[SSUE AND lNNOVATIONS IN NURSING PRACTICE

A critical incident study of nurses' responses to the spiritual needs of their patients

An] Narayanasamy rIA .M.Sc RGN RMN Ccrt Ed

l~esel;n'd1er; Trinity Care Spil'il'llality Research Project, Facultv a] Medicine m-u! /-Iealth Sciences, S,boo/ of Nursing, Qlleen.5 Medical Centre, University I)l Nattingbam, NOflil1gh,1NI. U f(

and Jan Owens MEd PhD RN

FIJrmerty enior Lecturer, UI1i1)cr'i'ly of Nottingham, Nottingbai«, England

Suhrnirred f"I' puhlication J 3 Murch 10().tJ '\<:c~rt~d for 1'~,hJi.:,,:!i"ll 1 J 0kr"hc,' 2QOO

Cor respon d ence. Am NarO)/(l1l6lsr.mry,

FII (14 11" of Medidlll! and H(!I1/tl1 . ,rL'I·/CeS. Sdwil/ of Nursmg,

Qlleens Medical Centre,

(jniversit)' of Ncutingbatn,

Nottlnglrarn NG7 2 U/-1.

UK.

E-mail.: 1In1.l1m·,.1)','I1(1S"W)! @l1ofl'iugh,m'/ .t1c.II!~

446

NA1Z,\YANASAMY 1\, & OWENS J. (20UI) [ourna! u( Advanced. Nursing 33(4), 446-4 -5

A critical incident study of nurses' responses [0 rhc spiritual needs of their patients Aim' of study. The. irns of the study were to carry pur ,1 critical incident study to: (I) Describe what IlII rses con ider ro be pirirual needs; (2) Explore how nurses re pond to the spiriruul needs of their patients: (3) Typify nurses' invol ernenr in spiritual dimensions of care; (4) Describe the effect of nUT es' intervention related to spiritual care.

Background. In rhc carir.l,g profession a focus on individual as bie-psychologicalspiritual beings i gainin.g recognirion ;1I1d this notion is based on the premise that there should be ,I balance DF mind, body and spirit for the maintenance of health in <1 per. on (Stoll] 979), Emerging research highligbts the i rnporta nee of spiritual care ill nur ing and suggests rhar there is cop for imprm'ing this dimension of care in order TO improve rhe quality of life fnr m'lllY patients. However, there i very licde evidence about how nul' es respond to the spiritual needs oftheir patients. Therefore the purpose of this study was to map by critical incideur techniques bow nurse construct and respond to patients' spiritual needs in a variety of clinical setrings. Methods. Critical incidents were obtai. ned from 115 nurses. The data from these incidents were subjected to content analysis and categories were developed and described. The emerging categories were subjected to peer reviews to ensure reliability and validity of findings.

Findings. The findings uggest that there is confusion over the norian of spirituality and rhe nurse's role related tospiritual care. A variety of approaches ro piritual care ~lilergedin[his,tl1d)'fromthecriticali"cid nrs derived frornnur ere pendent .The e were categorized a. 'personal', 'procedural' 'culrurulisir' Or 'evangelical'. There wa an overwhelming consensus that patients' hit.h and rrust in nurse producesa positive effect 011 patients and farnilie , and nurses themselves derived satisfacricn from the experience of givill~ spiritua I care. r n this respect, spiritual care interventions promote a sense of well-being in nurses as well as being a valuable part of total patient care. Conclusion. The study concluded that there is scope For developing an ideal model of

pirirunl care l sing the critical incident data from this study.

Keywords: critical incidents, religion, need, spiritual car, personal approach, nur 'ing intuition, cornperencie , beneficial effects, intervention models

(0 lOtH Blackwel] Science Lrd

lssues and inno ;niOI1S in nursing practice

Introduction

Til the caring professions a fo us 01] individual a' biopsychcscciul-spirirua! beings is gaining recognition and rhis notion is based all rhe premi e that there hould be a balance of mind body and spirit for the maintenance of health in ,1 person (Stoll 1979), Emerging research highlights the importance of spiritual care in nur in' and u~ge rs that there i. scope for improving thi dimension of care in order ro improve the quality of life For many patients. However, there is little evidence in the nursing literature to show clearly how nurses respond to rhe spiritual need of [heir patients. Therefore the purpose of the current study is ro map by critical incident technique how nurses construct and respond tc patients spiritual needs in a variety of clinical settings.

Literature review

Although nursing has irs roots in spiritualiry the link between the e two elements had become less obvious when 1110dew medicine began to make irs impact on health care at the turn of the 19th century, Since the 198.0. nursing began to return to irs traditional roots if) spirituality with". steady How of interest in the topic (Naraya.nasamy 1999a), resulting ill a variety of tradirions and perspectives. Despite rhis variety there is a consensus in the literature that spirirualiry is an important facet of humanity and that the are of body, mind and spirit is a hallmark of holistic arc (Highfield & Cason .l9S~, Clifford & Gruca 1987, MOlltgomery 199~1, Narayanasarny 1999a). The literature equates u : tare of wellbeing with the harmonious balance between the e three interrelated but distinct entities: hod.y, mind and spirit. Distress in anyone ef these areas affects rhe others and therefore a holistic approach in restoring the harmonious balance between these three components of humanity is paramount. Research ugge, t. rhar nurses are unclear about their role in providing spirirual Care, but does not offer a dear picture ahour the precise nature of the spiritual dimension of nursing (Harri (In 199 , Ross 1997)0, However, the literature i lenrilies the following barriers to spiritual care; lack of clarity among nurs e <1, ro the nature ( f spirituality, role ambiguity and lack of educational prepnration for the role of spiritual care (Ross 1997, . lcSherry & Draper 1995).

