What are the barriers to spiritual care in a hospital setting? Lucy Rushton
Key words: Spirituality ■ Holistic care ■ Wellbeing ■ Nursing education
S
piritual care is a vital component of care that is given to patients by health professionals in order to prevent poor health and treat illness (O’Connell and Skevington, 2005). However, patients’ essential spiritual needs are not being met in hospital (Royal College of Nursing (RCN), 2010). The aim of this article is to identify the main barriers that nurses encounter when providing spiritual care to patients in a hospital setting. A literature review was undertaken to explore the barriers to spiritual care. This topic was chosen because although spirituality in nursing has had much recognition in recent years, it lacks critical appraisal from people within the field of nursing (Swinton, 2006). Spiritual care, like all nursing practice, must be research-based and critically evaluated (Speck, 2005). There is no universally agreed definition of spirituality (Ledger, 2005). However, most people agree that spirituality relates to how people perceive life and death, and involves questioning things that are beyond the material aspects of life, such as love, values and the meaning of life (Hemstock, 2010). The Department of Health (DH, 2003) does not provide a definition of spirituality but states that spiritual care is provided through holistic care. Holistic care is the
Lucy Rushton is Staff Nurse, Maidstone Hospital, Kent Accepted for publication: March 2014
370
Search strategy The electronic databases used for the literature search were the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medline and the British Nursing Index (BNI). The search terms used were – (‘nurs*’) AND (‘spirituality’ OR ‘spiritual care’ OR ‘spiritual need*’) AND (‘problem*’ OR ‘issue*’ OR ‘barrier*’ OR ‘dilemma*’). Limiters were
© 2014 MA Healthcare Ltd
Abstract
Spiritual care is a vital component of care that is given to patients by health professionals in order to prevent poor health and treat illness. It is fundamental to patients’ wellbeing and nurses’ integrity that nurses carry out their care in a holistic manner and meet patients’ spiritual needs. However, a number of studies show that health professionals are failing to meet patients’ spiritual needs while in hospital. Nurses are unable to fulfil patients’ spiritual needs for a variety of reasons. The main barriers to spiritual care are the difficulty in defining spirituality; the lack of clear guidelines for the nurse’s role in providing spiritual care; nurses’ lack of time to provide spiritual care; and a lack of training and education on spirituality for pre- and postregistration nurses.
consideration of the whole person, taking into account physical, psychological, spiritual, economic, social and any other factors relating to the patient (Nursing and Midwifery Council (NMC), 2010). Spiritual care is a fundamental part of holistic nursing (Wordsworth, 2007). Narayanasamy and Owens (2001) maintain that spirituality is a part of holistic care that generates a state of wellbeing. Meeting patients’ spiritual needs through holistic care assists patient recovery and improves quality of life while in hospital (O’Connell and Skevington, 2005). Nurses must possess the skills needed to meet patients’ spiritual needs (NMC, 2010). The DH (2001) declares that patients can expect NHS staff to respect and be sensitive to their spiritual needs at all times. Spiritual care can be provided in a number of ways. Grant (2004) found the most popular ways of providing spiritual care were through listening, laughter, touch and spending time with the patient. Some health professionals believe that spiritual care is incorporated into everyday interactions with the patient (McSherry, 2006). For example, a nurse’s contact with a patient during a dressing change can be used to offer spiritual care and build a trusting relationship (McSherry, 2000). Patients’ views of spiritual care have been investigated and it was found that although some patients did not want any form of spiritual care, other patients did (Taylor, 2003). This highlights how treating each patient as an individual is critical when providing spiritual care. The RCN (2010) undertook a survey of 4045 nurses, which found that 90% of nurses felt meeting patients’ spiritual needs improves nursing care and 83% felt spiritual care is an essential aspect of nursing. Despite nurses recognising the importance of spiritual care, they are unable to fulfil patients’ spiritual needs for a variety of reasons (Narayanasamy, 2004; Ellis and Narayanasamy, 2009). Barriers to spiritual care need identifying and examining in order for solutions to be found. The DH (2003) has highlighted that considerable challenges are encountered when trying to identify and organise care for a diverse population, but that spiritual care is important to patients and can have a substantial benefit on patient outcomes.
British Journal of Nursing, 2014, Vol 23, No 7
British Journal of Nursing. Downloaded from magonlinelibrary.com by 130.113.111.210 on December 7, 2015. For personal use only. No other uses without permission. . All rights reserved.
PROFESSIONAL ISSUES used to narrow the search to find the most relevant papers. The limiters were: English language, age group (all adults), inpatients and publication year (1990–2011). Although the limit for the publication year was broad, it was felt that going back to 1990 would identify more papers and therefore offer some background information to spiritual care and the barriers health professionals face. The total amount of literature found across all three databases was 136 items, including research articles, opinion articles and book extracts. Abstracts were useful in providing a short summary of the key points for each article, and determining whether the literature was applicable. For example, research carried out in a community setting could be quickly identified and ignored because only the barriers of spiritual care in a hospital setting are being examined.
