated. 44 Some authors, who should know better, have even implied that Wesley did not know the difference between the Spiritual Gifts, enumerated by Paul in places like I Corinthians 12, and Spiritual Fruits, such as those mentioned in Galatians 5. 4~ While it is true that Wesley's terminology is not that of the Revised Standard Version, a reading of his thought makes it clear that he had this distinction in mind. 46 The distinction is simply this: Gifts of the Spirit are those special endowments that are provided individuals in order to accomplish certain vocations within the church. The Spiritual Gift of healing (I Corinthians 12:9), for example, could be interpreted to include the particular abilities with which some especially good nurses are endowed. Spiritual Fruits, on the other hand, are those manifestations of the Holy Spirit such as love, gentleness, and selfcontrol (Galatians 5:23) with which all Christians are equipped for the living of a life within the reign of God. (Galatians 5:21) One would not necessarily expect the nurse to exhibit the same Spiritual Gifts as a pastoral care worker, but one can expect the nurse to be sympathetic with, if not a personal possessor of, the characteristics of the Spiritual Fruits. In fact, owing to availability and involvement with the patient in ways that break down normal resistance and barriers {assistance with bathing or elimination}, the nurse may be in a better position to exhibit patience and self-control in a meaningful way than the floor chaplain or visiting minister.
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In 1968, Ruth Piepgras, writing in the American Journal of Nursing, posed some questions about nurses being involved in meeting patients' spiritual needs. 47 They remain critical questions. By addressing some of them, the theological positions put forth in this essay m a y be summarized, and the distinction between Spiritual Gifts and Spiritual Fruits m a y be further explicated. " B y what authority can a nurse undertake the spiritual guidance of a patient? I s n ' t it better to avoid taking a stand?" Because we are dealing with a wholistic approach to persons, we realize t h a t it is impossible not to take a stand with regard to spiritual needs. A t t e m p t s to avoid them are often interpreted either as hostility or a feeling t h a t spiritual and emotional needs are unimportant. Some statement about this component of the human person will be made one way or another. " I s it permissible to interfere in a private personal area of the human spirit? Will interference lead a nurse to impose her own point of view or, worse yet, her own confusion?" Interference is not advocated or acceptable according to the understandings we have outlined. The primary goal is to allow the patients to use the spiritual resources they already have, if any, or to discover meaning in the circumstance in which they find themselves. The Spiritual Fruits of love, joy, and patience can be manifested in empathy and non-judgmental understanding. Interference may well result if the nurse a t t e m p t s to exercise some specific gift such as didactic teaching or evangelization. There m a y be individuals with such gifts that they will exercise elsewhere, but t h a t will not be appropriate for them to use as nurses. " I s n ' t a nurse exceeding her ability when she discusses religious questions with the patient who is entrusted to her care and who trusts her?" He or she well may be. It is important to distinguish between the kind of spiritual care with which we have been primarily concerned and specifically religious matters in the sectarian sense. The nurse m a y support the patients' desire to deepen their relationship with God and be supportive of the patients' requests for prayer. At the point at which a Roman Catholic patient asks the Baptist nurse for aid in remembering the rosary, or at which the Pentecostal patient asks the Presbyterian nurse for a certain kind of spontaneous prayer, there should be no a t t e m p t at hollow compliance. It is possible, however, to be supportive and to seek appropriate help, perhaps from another nurse on the unit who will be comfortable in meeting the specific request. The discussion of religious questions, if it means debating the doctrines of differing or even competing churches, is not a part of spiritual care and violates the basic tenet of Arminianism mentioned earlier. 48 If it means a sharing of beliefs or meaningful experiences in a non-judgmental manner, it can be most valid and helpful. The question is a difficult one because it is a good one. Is a nurse exceeding his or her ability? That is an individual question that must be answered in each specific situation. " W o n ' t the nurse be competing with the clergy in a function t h a t is rightfully theirs?" Not if the nurse is involved in the area of Spiritual Fruits which enable the common ministry of all Christians. The clergy or commissioned lay workers have a particular vocation, generally recognized by a certain
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denomination and, more often than not, tied up with the promotion of that denomination's point of view. It m a y be appropriate on occasion for the visiting minister to exhort the patients to reaffirm their beliefs and remind them how members of their particular communion regard illness or suffering. It would be wholly inappropriate for the nurse to try to convert the patient to his or her point of view through similar exhortations. Sacramental and liturgical matters are the province of the official religious worker. For many Protestants an informal reading of the Bible and prayer time have special meaning because they are with the "Preacher." Verna Carson writes of the possibilities open to a nurse who is recognized as a "pray-er," 49one who is open to spiritual matters. A "pray-er" does not necessarily compete with the clergy, but is open to the spiritual dimension in his or her own way. It is when some general theological base is lacking and when the distinction between Spiritual Gifts and Spiritual Fruits has not been thought through that problems arise. "Witnessing" may be substituted for non-judgmental understanding; doctrinaire tracts may be placed on trays in an attempt to "do something." In many Protestant churches the only model the believer has for ministry or spiritual care is that of the pulpiteer; so exhortations that might be acceptable in a general context from the pulpit are used in a manner that is less than sensitive or helpful.
Conclusion The nurse can meet the spiritual needs of patients by applying the five theological tenets stated above. An awareness of the wholistic nature of persons m a y lead to an openness to and support of the spiritual dimension of the patient's life. Arminianism encourages focusing on the patient's beliefs and using the faith resources already at work in the individual. The practical bent of Wesleyan theology encourages the nurse to incarnate the qualities that make for spiritual health, entering into the experiences of suffering and grief in ways that enhance the redemptive possibilities for the patient. All of these goals m a y be achieved by exercising the ordinary Spiritual Fruits available to all without interfering with the patient's beliefs or usurping the role of the clergy.