There i a con t!IlSDS in the nursing literature that pirituality is an elusive concept when definition <II' attempted (tvfcSherrr & Draper 1'998, Narayanasaruy 1000). This problem is fu rrher compounded by the rnisu: e of the rerrn pirirnaliry, in that this word is frequently equarcd with

institutional religion such a

hrisrianiry and Judaism.

Nurses' tl!~/JJ!I1S('S to spiritua! needs ()f patients

Several rudics confirm confusion among nurses where spiritualiry is regarded as religion (Harrison & Burnard :1993, Narayana. amy 1993, R< s 1997). A cording to Narayanasamy'( 1999h), although the Unired Kingdom (UK) is regarded ,1$ a ecular society, the maj()rity of nurses working in UK health care ecrors have been reared in a culture permeated with Chri rinn rradirions and value _ From this ir can be inferred rhar nursing ca re is probable to be delivered from a value position characteristic of this hri tia n heritage. Some nursing theorists writing from a Christian rheological perspective (Shelley &. Fi-h 1988, Bradshaw ·1994) are uncornprorni ing and characterize piriruality as Christianity, However, whilst maintaining her stance on a Chri tian rheological per pective, Brudshaw (1994) in her exposition of spirirualiry doe provide a comprehensive review of this subject. Others stress the universality and durability of SI iritua.lity as an everlasting. phenomenon that ustain and pervades all cultures regardless of religious beliefs or nonbeliefs(M.acQu8rrie 1972,1 lay: 1994). Definitions of spirirualit)' have been identified ,1S;

• The essence or life principle of person (Colliron 198·1)

• A sacred journey (Mische 19.82)

• The e cperienc of the radical truth of things (Legere 1984)

• Giving meaning and purpose (Legere 198'4)

• f\ belief rnar relates J person CO rhe world (Soeken & Car on 1987)

• Being rooted in an awarenes which is part of the biological make up of the human species (Narayanusarny 1999a)

The findings of a. number of studies suggest rhat nurses tend to perceive spiritual care as the role of the chaplains ( larrison 199.3 Narayanasarny 1993, Ro s J997). Ro s' findings suggest that nurses who professed religious affiliatinu rend to attempt to provide spi ritual care bur it is nor clear from this study if the care given was (k-~iglled to meet religious needs rather rhan spiritual needs. Apart from role ambiguity, factors such a a lack of communication with other profe sionals (clergy): and envirorunental issues SLLCb as lack of time and space, peace, quiet and privacy interfered with nurses' attempt to provide pirirual care (Ross 1997), Several author identify nurse educati 1) as being responsi ble for the inadequate preparation of nurse For pirirual care in the UI ( urayanasarny 1993, Ross 1'797, McSlwrry& Draper 1998),

The findings of CUU:Cllt research Oil spiritual dimension of nursing COn .isrently suggest that spiritual care is not given adequate attention in nursing fur the three main reasons delineated above: role ambiguity, Lack of communication and euvironmental factors. However, much of the research reviewed () far is de criptive and exploratory in nature. Fur rhermore, these studio lack detail and fail to map out

@ 20(}1 Blackwell Scic:.DCC Ltd, [ournal o] Adllanced NUrsil1/;:, J (4).4·6--455

447

A. Narayanasamy and ], Owens

more clearly whar nur e. a wall)' do when rhey attempt ro provide spiritual care. In order CO fill thi gap in the literature, the current study was undertaken to provide a more comprehensive picture of how nurses construct patients' spiriruul needs and provide spiritual care.

The study

Aims

The aims of this study were therefore to;

• Describe what nurses consider to be spiritual needs.

• Explore how nurses respond to the spiritual needs of their patients.

• Typify nurses' involvement in spiritual dimensions of care.

• Describe the effect of nur es interventions related to spiritual care.

Methods

TIle study used a qualicarive approach incorporating a critical incident technique a choice that is compatible with the assumptions and philosophical approaches, set out by Leininger (1.98'9), Silverman (1991)., Field and Morse (1985) and Flannagan IJ.954). The critical incident technique a a method of data collection was popularized by Flannagan ( 1954) and is particularly useful for collecting dam from rhe direct observation of human hehnviour in order [Q Facilitate problem olving (Cormack .1996). According ro Cormack 'An incident relates to any ob crvahle human acriviry rhar is sufficiently complete in itself ro permit inferences ro be made' (p, 266). This method is used in preference to observation because of the practical. difficuhies and constraints often experienced by researchers [Ising oaservatinn particularly in clinical settings.