© 2014 MA Healthcare Ltd
Defining spirituality There is no generally agreed definition for the term ‘spirituality’ despite research identifying spirituality as a significant element for the patient experience (Clegg, 2006). Spirituality is difficult to define because it is unique to each individual’s opinions and beliefs (Jones, 2004). Draper and McSherry (2002) state that spirituality is becoming more visible and known within health care but the term spirituality is still difficult to interpret because of its subjectivity. The problem of defining spirituality presents a barrier for nurses trying to meet patients’ spiritual needs because people are confused as to what spirituality means (McEwan, 2004). The difficulty in defining spirituality is further complicated by the terms ‘religion’ and ‘spirituality’ being used interchangeably (Sessanna et al, 2007). An agreed definition of spirituality is essential for developing understanding (Narayanasamy, 2006). One of the main barriers that prevent nurses from meeting patients’ spiritual needs is the ambiguity surrounding the subject (Narayanasamy and Owens, 2001). Until spirituality has an agreed definition, health professionals will not treat spiritual care as an essential part of care (Sessanna et al, 2007). Sessanna et al (2007) completed an extensive review of the literature with the aim of gaining insight into the existing characteristics of spirituality in order to develop a definition. The literature review found 320 definitions of spirituality, which were then independently reviewed and discussed until there was absolute agreement of whether the definition was clear and concise. This resulted in 90 definitions being included in the concept analysis. The definitions were categorised into similar descriptions where four themes emerged: meaning and purpose to life, mystical phenomena, religious beliefs and nonreligious beliefs. Sessanna et al (2007) concluded that a definition of spirituality must incorporate all four themes in order to be relevant to everybody. They believed the most comprehensive description that included all four themes was by Fowler and Peterson (1997). Fowler and Peterson (1997) proposed that spirituality is the beliefs and values by which a person lives their life, which may or may not be expressed religiously. Furthermore, spirituality unifies a person with others, society and can include a relationship with a transcendental being. Fowler and Petersons’ (1997) definition of spirituality
British Journal of Nursing, 2014, Vol 23, No 7
is helpful to see that religion and spirituality are different. Narayanasamy and Owens (2001) distributed 130 questionnaires to post-registration nurses with the aim of exploring what nurses view spiritual needs to be (Narayanasamy and Owens, 2001). It was found that nurses were unsure on the differences between spirituality and religion (Narayanasamy and Owens, 2001). Although spirituality and religion are independent, separate concepts they are regularly used interchangeably (Kozier et al, 2008). Religion is a set of beliefs and practices often associated with such things as public rituals, religious officials and places of worship (Narayanasamy, 2004). Spirituality on the other hand, is an individuals’ search for meaning and purpose in life, and is not tied down to a set of rules (McBrien, 2006). Although defining spirituality is problematic, most researchers agree that spirituality involves the need to establish a purpose to life (Ledger, 2005). Chochinov (2006) states that spirituality should provoke a sense of exploring the worth and significance of life. Another interpretation is that spirituality is the unique internal source that connects us with others and is the guiding force within each person (Narayanasamy, 2006). Henery (2003) believes the use of scientific terms such as ‘force’ should not be used within the definition of spirituality because it cannot be scientifically tested. However, understanding spirituality would be difficult if unfamiliar terminology is used (Ellis and Narayanasamy, 2009). McSherry et al (2004) investigated patients’ and nurses’ understanding of spirituality by completing semi-structured interviews of 22 participants including nurses and patients. The interviews were recorded and transcribed, and the data analysed by a constant comparative method. When comparing nurse and patient interpretations of spirituality there were considerable differences in their understanding and use of language. The researchers found that many of the nurses described spirituality in a way that correlated with the definition provided by Murray and Zentner (1989), and suggested the similarities of the nurses’ definitions could be a result of the postgraduate education of the nurses, where the topic of spirituality was taught. The majority of the patients interviewed found it difficult to provide any definition of spirituality but did articulate that spirituality is a deeply personal and individual concept. McSherry et al (2004) concluded that the concept of spirituality is ambiguous and individual so developing a definition would be difficult. Bash (2005) recognises the importance of these findings and agrees that because spirituality is subjective, it cannot be easily defined. Instead, Bash (2005) offers an alternative interpretation of spirituality by suggesting spirituality is a range of human responses to life and each person is, either consciously or unconsciously, somewhere on that range. This helpful approach could help nurses to visualise each patient’s spiritual needs independently, resulting in patient-centred care. For the purpose of this article, the definition of spirituality that will be used is by Murray and Zentner (1989). Murray and Zentner (1989) state that spirituality is a characteristic feature that seeks to find the meaning and purpose to life, which is especially brought to the forefront of thinking through times of illness, stress, loss and death. This definition
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is being used because it recognises the individuality and distinctiveness of spirituality and encompasses the importance of meeting patients’ spiritual needs during times of poor health. Furthermore, the definition incorporates the four themes found by Sessanna et al (2007).
patients needs holistically (McSherry, 2006). MacKinlay (2006) agrees that the entire multidisciplinary team all have a part to play in meeting patients’ spiritual needs.