References 1. Burrows, M., An Outline of Biblical Theology. Philadelphia, The Westminster Press, 1946, p. 135. 2. McKenzie, J.L., Dictionary of the Bible. Milwaukee, The Bruce Publishing Company, 1965, p. 539. 3. Dickinson, C., "The Search for Spiritual Meaning," Amer. J. Nursing, October 1975, 75, 1790. 4. Kelsey, M.T., Healing and Christianity. New York, Harper and Row, 1973, p. 53. 5. Smith, M., Jesus the Magician. San Francisco, Harper and Row, 1978, p. 16. 6. Ellis, J.R., and Hartley, C.L., Nursing in Today's World. Philadelphia, J. B. Lippincott Company, 1980, p. 14. 7. Dolan, J.A., Nursing In Society. Philadelphia, W.B. Saunders, 1978, p. 43. 8. Kelsey, op. cit., p. 233. 9. Wesley, J. In Burtner, R.W., and Chiles, R.E., A Compend of Wesley's Theology. New York, Abingdon, 1954, p. 245.
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10. Ki]ng, H., EternaILife? Garden City, New York, Doubleday, 1984, p. 23. 11. Kelsey, o19. cit., p. 27. 12. Lynch, J.J., The Broken Heart: The Medical Consequences of Loneliness. New York, Basic Books, 1977, p. 23. 13. Kelsey, o19. cit., p. 26. 14. Wolff, L.; Weitzel, M.; Zornow, R.; and Zsohar, H., Fundamentals of Nursing, 7th ed. Philadelphia, J.B. Lippincott, 1983, p. 118. 15. Graves, C.C., "Religion: Cause or Cure?" Perspectives in Psychiatric Care, 1983, 21 27, 37-38. 16. Griffith, E.E.H., "The Significance of Ritual in a Church-Based Healing Model," Amer. J. Psychiatry, May 1983,140 568-572. 17. Ibid., 570. 18. Simpson, M., ed., Cyclopedia of Methodism. Philadelphia, Everts and Stewart, 1878, pp. 53-54. 19. Outler, A.C., ed.,John Wesley. New York, Oxford University Press, 1964, p. 478. 20. Wesley, In Burtner and Chiles, op. cit., p. 242. 21. . In Outler, ed.,John Wesley, o19. cit., p. 478. 22. Darocy, C., "Religious Considerations in Patient Care," J. Practical Nursing, December 1979, 18-21, 31. 23. Herbsman, H., "Treating the Jehovah's Witness," Emergency Medicine, January 15, 1980, 75-76. 24. Fish, S., and Shelly, J.A., Spiritual Care: The Nurse's Role. Downer's Grove, Illinois, InterVarsity, 1983, p. 30. 25. Piepgras, R., "The Other Dimension: Spiritual Help," Amer. J. Nursing, December 1968, 68 2613. 26. Wesley, J. In Outler, Albert C., Theology in the Wesleyan Spirit. Nashville, Tidings, 1975, p. 83. 27. Outler, ed.,John Wesley, o19. cit., p. 283. 28. - - , Theology in the Wesleyan Spirit, p. 72. 29. Dickinson, op. cit., p. 1790. 30. Manfreda, M.L., and Krampitz, S.D., Psychiatric Nursing. Philadelphia, F.A. Davis Company, 1977, pp. 253-259. 31. Shelly, J.A.; John, S.D.; et al., Spiritual Dimensions of Mental Health. Downers Grove, Illinois, InterVarsity, 1983, p. 87. 32. Wolff et al., op. cit. pp. 772-776. 33. Peterson, E.H., Five Smooth Stones for Pastoral Work. Atlanta, John Knox Press, 1980, pp. 93-94. 34. Dickinson, o19. cit. p. 1790. 35. Studer, J.N., "Toward a Theology of Healing," J. Religion and Health, 1982, 21, 4,286. 36. Peterson, op. cit., pp. 99-101. 37. Dickinson, op. cit., p. 1792. 38. K~ng, op. cit., pp. 230-234. 39. Soelle, D., Suffering. Philadelphia, Fortress Press, 1975, p. 103. 40. Ibid., p. 88. 41. Ibid., p. 108. 42. Simundson, D.J., Faith Under Fire. Minneapolis, Augsburg Publishing House, 1980, pp. 144-151. 43. Wesley. In Burtner and Chiles, op. cir., pp. 102-104. 44. Outler, Theology in the Wesleyan Spirit, op. cit., p. 78. 45. Kinghorn, K.C., Gifts of the Spirit. Nashville, Abingdon, 1976, p. 16. 46. As these t h o u g h t s were being organized, a student presented a concern that has become increasingly common in recent years: he had been in a service where it was asserted t h a t anyone who did not speak in tongues was not a true believer. There was then an opportunity for those in attendance to go forward, be slain in the spirit, and speak in tongues. He was troubled since his Nazarene background was at variance with what he had experienced. As a Nazarene with Wesleyan background, it was not hard to discuss the difference between Spiritual Fruits and Gifts and to distinguish between Christian Sanctification and "Enthusiasm." 47. Piepgras, o19. cit., p. 2611. 48. See my discussion of Arminianism earlier in this paper. 49. Carson, V., "Meeting the Spiritual Needs of Hospitalized Psychiatric Patients," Perspectives in Psychiatric Care, 1980,18, 20.