An added advantage of rhis method is thar it depends on the description of actual event, rather than de criptions of rhinzs as [hey should be. The method brings credence ro practi e because the technique i largely concerned with the rea I, rather than the abstract world, and at the same time it acknowledges rhe constraints and lirnltarions that we encounter in the WQ;Fld in. which we live and work,

Data collection

Critical incident questionnaires were distributed to (30 nun es attending a posrregi marion 111 odular cour e at the university where the study rook place. Participants were asked to complete detail of in idenrs of piritua I care in relation to the following four topic areas:

• De cription of ,1 nursing : iruarion which showed when and how respondent recognized rhar patients had pirirual needs. • How and why re .pondenr idenrified pecific pirirual needs .

• Description of what resporidertr did to rry tr» help patients to meet their spirirua I needs .

• Descriptinn of the effect 011 rhe .patienrslfamilies of the their actions and rhe reasons why respondents concluded rhat their ~KtiO!1 had re ulred in such effects.

The questionnaire incorporated further information about the purpo c of the study, the \/< lunrary nature of parriciparion, respondents' anonymity and confidentiality. Respondents completed the que riunnnire in j1i·i,vacy and liS questionnaires were returned (response rate R8'),q. Fourteen nurses From those wh.o reo p< ndcd had ~ diploma in higher education and they provided marginally more derailed incidents than tho e not educated tu this Ievel. There were nr significant difference' in the responses between nur: es educated at diploma level and certificate level.

1\"'0 main reasons can be hypothesized why some nurse. fa,jled r return completed questionnaire .. Fir. r, some nonre-

pondcur may have failed initially to recognize any need for spirirual care. This hypothesis is .upported by rhe literature which suggests that nul' es are unuware of patients' spiritual needs (Harrison J.993, Narayanasaruy 1993, ROSS 19971. Second, some nurse may have recognized spiritual needs bur I11;)Y have been unable (or unwilling) to respond to such need. ami were therefore unable to describe ,1 critical in i lent.

[early, the re ear A design favoured those nurses who were both able co recognize and had rc 'ponded to patient spiritual needs 0 rhat rhe finding do not fully reflect the actions of nurses who are las a ware of patients spiritual need s, Tel bles . .t and 2 bel.owi.ndude figures related to respondents ill terms 'of I1l1 rsing areas and specialities.

Data analysi:

Da~::I obtained from the c questionnaires were subjected to ontent analysis, a llexiblc procedure that enabled the researchers to test theoretical is ues to enhance LTD Iersranding of the data tDownc-Wamboldr 1992). Data was managed ill

Table 1 Respondents

ltll'sing branch

No

AJ~I·lr

Mental health Children

TOlal

ItS

448

© 20(1'1 Blackwell Science Ltd, )w(1'II~11 '4 Ad~'llnced Nursing, J3(4), 446-45,)

I sue and innovation in nursing practice

Table 2 Respondents

Nursing .pe ialities

Acute adult Cominuing care CU nuuun ity Mental health Children

38 29 is 22

Tor;) I

11.'1

an objective and systematic way that led ro the drawing of inference {l-lolsti 1968). Initially several caregories were identified and these were Then collap ed independently by me two researchers into key themes related to spiritual care. Through repeated meetings and continued individual work, categoric and themes were compared and revised. These interacrive measures attempted to minimize the influence of individual frames of reference. The ate orie and themes were then subjected [0 review by a panel of experts in rhe subject area' and inter-rarer validation to ensure rhe credibility of the analysi .

Findings and discussion

The rhemes and categories that :merged. from the critical incident data and the emerging' rheoretica I understanding derived from rhe analy i. are de oribed and di cus ed below (see Table 3 below).

Nurses' awareness of patients' spiritualneeds

The findings of this study suggest that in the course of their encounters with parierrr , rhe nurse became aware of patients spiritual needs when the following were recognized: Patients' religiou background, hared rt'ligioli. background, and

Table 3 'rhl: process and Outcome'S vi rc pending to patienrs'

How nurses became aware of patients' spiritual needs

reported oncerns

The nurses' nctions

R~liJ:ri()I.IS I nckground

Nurses' I'rSpUN cs to ipirituo! needs f patients

'pirirually/religiou I)' loaded conversation and diagnosis. The e acted as strong I WnlI?ters for nurses to respond to their, patients' spiritual needs.

l~eligiotls b~,d~§I"(J/,mc{

lnforrnation about parienrs' religious backaround acted as a 'rr(1llg indicator for nur .es to initiate acri m that brought {1 bout religious care interventions. One 13U(.e'S ac .. xount re fleets thi s:

Patienr and family have strong religious needs. The patient was experiencing 11 psychotic illne s, burwi 'hell ro arrend 11 church service each Sunday (Mental Health Nurse).

This background in forma tion offered a concrete means to deliver services that could be descri bed <IS religious in nature rather than spiritual. The Chaplaincy services were u ed frequently as a way of meeting parienrs perceived religious needs.