The nurse’s role in providing spiritual care
Patients’ spiritual needs are not being met because health professionals do not have enough time to spend with patients (Pearce, 2009). Having the time to listen and engage with patients is not always possible in a hectic healthcare environment (Buswell, 2006). However, some view spiritual care as nothing different from holistic nursing care, making the excuse of time constraints superficial (McSherry, 2000). Compared with other priorities of the nurse such as providing patients with their medication, spiritual care is a low concern when nurses are faced with time constraints (McSherry, 2000). Kristeller et al (1999) completed a survey of 267 oncology nurses with the aim of exploring nurses’ attitudes to spirituality. They found that when nurses faced time constraints, spiritual care was ranked in the bottom three in a list of 18 tasks. Other tasks included addressing pain, discussing prognoses and addressing poor dietary habits (Kristeller et al, 1999). The researchers concluded that time constraints on nurses acted as a barrier to supporting patients’ spiritual needs. Although this research was completed in the USA and generalising the finding to the UK is uncertain, similar findings have been found in British studies. Milligan (2004) used questionnaires to examine nurses’ opinions on factors that affected their ability to meet patients’ spiritual needs. The questionnaire was given to 59 nurses undertaking a training course on palliative care. The nurses identified the most significant barrier to spiritual care as not having enough time. The practicalities of meeting patients’ spiritual needs are further complicated by their personal and sensitive nature (Clegg, 2006). Murray et al (2004) conducted quarterly, qualitative interviews on 40 palliative patients over a 1-year period.The aim was to explore patients’ views and experiences on having their spiritual needs met. It was found that some patients felt uncomfortable expressing their spirituality. Some patients did express a need for love, meaning and in some cases, transcendence, but health professionals lacked the required time to identify and meet such spiritual needs. Murray et al (2004) concluded that in order for patients to feel comfortable enough to ‘open up’ about their spirituality, nurses must spend sufficient time with the patient, building a trusting relationship. In addition, nurses must be adequately prepared to deal with such issues (Ross, 2006).
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Training and education related to spiritual care There are numerous issues with educating and training preand post-registration nurses on spiritual care. There is a risk that because there is no concrete definition of spirituality, the potential information to be included in the training is unlimited, leading to spiritual care being taught in a vague and simplistic way (McSherry et al, 2004). On the other hand, nurses could be taught specific definitions, creating boundaries and preventing nurses exploring different points of view (Swinton, 2006).
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The nurse’s role in meeting a patient’s spiritual needs has not been clearly outlined (Narayanasamy, 2004).The NMC (2008) does not refer to spirituality in the Code of Professional Conduct. Ellis and Narayanasamy (2009) propose that nurses would value spirituality more if it was included in the NMC Code.When the Code was being revised, meeting the spiritual needs of patients was included in the draft copy (NMC, 2007). The Code initially stated that nurses must help support and improve the wellbeing of patients by meeting their spiritual needs, together with their physical, psychological, social, emotional and developmental needs (NMC, 2007). However, in a focus group consultation, the statement was seen as unclear and confusing, and was therefore replaced (Focus Group UK, 2007). Currently, the Code states that nurses must listen to patients and respond to their individual preferences and concerns, which could be seen as providing spiritual care. The NMC (2010) also includes spirituality as one of the factors of holistic care and person-centred care. Moreover, spiritual assessment is mentioned in the Standards for PreRegistration Nursing Education (NMC, 2010).This states that student nurses must complete a holistic assessment of a patient and this includes spiritual needs. In contrast, it is sometimes argued that spiritual care should be regarded as a distinct, separate aspect of care, and therefore carried out by a specialist team and not by nurses (Milligan, 2004). Cavendish et al (2006) completed semi-structured interviews on eight discharged patients with the aim of exploring patients’ views of nurses providing spiritual care. It was found that patients did not view nursing actions such as being kind and compassionate as spiritual care. Nor did patients view spiritual care as being part of the nurse’s role. Florence Nightingale’s theory is in direct conflict with this view, stating that the nursing profession is spiritual and that the care involved is an expression of that spirituality (Bradshaw, 1994). Ellis and Narayanasamy (2009) state that this approach could be seen as outdated and idealistic. However, aspects of quality holistic care such as listening, connecting and spending time with a patient are integrated with spiritual care (MacKinlay, 2006). Spiritual care is not a separate element of care, because it is already ingrained into holistic practice (Taylor, 2006). Cray (2009) affirms that nurses must take responsibility for meeting patients’ spiritual needs in order to achieve true holistic care. McSherry (2006) carried out semi-structured interviews with 53 participants including nurses, patients, physiotherapists, a social worker and an occupational therapist. The aim was to gain a deeper understanding into factors that may restrict or promote spiritual care. It was found that health professionals perceive the caring process to include spiritual care but that it is often unseen because it is provided through consistent interactions with patients. Furthermore, health professionals affirmed that multidisciplinary working is the best way to meet
Practicalities of meeting patients’ spiritual needs
British Journal of Nursing, 2014, Vol 23, No 7
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PROFESSIONAL ISSUES Appropriate training is required for nurses to carry out spiritual care (National Institute for Health and Care Excellence (NICE), 2004). The NMC (2010) states that nurses must possess the skills needed to meet patients’ spiritual needs. However, many nurses do not understand the concept of spirituality and need to be taught its meaning (Walter, 2002). If spirituality is not addressed within nursing education, it is likely to be neglected in practice (Ellis and Narayanasamy, 2009). Milligan (2004) completed research with the aim of exploring nurses’ views on barriers to spiritual care. The research found 68% of the nurses felt they had received inadequate training and education on spirituality (Milligan 2004). Furthermore, the nurses felt they lacked knowledge on spirituality, which therefore affected their ability to meet patients’ spiritual needs (Milligan, 2004). Milligan (2004) concluded that nurses recognise the importance of spiritual care, but feel ill-prepared to meet patients’ spiritual needs. McSherry et al (2008) explored the views of 176 preregistration nursing students on the teaching of spirituality. A longitudinal design was used to follow the students through their 3-year course with questionnaires being used to gather the data. It was found that the majority of the students wanted to be taught about spirituality but questions were raised as to how such a subjective topic could be taught. Students believed that lecturers should not say whether they agreed or disagreed with the students’ point of view. Nonetheless, lecturers would not be able to teach such a subjective topic without influencing the students, consciously or subconsciously (McSherry et al, 2008). A training framework is needed to facilitate the education of spiritual care (McManus, 2006). Shih et al (2001) tested a practical spiritual care study programme in Taiwan.They conducted research to implement and appraise a spiritual care programme of study for 22 postregistration nurses. The 18-week course included field trips, observation, lectures, case studies, clinical implications and appraisal stages. There were 14 topics incorporated into the course, including an introduction to spirituality, spiritual development, patient care plans and spiritual assessment. The researchers established that students found the course helpful in clarifying concepts of spirituality, developing care plans and building on the nurses’ own spirituality. Shih et al (2001) concluded that teaching with a programme of study helps nurses to provide quality spiritual care to patients.