Shared religious background

Besides the idenrificari. n of patients' religious needs, when 11m es knew that patients shared a similar religious background with them. they fdrrl"u this offered the opportunity to develop :1 close relarioruhipwirh the patient:

J found our thar they were a Roman Catholic fmnily ... [ am myself <1 ,hri$['ian. We talked openly of our rnuruul Iairh from early 011 in our encounter ... we prayed rogether I omrnuniry Nurse).

This mutual faith legitimized their intervention' related to pirirual care. Ross (1997) identified that nurses who claimed religious affiliation were better than those without in identifying patients' .spiritual needs. It can be inferred from chis claim that nurses' personal belief systems influenced their participation in spiritual care. This is consistent with the findings '(~f other studies where the link between nurses'

The outcome of nurses' intervention

Religious needs

Persona 111 nruirive approach e.g .. Persoual involvcmeno' cngagerneur/su Plmrtj vc

EFfects on patient

e.g. FediL1~ a sense of uniqueness ,If[,d bel Ilg (a reel for

Effects 011 fam.ily

c.g. Coming to terms/acceptance procedural. routines

Effecn 011 nur es

c.g, Rewarding experience

Diagnosis prompted

Spiritual needs

Procedural approach e.g. Logicul/srcps/

.ulrural appronch

c.g. 1-1011\'51.' reflexive :l('COUOts Evangel ica I approach

t!.g '; Shared rcli ~j(lll background

© lOO! Blackwell Science l.rd, lOlt.m<!l nr Adu{,lllc.ed N,.mh,g, 33(4),446-455.

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A. Naraytllwsamy and J. Cuoens

willingness to be involved in general and spiritual care and their personal belief system ha been established (Pile 1986, Forre st 19.89\ arnarel 1991).

Spi·rit.uaUykeligi0I1sly loaded com/ersation

\When patients' conversation was found ro have strong spiritual or religious dimension nurses used these as prompters to initiate spiritual are interventions:

On a psychiarric ward, r used rf) spend considerahle rime mlking wirh [his parienr. His spiritual needs seemed [0 be [usr ro ralk nbour what he believed, what he loubred and somewhere ro lind hope and strength, something [0 be angry wirh ... (Mental Health Nurse)

Nul' es who inve ted in building ~1 nurse-patient relation hip often picked up C11(:S which could be described as spiritual in nature in order to initiate spiritual .care interventions. This suggests that nurses who used uch an approach arc more reo ponsive ro patients' spiritual needs as opposed to religious need .. This is consistent with Ro s's (J 997) findings where she found rhar nurses who built a stronger rapport with patients gave pirirual care at a deeper level than those lacking them, Where needs were identified a religiousin nature parienrs were referred co Hospital Chaplain. or other rei igious experts.

Diagnosis 1)romtlted response

Apart from religious needs and shared background, patients' diagnoses acred ,1S a mmg prompter fQr nurse." to initiate

plrirual care interventions:

The situation occurred when a patient wanted ro know his diagnosis, no medical sr_a{f were available. He had carcinoma of rhe lung. He asked if 1 would object to pr.lying with him, ·Ar the rime r fclr I·C~S~l.IrDn<.;c and support in :1 rime of crisis W:lS his need - to comrnumcatc his distress without distressing his falJlilylt-denbll Health Nurse).

The severity of the diagnosis often prompted nurses ro initiate interventions to meet patient's' spiritua] needs. Cancer :1I1d other forms of terminal illness prompted nurses [0 give 'on the. pot SI irirua] care and in some instances the hospital chaplains were called to supplement tilt! nurses' effort and ro provide 'expert' help.

The nature of patients' reported concerns

Religious needs

Nurses' reported concern centred around two areas which could be described as religious need and piritual needs in broad t rrns.

Expression of religious helte(s and practices led uur es to initiate religious care inrerveurious:

The nursing ream as a whole recognized rewards rhc larter smg~ of rhe parienr's life that he be arne vcr)' aggressive and hostile. His rclnrives felt rhar this was due L'O lack of attention [0 his 'spiritual needs, and (hey admitted rhnr rhe patient had been deeply religious unril rrngic event cook over ... lr ro\lk time for rhe nursing ream ro sir with the family and patient to work I)Ut' whar W,lS required, which led ro eventual pn. roral support (Adult 'arc Nurse) ..

In many instances these needs were referred to the chaplains who were called to sec patients. 011 some occasion, in re ponse to reported concerns, nurses prayed with pari nrs or encouraged them to carry out religiou practices and ritual. ln particular the wishes of patients from ethnic minority backgrounds were re peered arid considered sensitively. For. example, diemfY needs related [0 rhe patients' religion and culture were considered a part of the care planning. Similar considerations were given in rhe case of dying patients who were from minority cultural and religious groups.

The symbolic aspects of some parients' lives ucb as tile eros, crucifi: and other religious artefacts acted as concrete factors that led ro rccoguiriou of religious needs and the e prompted nursing attention. h ~lprears that nurses were good at recognizing religious needs in terms of the outward exprcssionsof religious beliefs, [1) almost all cases, religious care interventions took place when such religious needs were identified. Although this is a good ign, it may be the ca e that other spirirual need such as the search for meaning and purpo e, and the need For love and security auld have been overlooked. These factor have been considered ro be an important part of patients' . piritual dimension' (Legere J 984 Narayanasaruy 1999b). There is consensu in the lirerarure that al though nurses lI. ually display some knowledge of and ability to identify rhe concrete aspects of patients' religious needs, for example, communion (Chadwick 1973., Narayana amy 1993, Ro s J 997), they find ir more difficult to recognize spiritual' needs, which could be described as predomin;lntly psychological in nature (Highfield & ason 198~).

'piritua! need,

The finding ill the Curren'[ rudy showedthat a. number of nurses identified patients' spiritual concerns in nonreligious terms which included expressions Or feelrl'lgs/CI'I10IiOIlS, 1/'1,d searching (()f meaJling and p~/.'rpr)S£l .. Extracts from rwo -of the nurses' critical incidents illustrate the e factors:

Through our conversation fear became the overriding factor causing tense andemotional pain. The parienr was afra id ofdying and didn't wane ro upscr her hu. hnnd in rdayinR herfears [Comrnuniry Nurse).

A patient needed I'\Llldancc, seeking meaning and purpose ... wanting ,\ 1l1COllC TO guide him througn his emorional rurrn il. .. 1 rricd ro ralk

4:50

© IOOI 1.'1ll1ckwali SdelKc Lrd, journal of .Adllr.lllced Nursing, 33(4),446-455

Issues and innovationsin nursing practice

to the patient and liis· fmnily burl felt out of ml' depth and asked them to speak It) a more experienced colleague .. .I didn't feel [ had enough kum"iedge or confidence to completey guide them through the sil'uatjO(J .( Comrnuniry Nurse).

Nurses in this study who appeared to have invested in building a nurse-parienr relationship reported using a more personal approach that a.lowed them to identif}' emotional tensions and rurrnoll, and made efforts to be involved in giving xocnselliug support ro patients to overcome their spiritual distress. Thisis consistent with Ross: study in which she. found n urses who had dear views about the meaning of life andrelated issues often engaged ar a deeper level with patients when providing spiritual care.

The nul' CS· actions

The findings of this srudy swgges~ that nurses, on idcntificarion of patients' spiritual/religiou needs, used four approaches: (1) Personal, (l),Procedura.!, (3) Culturalist and (4) Evangelical. The four .approaches described lind discussed below are analytical categories constructed from the data but in reality of course, very few of the respondents' accuunts of critical incidents feU neatly into .only one category, but rarher there were elements of more than one approach in marry respondents' accounts.

Personal approacb

Many nurses described spiritual needs in nonreligious terms. These spiritual needs related TO emotional feelings, thoughts and expression of the need eo explore meaningand purpose h' patients. Many nurse who described spiritual needs in nonreligious terms tended to use a more personal approach, A nurse working in a medical ward recalls:

I' tried to be as hOIlc.st as possib.o 11m] discuss. the rhoughrs and feelings of "meaning of life'and 'why her' to ~ d'~grte rhar r felt cnmfortahlc wirh ... l fed rhur the patienr and family appreciated 'honest' answers, nnel grew 1".0 trust the ,ta'ff as we didn't; make lIny 'false' promises.J think this was because they seemed CD Fed at ease to discuss their most iMim.ace thoughrs and f~eling~ until theytook their mother home to die. [ll' the time they did this rhey appeared to all (including [he patient] ro ')C<:~Pl rhat death W:;iS inevitable (Aduk Care Nurse).

Nurses Who adopted rhis approach were 11orsoll,allji inuolved in addressing paticurs'<spirirual needs. They were willing to give rime and attention. t.o patienrsand engage in all aspects of patient care. This approach to spiriruu! cf\n:cQuld he described as holistic. The relationship wkh patients tended to be mutua! and based 011 an equal partnershii» that

prornpred feelings of trust ami security <lmDng patients. Nurses used a (;QuI/selling approach and often isupperted patients during critical stages of their illness. 111is confirms earlier h(lciings (Montgomery 1(91) which SHe sed the importance of a personal approach comprising the elernenrs identified carliervnarucly persenal 'involvement, partnership, mutua lity and counselling approach _ Mnnrgornerv (199 J ) observed that J1L1IS(lS who allow themselves to be dose to patients actually experience on some level the patient'S healing or the positive effects of their caring. It would seem that this approach could be considered to be the ideal model for spiritual care,

Procedura! a:/~PI'Otn-h

The procedural approach tended to address needs which could be described as religious ill nature, Patients expression [rf -religious bdlllfs and practices are perceived as spiritual needs.

On admission of the r~t'i.ei\r it W.,15 apparent that the parieut W~~ Church of England and went to church e'~ery Sunday. They "poke openly (l'hO(lt their re.ligi.OllS hcli.efs and rhey had used the church with rheir health prrsblerns to combat iU:L1cSS 1n the past. The patient had.~ myotll.rdi.tll ilJf~ftrion and on initial assessment were asked if th~y would 11k" TO go. TO church when well. Tbey were in lavour of this ... I felt that the paticnr wouldlike ro see l'he CI1<lp!ail~ in the hnspita]. I was able to confirm rhis (IS the patient was so. gra~cful when t ]l)1"f,}posed the idea (Adu],r Care Nurse).