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Conclusion Health professionals have a duty of care to meet patients’ spiritual needs while in hospital (DH, 2003). However, they are failing to provide spiritual care for a variety of reasons (NICE, 2004).These include there being no agreed definition of spirituality; confusion as to the nurse’s role in providing spiritual care; the lack of time available to meet patients’ spiritual needs; and the lack of education and training for preand post-registration nurses on spirituality. Further research into the definition of spirituality is needed in order to gain a deeper understanding of spirituality and agree a definition BJN (Burkhardt, 2007). Conflict of interest: none
British Journal of Nursing, 2014, Vol 23, No 7
KEY POINTS n Spiritual
care is a fundamental part of holistic nursing
n Health
professionals are failing to meet patients’ spiritual needs while they are in hospital
n The
main barriers to spiritual care are the difficulty in defining spirituality; the lack of nurse guidelines for providing spiritual care; nurses’ lack of time; and lack of training and education
n To
meet patients’ spiritual needs, nurses must provide holistic patient-centred care
Bash A (2005) Commentary on W McSherry, K Cash and L Ross (2004) Meaning of spirituality: implications for nursing practice. Journal of Clinical Nursing 13 934-941. J Clin Nurs 14: 1268-9 Bradshaw A (1994) Lighting the Lamp:The Spiritual Dimension of Nursing Care. Scutari Press, Middlesex Burkhardt M (2007) Commentary on spirituality in nursing and health-related literature: A concept analysis. Journal of Holistic Nursing 25(4): 263-4 Buswell J (2006) Ask the experts: spirituality in care. Nurs Older People 18(1): 14-15 Cavendish R, Konecny L, Naradovy L et al (2006) Patients’ perceptions of spirituality and the nurse as the spiritual care provider. Holist Nurs Pract 20(1): 41-7 Chochinov H (2006) Dying, dignity and new horizons in palliative end-of-life care. CA Cancer J Clin 56(2): 84-103; quiz 104-5 Clegg A (2006) Ask the experts: spirituality in care. Nurs Older People 18(1): 14-15 Cray A (2009) Respecting a patients religious needs is key to holistic care. Nurs Stand 23(40): 27 Department of Health (2001) Your Guide to the NHS. DH, London Department of Health (2003) NHS Chaplaincy: Meeting the religious and spiritual needs of patients. DH, London Draper P, McSherry W (2002) A critical view of spirituality and spiritual assessment. J Adv Nursing 39(1): 1-2 Ellis H and Narayanasamy A (2009) An investigation in the role of spirituality in nursing. Br J Nurs 18(14): 886–90 Focus Group UK, The (2007) Consultation Report on The Code of Conduct. http:// tinyurl.com/ovfpwr2 Accessed: 27 March 2014 Fowler M and Peterson B (1997) Spiritual themes in clinical pastoral education. J Supervision Train Ministry 18: 46–54 Grant D (2004) Spiritual interventions: how, when and why nurses use them. Holist Nurs Pract 18(1): 36–41 Hemstock J (2010) Provision of Spiritual and Pastoral Care Policy. Nottingham University Hospitals: NHS Trust Henery N (2003) Construction of spirituality in contemporary nursing theory. J Adv Nurs 42(6): 550–7 Jones L (2004) Practicalities of spiritual assessment. Int J Palliat Nurs 10(8): 372 Kristeller J, Zumbrun C, Schilling R (1999) ‘I would if I could’: how nurses address spiritual distress in cancer patients. Psychooncology 8(5):451–8 Kozier B, Erb G, Berman A, Snyder S, Lake R, Harvey S (2008) Fundamentals of Nursing: Concepts, Process and Practice. Pearson Education, Harlow Ledger S (2005) The duty of nurses to meet patients spiritual and/or religious needs. Br J Nurs 14(4): 220–5 MacKinlay E (2006) Spiritual Growth and Care in the Fourth Age of Life. Jessica Kingsley Publishers, London McBrien B (2006) A concept analysis of spirituality. Br J Nurs 15(1): 42–5 McEwan W (2004) Spirituality in nursing, what are the issues? Orthop Nurs 23(5): 321–6 McManus J (2006) Spirituality and health. Nursing Management 3(6): 24–7 McSherry W (2000) Making Sense of Spirituality in Nursing Practice: an Interactive Approach. Churchill Livingston, Edinburgh McSherry W (2006) The principal components model: a model for advancing spirituality and spiritual care within nursing and health care practice. J Clin Nurs 15(7): 905–17 McSherry W, Cash K, Ross L (2004) Meaning of spirituality: implications for nursing practice. J Clin Nurs 13(8): 934–41 McSherry W, Gretton M, Draper P, Watson R (2008) The ethical basis of teaching spirituality and spiritual care: a survey of student nurses perceptions. Nurse Educ Today 28(8): 1002-8. doi: 10.1016/j.nedt.2008.05.013 Milligan S (2004) Perceptions of spiritual care among nurses undertaking post registration education. Int J Palliat Nurs 10(4): 162–71 Murray R and Zentner J (1989) Nursing Concepts for Health Promotion. Prentice Hall, London Murray S, Kendall M, Boyd K, Worth A, Benton T (2004) Exploring the spiritual needs of people dying of lung cancer or heart failure: a prospective qualitative interview study of patients and their carers. Palliat Med 18(1): 39–45 Narayanasamy A (2004) The puzzle of spirituality for nursing: a guide to practical assessment. Br J Nurs 13(19): 1140–4 Narayanasamy A (2006) Spiritual Care and Transcultural Care Research. Quay Books, London Narayanasamy A and Owens J (2001) A critical incident study of nurses response to the spiritual needs of their patients. J Adv Nurs 33(4): 446–55