Nurses in rhe study whoused [his approach took iogic,1Js1,ep.s and adhered to procedura] '17C:Jlltt!1'les when addressing patients' religious needs. When religious needs were identified patients were referred to, thechaplains Eor visits from them, Stereotypi1rg, of patients in terms of religious and cultural labels was common among nurses in this study who followed the procedural approach. Some nurses who used this approach appeared to be addressing patients' religious needs as a way of appeasing relatives rather than frdfiUi-ng patients' wishes. Nurses sometimes colluded and collaborated with patients' families, often without patients' prior knowledge, before initiating sctiondirccrly or indirectly related to spiritual or religious care inrerventions, An. incident illustrates this situation:

An elderly paricnt WIH) was dcmenting ... f\~ rhis rime if was rnore for the Iarnily and rclnrives to have rc.ligious support through chaplaincy..;

Although the procedural appr.mlchis .cornmendahle in addressing the religious and cultusa l needs of patients, i1lU'SCS often appeared to be impersonal in their approach ill that procedures f.111d religious routines set rhe tone for spiritual

451

A. Nan~yal'lasa"I'iY and f. Ow('ns

care intervention. This state of practice raises the question whetherspiritual distress displayed in nonreligious ternrs and expressions would receive any' spiritual care interventions fromsame nurses. It may be tharsuch expressions would go unnoticed, Srereotyping of patients in terms of religious and cultural needs may lead to rhe rigid application of religion practices and routines without consideration of actual needs related to patients' spirituality, For example, an account from a nurse working in [he mental health field illustrates this:

We had al~ldy who was a Muslim .. ,J spoketo her parrncr in order [f) get some insight into rhis faith. I cxplainedte her rharwe could get ill touch .with someone horn rhccorumunlry if needed ·(,Vlenral Health Nurse) .'

Concerns are expressed in the literature that certain groups of people mav be treated ina r,igid way 'in terms of assurnprions .about their race, culture and faiths (Henley & Schott 1999).

Such al~ approach also raises the rc)~~ibilinf that nurses feel secure in adhering to concrete procedural routines tel deal with parienrstspiritual/religious needs, It is a] 0 probable that the nursing culture based on doing things for patients in terms of cencrcre and tangible measures lends irselfwell ro rhc procedural approach. The high incidence: 'of referral to the chaplains to dcalwirh patients' religious needs 111ilY be part of this picture, and such measures may have acted as a shield to respondents' perceived inadequaciesin spiritual care knowledge and competencies. This aspect of the finding is consistent with Narayanasaruy's (1993) study which fOLH)d that nurses depended on religious agents such as the hospital chaplains to shield them from becoming involved in spiritual care because of their poor knowledge and skills relaxed to spiritual care. Ina similar vein, Millison (J 988) suggests that many carers steer dear of spiritual care for lack of skill in this area, or because they simply feel that it i.s not part of their role. However, it is encouraging tb.:lt respondenrs ill the: presenr study are pl;;lY'iJlg ari important role in spiritual care by referring patients ro hospital chaplains, and it may be the case rhat respondents felt that this is the most appropriate and sensitive action on their parr in meeting patients' spiritual needs ..

Odtu'l'al,a1lproach

A small number of nurses 111 this study used a cultural interactionistapproach to initiate spiritual careinrervenrions.

Clients who wi h to pray to Mecca n1,IY have the curtains pulled reunr], he given a sideward or taken ttl th" mosque.on D floor ,IS does happ'elil",Ct,$tr,jjllS of differeru ~ul:t1j'leslrel'it;ions 'He TGciJgnhl'cI as ,they arise and every effort .made to acoommodnte requesrs .iAdlllr Care Nurse)

Patients perceived to be belonging to minority faiths and cultures Were recognized with relative ease by nurses. Patients' cultural and religious videntity gave nurses vital cI lies as to what course of action should he initiated to meet these needs. Nurse using this approach used a holistic ,I pproach i,n which the)! consu lted and involved relatives and farniliesro be part (Jf the overall care. Participants sought expert advice ;)·5 well in addressing the cultural and spiritual needs of patients helonging to minority cultural and religious groups. These nurses took practical measures to ensure that privacy and special provisions were available to these groups: of patients where feasible. However, when they were unable te make special provisions for patients from minority religious ;;1J]d cultural groups they gave banest. tefl'exi've accounts as to why they failed to measure-up rocxpecrarions 01' good spiritual ~rid cultural care, A nurse reflects this:

Some bmily members needed more SlIppon than others, although with a yOLln~ family :I felt it was hard enough C[)pin~ with them, work, aad my Own emotlens to try ro meet their spiritua! needs rCu.rnrntmiry NLlrs~l.

These sltorrcomings were apparently because -of lack of support From colleagues and lack of practicul provisions t~J niece such needs. The Inability to be contprehensive jn their approach led to eth.ical dileuuuax for [helle nurses, that they cOl1ld provide better ·ca~e iF they had adequate knowledge, skills, peer and management support; and resources, The ethical principles of beneficence and justice asdescribed by Beauchamp and Childress ("1994)' have the potential ro be eompromised.