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National Institute for Health and Care Excellence (NICE) (2004) Guidance on Cancer Services: Improving Supportive and Palliative Care for Adults with Cancer. NICE, London Nursing and Midwifery Council (NMC) (2007) The Code of Conduct. http://tinyurl. com/pb8eq44 Accessed: 27 March 2014 NMC (2008) The Code: Standards of Conduct, Performance and Ethics for Nurses and Midwives. NMC, London NMC (2010) Standards for Pre-registration Nursing Education. NMC, London O’Connell K, Skevington S (2005) The relevance of spirituality, religion and personal beliefs of health related quality of life: themes from focus groups in Britain. Br J Health Psychol 10(Pt 3): 379–98 Pearce L (2009) Delivering spiritual care. Nurs Stand 23(28): 22–23 Ross L (2006) Spiritual care in nursing: an overview of the research to date. J Clin Nurs 15(7): 852–62 Royal College of Nursing (RCN) (2010) Patients missing out on spiritual care, say nurses. http://www.rcn.org.uk/newsevents/press_releases/uk/patients_missing_
out_on_spiritual_care,_say_nurses Accessed: 27 March 2014 Sessanna L, Finnell D, Jezewski M (2007) Spirituality in nursing and health-related literature: a concept analysis. J Holist Nurs 25(4): 252–62; discussion 263–4 Shih F, Gau M, Mao H, Chen C, Kao Lo C (2001) Empirical validation of a teaching course on spiritual care in Taiwan. J Adv Nurs 36(3): 333–46 Speck P (2005) The evidence base for spiritual care. Nursing Management 12(6): 28–31 Swinton J (2006) Identity and resistance: why spiritual care needs ‘enemies’. J Clin Nurs 15(7): 918–28 Taylor E (2003) Nurses caring for the spirit: patients with cancer and family caregiver expectations. Oncol Nurs Forum 30(4): 585–90 Taylor E (2006) Prevelance and associated factors of spiritual needs among patients with cancer and family caregivers. Oncol Nurs Forum 33(4): 729–35 Walter T (2002) Spirituality in palliative care: opportunity or burden? Palliat Med 16(2): 133–9 Wordsworth H (2007) Reclaim the spirit. Nurs Stand 22(10): 22–23
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Key words: Spirituality ■ Holistic care ■ Wellbeing ■ Nursing education
S
piritual care is a vital component of care that is given to patients by health professionals in order to prevent poor health and treat illness (O’Connell and Skevington, 2005). However, patients’ essential spiritual needs are not being met in hospital (Royal College of Nursing (RCN), 2010). The aim of this article is to identify the main barriers that nurses encounter when providing spiritual care to patients in a hospital setting. A literature review was undertaken to explore the barriers to spiritual care. This topic was chosen because although spirituality in nursing has had much recognition in recent years, it lacks critical appraisal from people within the field of nursing (Swinton, 2006). Spiritual care, like all nursing practice, must be research-based and critically evaluated (Speck, 2005). There is no universally agreed definition of spirituality (Ledger, 2005). However, most people agree that spirituality relates to how people perceive life and death, and involves questioning things that are beyond the material aspects of life, such as love, values and the meaning of life (Hemstock, 2010). The Department of Health (DH, 2003) does not provide a definition of spirituality but states that spiritual care is provided through holistic care. Holistic care is the
Lucy Rushton is Staff Nurse, Maidstone Hospital, Kent Accepted for publication: March 2014
370
Search strategy The electronic databases used for the literature search were the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medline and the British Nursing Index (BNI). The search terms used were – (‘nurs*’) AND (‘spirituality’ OR ‘spiritual care’ OR ‘spiritual need*’) AND (‘problem*’ OR ‘issue*’ OR ‘barrier*’ OR ‘dilemma*’). Limiters were
© 2014 MA Healthcare Ltd
Abstract
Spiritual care is a vital component of care that is given to patients by health professionals in order to prevent poor health and treat illness. It is fundamental to patients’ wellbeing and nurses’ integrity that nurses carry out their care in a holistic manner and meet patients’ spiritual needs. However, a number of studies show that health professionals are failing to meet patients’ spiritual needs while in hospital. Nurses are unable to fulfil patients’ spiritual needs for a variety of reasons. The main barriers to spiritual care are the difficulty in defining spirituality; the lack of clear guidelines for the nurse’s role in providing spiritual care; nurses’ lack of time to provide spiritual care; and a lack of training and education on spirituality for pre- and postregistration nurses.
consideration of the whole person, taking into account physical, psychological, spiritual, economic, social and any other factors relating to the patient (Nursing and Midwifery Council (NMC), 2010). Spiritual care is a fundamental part of holistic nursing (Wordsworth, 2007). Narayanasamy and Owens (2001) maintain that spirituality is a part of holistic care that generates a state of wellbeing. Meeting patients’ spiritual needs through holistic care assists patient recovery and improves quality of life while in hospital (O’Connell and Skevington, 2005). Nurses must possess the skills needed to meet patients’ spiritual needs (NMC, 2010). The DH (2001) declares that patients can expect NHS staff to respect and be sensitive to their spiritual needs at all times. Spiritual care can be provided in a number of ways. Grant (2004) found the most popular ways of providing spiritual care were through listening, laughter, touch and spending time with the patient. Some health professionals believe that spiritual care is incorporated into everyday interactions with the patient (McSherry, 2006). For example, a nurse’s contact with a patient during a dressing change can be used to offer spiritual care and build a trusting relationship (McSherry, 2000). Patients’ views of spiritual care have been investigated and it was found that although some patients did not want any form of spiritual care, other patients did (Taylor, 2003). This highlights how treating each patient as an individual is critical when providing spiritual care. The RCN (2010) undertook a survey of 4045 nurses, which found that 90% of nurses felt meeting patients’ spiritual needs improves nursing care and 83% felt spiritual care is an essential aspect of nursing. Despite nurses recognising the importance of spiritual care, they are unable to fulfil patients’ spiritual needs for a variety of reasons (Narayanasamy, 2004; Ellis and Narayanasamy, 2009). Barriers to spiritual care need identifying and examining in order for solutions to be found. The DH (2003) has highlighted that considerable challenges are encountered when trying to identify and organise care for a diverse population, but that spiritual care is important to patients and can have a substantial benefit on patient outcomes.
British Journal of Nursing, 2014, Vol 23, No 7
British Journal of Nursing. Downloaded from magonlinelibrary.com by 130.113.111.210 on December 7, 2015. For personal use only. No other uses without permission. . All rights reserved.
PROFESSIONAL ISSUES used to narrow the search to find the most relevant papers. The limiters were: English language, age group (all adults), inpatients and publication year (1990–2011). Although the limit for the publication year was broad, it was felt that going back to 1990 would identify more papers and therefore offer some background information to spiritual care and the barriers health professionals face. The total amount of literature found across all three databases was 136 items, including research articles, opinion articles and book extracts. Abstracts were useful in providing a short summary of the key points for each article, and determining whether the literature was applicable. For example, research carried out in a community setting could be quickly identified and ignored because only the barriers of spiritual care in a hospital setting are being examined.
© 2014 MA Healthcare Ltd
Defining spirituality There is no generally agreed definition for the term ‘spirituality’ despite research identifying spirituality as a significant element for the patient experience (Clegg, 2006). Spirituality is difficult to define because it is unique to each individual’s opinions and beliefs (Jones, 2004). Draper and McSherry (2002) state that spirituality is becoming more visible and known within health care but the term spirituality is still difficult to interpret because of its subjectivity. The problem of defining spirituality presents a barrier for nurses trying to meet patients’ spiritual needs because people are confused as to what spirituality means (McEwan, 2004). The difficulty in defining spirituality is further complicated by the terms ‘religion’ and ‘spirituality’ being used interchangeably (Sessanna et al, 2007). An agreed definition of spirituality is essential for developing understanding (Narayanasamy, 2006). One of the main barriers that prevent nurses from meeting patients’ spiritual needs is the ambiguity surrounding the subject (Narayanasamy and Owens, 2001). Until spirituality has an agreed definition, health professionals will not treat spiritual care as an essential part of care (Sessanna et al, 2007). Sessanna et al (2007) completed an extensive review of the literature with the aim of gaining insight into the existing characteristics of spirituality in order to develop a definition. The literature review found 320 definitions of spirituality, which were then independently reviewed and discussed until there was absolute agreement of whether the definition was clear and concise. This resulted in 90 definitions being included in the concept analysis. The definitions were categorised into similar descriptions where four themes emerged: meaning and purpose to life, mystical phenomena, religious beliefs and nonreligious beliefs. Sessanna et al (2007) concluded that a definition of spirituality must incorporate all four themes in order to be relevant to everybody. They believed the most comprehensive description that included all four themes was by Fowler and Peterson (1997). Fowler and Peterson (1997) proposed that spirituality is the beliefs and values by which a person lives their life, which may or may not be expressed religiously. Furthermore, spirituality unifies a person with others, society and can include a relationship with a transcendental being. Fowler and Petersons’ (1997) definition of spirituality
British Journal of Nursing, 2014, Vol 23, No 7