EV(1I'1geiica/appro.at.;'h

A small number of nurses !;alfe ,1CCQLl.qts of spiritual care incidents which could' be described as 1:lsing an Evallgeii.c;.tj approach. Nurses whrJ 'shared ,7 simi] u 1' religious b(JckgrQund with patients made gmat efforts to re-affirm patients' fairh, cspecia'lly if they appeared to be relapsed hristians, One incidenc illusrrares thls:

We both shared similar religious beliefs. r think he W,IS r~g:rctfLd nf the past and W8', i(wking for 11 W'l)' CO say sI'lrry and ro know thar 'he would be forgiven ... I told rhe patient despite h'is past life rharthcrc is a G,)d who "ares and who promised Forgi"~ne,,s for rhose who believe MId who ask for fmgivelics, (M~I1t'a1 Health Nurse).

Likewise, in rhe case of very ill babies and infants some nurses in this study went our (')f rheirwaj to baptise them in ord e r to fulfil their own religious beliefs. W'hen opportunities arose they used them toimpose their personal beliefs upon patients and their families:

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Issues and innovutiousin nursing I:'raclice

f\ b"by was cddc~\lly ill Oil Chrisunas eve 1996 - [he baby had nor been baptised, 1 slIggl'sted to the parent's that they may be would like ro trrlk Qo 11 chaplain. .. the mother declined but ~hc Dad wanted ro, so r conrncred a' chaplain who carne to talk to th~I11 ... the mother W3S adarnanr rhar she did not want her haby baptised .. J suppose I'ny personal beliefs .. .rnorivared me ro take this action. The cltaplain arrived, rhe mum changed her "'lin(L The b,Jby W:lS bapri .ed with mysel present. I felt this helped rhe p<ll'cms immensely [Children Nurse].

Although these nurses reported that they avoided direct coercion, they were apparently very persuasive in .encouraging parents. to consider baptism for their babies and. infants .. Nurses provided several. incidents related ro outcomes of success with their persuasion. Some nurses believed that baprisrn actually saved SOJ\le children from death as a result of serious illness. Thcs religious convictions and. subsequent evangelical. approach seemed to be prompted by a belief in Divine interventions when medical care was failing,

However well intended the evangcljcal approach mal' be, it raises ethical questions. Although [he numbers were small it is probable that tilis study may have reflected a larger problem with regard to evangelism within norsing.Tfowever, Benson and Stark .( 19%,) have argued that if such measures do not produce harm as they conform ttl the principles of norunaleficence (Beauchamp & Childress J994), then there is no problem, Likewise, the principles of .autouomv (Heall;" champ & Childress 1994) have been followed in that patients/parents have fully consented to nurses" actions; although autonomy 3.l1.cl consent in ,111 unequal power relationship {healtb care worker and patient) cou Id he questicned. IB spite of these claims, such nursing actions could be perceived as unacceptable practices from ·,1n ethical point Q:f view, in terms of the imposition of personal values on a vulnerable group oi individuals.

The. outcome of the nurses' interverrtions

Nurses from this stud}' identified that rhe outcome of thei r spiritual care intervenrions bad rherapeutic effects on patients, families and nurses on most occasions.

Positure effect O,n patients and rda,tivils

Following spiritual care incerventions, patients appear l)eace(ul, relaxed and c:al1n,G1'Id grtltr:f.j/". Such states were believed tuaid patients' healil.lg and recovery (or peaeeful death). A nurse working in the mental health field illustrates this:

.... by explaining and ~hq~Nil'lg him about .1:11<: need to think of the Fll~lI.re, he was able ro sec' that there was something beyond the here

Nurses' responses to !i/lifittutl Heeds o(pai:ieuts

alild n(1\\1, which made hirn more relaxed and cornfO,tliole .. .less fearful. The expression OJl his bceS8.id it' ::III (Mental Health Nurse).

Added to this, nurses til rhis rudy reported rhar many patients felt: comfo.rted and supported as a direct result of spiritualcare inrervenrions. Other patients were reported to have said that they derived a sense of reeling unique and cared [or, others felt stronger to cope as a directoutcOlue' of spiritual care intervention, From this it could be surmised that spiritual 'care interventions directlyor indirectly reduced distress and enabled patients to gather emotional strength co cope with rheir illness and suffering .. It can be assumed thar indicators .of spiritual well-being. could be developed using these descriptors. Presently such indicators based an ,emp.irical evidence are not readily available .. The descriptors related to spiritual well-being could be used for die development of spiritual care indicarors when evaluation of spiritual care is being considered.

Effects on Iamil y.

Further to the Qlbove effects of spiritual care inrerventious 011 patients, 1J1ITSe~ gave accounts which suggested that such interventions had positive effectson patientsfamilies as well Many families expressed gTCft.it:Nde and leel!ngsof being ;;o'l'l'lforted and. ha,/WY ,15 a result of spiritual care inrerventions hy nurses, ill addition to this effect, SOTl1t: relatives came tn terms with patients' illness by accetlting the situation: .. This. generalstate of well-being: of patients and families appears to be .,1 product of holistic care, of which spiritual care is an importnnt dimension.