is helpful to see that religion and spirituality are different. Narayanasamy and Owens (2001) distributed 130 questionnaires to post-registration nurses with the aim of exploring what nurses view spiritual needs to be (Narayanasamy and Owens, 2001). It was found that nurses were unsure on the differences between spirituality and religion (Narayanasamy and Owens, 2001). Although spirituality and religion are independent, separate concepts they are regularly used interchangeably (Kozier et al, 2008). Religion is a set of beliefs and practices often associated with such things as public rituals, religious officials and places of worship (Narayanasamy, 2004). Spirituality on the other hand, is an individuals’ search for meaning and purpose in life, and is not tied down to a set of rules (McBrien, 2006). Although defining spirituality is problematic, most researchers agree that spirituality involves the need to establish a purpose to life (Ledger, 2005). Chochinov (2006) states that spirituality should provoke a sense of exploring the worth and significance of life. Another interpretation is that spirituality is the unique internal source that connects us with others and is the guiding force within each person (Narayanasamy, 2006). Henery (2003) believes the use of scientific terms such as ‘force’ should not be used within the definition of spirituality because it cannot be scientifically tested. However, understanding spirituality would be difficult if unfamiliar terminology is used (Ellis and Narayanasamy, 2009). McSherry et al (2004) investigated patients’ and nurses’ understanding of spirituality by completing semi-structured interviews of 22 participants including nurses and patients. The interviews were recorded and transcribed, and the data analysed by a constant comparative method. When comparing nurse and patient interpretations of spirituality there were considerable differences in their understanding and use of language. The researchers found that many of the nurses described spirituality in a way that correlated with the definition provided by Murray and Zentner (1989), and suggested the similarities of the nurses’ definitions could be a result of the postgraduate education of the nurses, where the topic of spirituality was taught. The majority of the patients interviewed found it difficult to provide any definition of spirituality but did articulate that spirituality is a deeply personal and individual concept. McSherry et al (2004) concluded that the concept of spirituality is ambiguous and individual so developing a definition would be difficult. Bash (2005) recognises the importance of these findings and agrees that because spirituality is subjective, it cannot be easily defined. Instead, Bash (2005) offers an alternative interpretation of spirituality by suggesting spirituality is a range of human responses to life and each person is, either consciously or unconsciously, somewhere on that range. This helpful approach could help nurses to visualise each patient’s spiritual needs independently, resulting in patient-centred care. For the purpose of this article, the definition of spirituality that will be used is by Murray and Zentner (1989). Murray and Zentner (1989) state that spirituality is a characteristic feature that seeks to find the meaning and purpose to life, which is especially brought to the forefront of thinking through times of illness, stress, loss and death. This definition
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is being used because it recognises the individuality and distinctiveness of spirituality and encompasses the importance of meeting patients’ spiritual needs during times of poor health. Furthermore, the definition incorporates the four themes found by Sessanna et al (2007).
patients needs holistically (McSherry, 2006). MacKinlay (2006) agrees that the entire multidisciplinary team all have a part to play in meeting patients’ spiritual needs.
The nurse’s role in providing spiritual care
Patients’ spiritual needs are not being met because health professionals do not have enough time to spend with patients (Pearce, 2009). Having the time to listen and engage with patients is not always possible in a hectic healthcare environment (Buswell, 2006). However, some view spiritual care as nothing different from holistic nursing care, making the excuse of time constraints superficial (McSherry, 2000). Compared with other priorities of the nurse such as providing patients with their medication, spiritual care is a low concern when nurses are faced with time constraints (McSherry, 2000). Kristeller et al (1999) completed a survey of 267 oncology nurses with the aim of exploring nurses’ attitudes to spirituality. They found that when nurses faced time constraints, spiritual care was ranked in the bottom three in a list of 18 tasks. Other tasks included addressing pain, discussing prognoses and addressing poor dietary habits (Kristeller et al, 1999). The researchers concluded that time constraints on nurses acted as a barrier to supporting patients’ spiritual needs. Although this research was completed in the USA and generalising the finding to the UK is uncertain, similar findings have been found in British studies. Milligan (2004) used questionnaires to examine nurses’ opinions on factors that affected their ability to meet patients’ spiritual needs. The questionnaire was given to 59 nurses undertaking a training course on palliative care. The nurses identified the most significant barrier to spiritual care as not having enough time. The practicalities of meeting patients’ spiritual needs are further complicated by their personal and sensitive nature (Clegg, 2006). Murray et al (2004) conducted quarterly, qualitative interviews on 40 palliative patients over a 1-year period.The aim was to explore patients’ views and experiences on having their spiritual needs met. It was found that some patients felt uncomfortable expressing their spirituality. Some patients did express a need for love, meaning and in some cases, transcendence, but health professionals lacked the required time to identify and meet such spiritual needs. Murray et al (2004) concluded that in order for patients to feel comfortable enough to ‘open up’ about their spirituality, nurses must spend sufficient time with the patient, building a trusting relationship. In addition, nurses must be adequately prepared to deal with such issues (Ross, 2006).
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Training and education related to spiritual care There are numerous issues with educating and training preand post-registration nurses on spiritual care. There is a risk that because there is no concrete definition of spirituality, the potential information to be included in the training is unlimited, leading to spiritual care being taught in a vague and simplistic way (McSherry et al, 2004). On the other hand, nurses could be taught specific definitions, creating boundaries and preventing nurses exploring different points of view (Swinton, 2006).
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The nurse’s role in meeting a patient’s spiritual needs has not been clearly outlined (Narayanasamy, 2004).The NMC (2008) does not refer to spirituality in the Code of Professional Conduct. Ellis and Narayanasamy (2009) propose that nurses would value spirituality more if it was included in the NMC Code.When the Code was being revised, meeting the spiritual needs of patients was included in the draft copy (NMC, 2007). The Code initially stated that nurses must help support and improve the wellbeing of patients by meeting their spiritual needs, together with their physical, psychological, social, emotional and developmental needs (NMC, 2007). However, in a focus group consultation, the statement was seen as unclear and confusing, and was therefore replaced (Focus Group UK, 2007). Currently, the Code states that nurses must listen to patients and respond to their individual preferences and concerns, which could be seen as providing spiritual care. The NMC (2010) also includes spirituality as one of the factors of holistic care and person-centred care. Moreover, spiritual assessment is mentioned in the Standards for PreRegistration Nursing Education (NMC, 2010).This states that student nurses must complete a holistic assessment of a patient and this includes spiritual needs. In contrast, it is sometimes argued that spiritual care should be regarded as a distinct, separate aspect of care, and therefore carried out by a specialist team and not by nurses (Milligan, 2004). Cavendish et al (2006) completed semi-structured interviews on eight discharged patients with the aim of exploring patients’ views of nurses providing spiritual care. It was found that patients did not view nursing actions such as being kind and compassionate as spiritual care. Nor did patients view spiritual care as being part of the nurse’s role. Florence Nightingale’s theory is in direct conflict with this view, stating that the nursing profession is spiritual and that the care involved is an expression of that spirituality (Bradshaw, 1994). Ellis and Narayanasamy (2009) state that this approach could be seen as outdated and idealistic. However, aspects of quality holistic care such as listening, connecting and spending time with a patient are integrated with spiritual care (MacKinlay, 2006). Spiritual care is not a separate element of care, because it is already ingrained into holistic practice (Taylor, 2006). Cray (2009) affirms that nurses must take responsibility for meeting patients’ spiritual needs in order to achieve true holistic care. McSherry (2006) carried out semi-structured interviews with 53 participants including nurses, patients, physiotherapists, a social worker and an occupational therapist. The aim was to gain a deeper understanding into factors that may restrict or promote spiritual care. It was found that health professionals perceive the caring process to include spiritual care but that it is often unseen because it is provided through consistent interactions with patients. Furthermore, health professionals affirmed that multidisciplinary working is the best way to meet
Practicalities of meeting patients’ spiritual needs
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PROFESSIONAL ISSUES Appropriate training is required for nurses to carry out spiritual care (National Institute for Health and Care Excellence (NICE), 2004). The NMC (2010) states that nurses must possess the skills needed to meet patients’ spiritual needs. However, many nurses do not understand the concept of spirituality and need to be taught its meaning (Walter, 2002). If spirituality is not addressed within nursing education, it is likely to be neglected in practice (Ellis and Narayanasamy, 2009). Milligan (2004) completed research with the aim of exploring nurses’ views on barriers to spiritual care. The research found 68% of the nurses felt they had received inadequate training and education on spirituality (Milligan 2004). Furthermore, the nurses felt they lacked knowledge on spirituality, which therefore affected their ability to meet patients’ spiritual needs (Milligan, 2004). Milligan (2004) concluded that nurses recognise the importance of spiritual care, but feel ill-prepared to meet patients’ spiritual needs. McSherry et al (2008) explored the views of 176 preregistration nursing students on the teaching of spirituality. A longitudinal design was used to follow the students through their 3-year course with questionnaires being used to gather the data. It was found that the majority of the students wanted to be taught about spirituality but questions were raised as to how such a subjective topic could be taught. Students believed that lecturers should not say whether they agreed or disagreed with the students’ point of view. Nonetheless, lecturers would not be able to teach such a subjective topic without influencing the students, consciously or subconsciously (McSherry et al, 2008). A training framework is needed to facilitate the education of spiritual care (McManus, 2006). Shih et al (2001) tested a practical spiritual care study programme in Taiwan.They conducted research to implement and appraise a spiritual care programme of study for 22 postregistration nurses. The 18-week course included field trips, observation, lectures, case studies, clinical implications and appraisal stages. There were 14 topics incorporated into the course, including an introduction to spirituality, spiritual development, patient care plans and spiritual assessment. The researchers established that students found the course helpful in clarifying concepts of spirituality, developing care plans and building on the nurses’ own spirituality. Shih et al (2001) concluded that teaching with a programme of study helps nurses to provide quality spiritual care to patients.
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Conclusion Health professionals have a duty of care to meet patients’ spiritual needs while in hospital (DH, 2003). However, they are failing to provide spiritual care for a variety of reasons (NICE, 2004).These include there being no agreed definition of spirituality; confusion as to the nurse’s role in providing spiritual care; the lack of time available to meet patients’ spiritual needs; and the lack of education and training for preand post-registration nurses on spirituality. Further research into the definition of spirituality is needed in order to gain a deeper understanding of spirituality and agree a definition BJN (Burkhardt, 2007). Conflict of interest: none
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KEY POINTS n Spiritual
care is a fundamental part of holistic nursing
n Health
professionals are failing to meet patients’ spiritual needs while they are in hospital
n The
main barriers to spiritual care are the difficulty in defining spirituality; the lack of nurse guidelines for providing spiritual care; nurses’ lack of time; and lack of training and education
n To
meet patients’ spiritual needs, nurses must provide holistic patient-centred care
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