Effecrs Oil nurses

Apart from parienrs and relatives, nurses frOln this study gave ;~CCOllLlt5 that suggest that they felt that g.iving spiritual car€ and the effects it had on patients is a rewarding experience. One nurse reflected with colleagues that things; went well:

The relarionslnps forged 10d ro quite strong' bonds wieh a smallgroup of nurses ... Parienr and 'family felt special recQgnizing the efforr staff showed w understand their specific oircumsrancesar-d be1iefs ... led to the conclusion through positive feedback Irom paticnrs and families, as well as i11(~!iriDn and reflectinuwith eclleaguesrhat things wcrrr well (Ccnrinuing Care Nurse).

This suggests that nurses' personal involvement by being supportive of patients during distress and being able to give time-and attention to patients' spiritual needs is rewarding. There is probably a strong link between the personal approach co spiritual care and the rewarding experience felr

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by 11IJTSeS. Almost all nurses in this study suggestedthat they derived a. positive effect from this. This part of the study provides strong supporting evidence rhar spiritual care should be an integral parr of the nurses' role as it can be a rewarding' experience. The significance of this experience should be emphasized in nurse education and training programmes on spiritual care, Ir could be suggested tentatively that if spiritual (fire is an active component of nurses' role, it is most probable to be rewarding and satisfying, leading to overall improved role satisfaction and morale flmOl1g nurse, leading ultimately to better toral patienr care.

'However, some nurses from this study gave accounts that suggested that the inability to provide proper spi;ritUal care because of lack of peer and management support, poor rraiRiLlg and education and resources, posed ethical .dilennnas. These nurses g-ave honest reflexive accounrs ill which the)' said that they .fek unfulfilled as rhey Feltinmir.ively that, they were unable to help patients with their spiritual needs:

.. .His f'lrnily. especially bls new wife' were-more difficult to assess and the care we had given rhem, Ir is frusrrating that there is no way to foli,f)w rhe bereaved rhrOlug:ll(Aclulr Care Nunse).

However, the overall findings add strength to the ear I iercla im that spiritual tare interventions lead to positive outcomes ,i1,] patients and relatives, and this state tlf practice has [urther effects on nurses where equall y they deri ve a sense df.hd.'fiJment. Messages of this natu re d er iv ed from C l;np iri cal evi deuce should be disseminated to, all nurses and' health care managers.

Limitations of the study

This study could have been followed-up by further interviews with nurses to establish comparability between written and 'oral accounts of the incidents related to spi ritual care. The sample size could have been expanded to elicit more incidcuts of spiritual care. Furthermore, although the data analysis was subjected to reviews by H panel of experts in the subject area and inter-rarer validation, there is still the danger that researchers' bias and values may have influenced interprera[ions. Therefore, caution is needed when generalization is being considered from the nndLngs of this study, given the small samplesize from MentalHealthand Children's Nursing as-well as the potential fOJ: b-ias and value 'influences (In the part of the researchers. The other limitation is that this study does not include samples from the learning disability nursing branch. Howevet.jn spite of rhese Ijmi,ta6011S the strength of this study lies in ecological validiry in that it is based on real accounts from nurse respondents working in a -variety of clinical sertings. Overall, this study provides scope for more research involving

in-depth interviews to follOW-LIp some ofthe issues which could benefit hom further exploration.

Conclusion

This research is the first of its kind in the study of s pi ritual care as described by nurse participants, Overall, the hndings suggest that there is COJ1fusi~)I1 over the notion of spirituality and rolesrclated ttl spiritual care. A variety of models of spiritual care emerged in. this study from the critical incidents derived from nul'S, respondents. The approacb to spiri rua 1 care was apparently largely unsystematic and delivered haphazardly, ~lltho:Ltgh there were somegood examples of practice as well as areas showing stope for irnproverncnr .. The study acknowledges that good care can be unsystematic, personal and intuitive. There appears' to bean overwhelming consensus that Faith and trust in nurses produces a positive effect on. patients and families. This is consistent with the findings ot rhe literature (Montgomery 199], Benson & Stark 1996) which has dernonsrrared a clear link between positive nurse pariene relationships and healing .. This aspect of the findings trorn current research adds weight to the claim that there is ,1 elese i i 11 k betwce n rhe body, mind and spirit, An harmcnlous ba lance between these three elements is paramourrr For the well-being of patients, The findings of the stud), suggest (hat nurse participants also derived personal satisfaction when, [hey impleruented spiritual care. In this respect, spiritual care interventions promote a sense of wellbeing in nurses as well' as being a valuable part of total patient care,

The .Hnd.ings of this study offer prospects Fox developing (he Personal and Cultural Approaches of care as models of spiritual care. The elements of good practices from both approaches could be drawn together 'to produce a model of spiritual care-that hould be piloted andtested forvalidation, It is hoped that this will be the basis for our .next research project [Q develop an ideal model. of spiritual care using the rich elata derived from this study.

Acknowledgement

This study is larger pan 11£ a project on spiritual care research sponsored by Trinity Care pic. We would ILk~ to rhauk rhe nurses who participated in this study. liiually, we are indebted to the critical reviewers ef this study.

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