SPIRITUALITY IN

NURSING PRACTICE
HANA RIZMADEWI AGUSTINA, S.Kp, MN
DEPARTMENT OF FUNDAMENTAL NURSING
EMAIL: hra@fkep.unpad.ac.id

Definition

It is integral to the wellbeing of all human beings, whether we

are conscious of that need for reflection and wholeness or not.
It is the lifelong process through which we find our center in
the world, how we establish our relationships, find love,
meaning, connection. That is why an affirmation of spirituality
in nursing at every level is long overdue (Wright and Neuberger,
2012).
Spirituality is an essential part of the existential domain
measured in quality-of-life scores. Positive reports on those
measuresa meaningful personal existence, fulfillment of life
goals, and a feeling that life to that point had been
worthwhilecorrelated with a good quality of life for patients
with advanced disease (Cohen et al, 2001)

Definition

The concept of spirituality is broader than the concept of religion. Religious

beliefs and practices can be expressions of spirituality, but spirituality exists
apart from religion. (Berry, 2005; Flanelly et al, 2007; Chiu et al, 2004 in
Smith, 2006)

The consensus is that spirituality is defined as the manner by which persons

seek meaning in their lives and experience transcendence connectedness to
that which is beyond the selfwhereas religion is best understood as
adherence to an accepted formalized system of belief and practices (Flanelly
et al, 2007; Koenig et al, 2004 in Smith, 2006).

Spirituality as a universal phenomenon, for although all persons do not

understand and accept the supernatural, all persons have needs for seeking
meaning and acceptance in their lives (Koenig et al, 2004; Dobratz, 2005 in
Smith, 2006).

Definition

AAMC

Spiritual Care

Spiritual care is defined as the provision of interventions in the domain of spirituality

and has long been the focus of hospital chaplains.

Spiritual care also has been accepted as a legitimate focus of nursing practice.

The North American Nursing Diagnosis Association has 2 accepted nursing diagnoses
for spirituality: spiritual distress and readiness for enhanced spiritual well-being.
13,14

The Nursing Outcomes Classification includes 20 indicators for spiritual health, and
the Nursing Interventions Classification includes 4 specific interventionsfor spiritual
carereligious ritual enhancement, spiritual support, spiritual growth facilitation,
and forgiveness facilitationand 2 more general interventions that are often used in
spiritual care: bibliotherapy with sacred texts and presence.13,14

Spiritual Care = Companssion Care

The word compassion means to suffer with. Compassionate care

calls physicians to walk with people in the midst of their pain, to be
partners with patients rather than experts dictating information to
them.

Victor Frankl, a psychiatrist who wrote of his experiences in a Nazi

concentration camp, wrote: Man is not destroyed by suffering; he is
destroyed by suffering without meaning.

One of the challenges physicians face is to help people find meaning

and acceptance in the midst of suffering and chronic illness. Medical
ethicists have reminded us that religion and spirituality form the basis
of meaning and purpose for many people.

(Pulchaski, 2001)

Compassion Care

Spiritual or compassionate care involves serving the whole

personthe physical, emotional, social, and spiritual.
Such service is inherently a spiritual activity. (Pulchaski,
2001)

Helping, fixing, and serving represent three different

ways of seeing life. When you help, you see life as weak.
When you fix, you see life as broken. When you serve, you
see life as whole. Fixing and helping may be the work of
the ego, and service the work of the soul (Remen, 2001)

Spirituality about

hope and strength

trust

meaning and purpose

forgiveness

belief and faith in self, others, and for some this includes a
belief in a deity/higher power

peoples values

love and relationships

morality

creativity and self expression.

Spiritual Care
That care which recognizes and responds to the needs of the
human spirit when faced with trauma, ill health or sadness and
can include the need for meaning, for self worth, to express
oneself, for faith support, perhaps for rites or prayer or
sacrament, or simply for a sensitive listener. Spiritual care begins
with encouraging human contact in compassionate relationship,
and moves in whatever direction need requires
(NHS Education for Scotland, 2009).

Spirituality during a time of Crisis

It has been said that Often it is not until crisis,
illnessor suffering occurs that the illusion (of
security) is shatteredillness, suffering...and
ultimately deathbecome spiritual encounters as
well as physical and emotional experiences
(Ganstrom in Hitchins, 1988).

Innate compassion

Nurses who are aware of these concepts, and who like being in the world of their work, will
not harm patients simply because by caring for others they care for themselves.

They do not have to 'do' compassion. They just need to source their own deeply felt humanity
from which compassionate action flows with ease and grace. Cruelty usually stems from the
frightened self.

Spirituality cultivates a deepening of our understanding of what it is to be human, of

resources we can draw on to connect with and serve others. It encourages us to feel
comfortable in the world and to be more likely to respond to the things life throws at us from
a position of love and respect, rather than fear.

These are some of the main reasons why spirituality is every bit as relevant to patientcentered care as having the right skills and resources to do the job.

(Walter & Neuberger, 2012)

Sense of separateness

Viewing patients through this lens of separateness means we can feel under attack when they
become demanding or needy. That sense is heightened if we feel uncertain about our ability to
do the job, or do not feel supported by our boss or the organisation.

We may then seek to defend ourselves from our responses to patients. Under such pressure, we
may not only look and seem uncaring to patients, but actually find excuses to avoid contact with
them, or even worse, assault and harm them verbally or physically.

'They' cease to be human like us, instead becoming aliens without the same feelings or
understanding as ourselves. Patients become wholly objectified, people to whom and for whom
things must be done.

Unless we have become mature, well-rounded human beings with insight about always needing
to see ourselves and others as fully human, the chances are that, under pressure, we will start to
operate in ways that are uncaring.

This decision to see others as separate from ourselves can be expressed as: 'You are different
from me, I am on my own here.' The language of our deeper humanity (in some traditions our
'soul' or 'higher consciousness') says: 'We are the same, we are of one common creation, there is
no "other".'

(Walter & Neuberger, 2012)

Research in Spiritual Care

Mortality
Some observational studies suggest that people who have regular
spiritual practices tend to live longer (Strawbridge, 1997). Another study
points to a possible mechanism: interleukin (IL)-6. Increased levels of IL6 are associated with an increased incidence of disease. A research study
involving 1700 older adults showed thatthose who attended church were
half as likely to have elevated levels of IL-6 (Koenig et al, 1997)). The
authors hypothesized that religious commitment may improve stress
control by offering better coping mechanisms, richer social support, and
the strength of personal values and worldview.

Coping

Patients who are spiritual may utilize their beliefs in coping with illness, pain, and life
stresses.

Some studies indicate that those who are spiritual tend to have a more positive outlook anda
better quality of life. Patients with advanced cancer who found comfort from their religious
and spiritual beliefs were more satisfied with their lives, were happier, and had less pain
(Yates et al, 1981).

Spiritual well-being was related to the ability to enjoy life even in the midst of symptoms,
including pain. This suggests that spirituality may be an important clinical target (Cohen et
al, 1995).

Prayer as a method of pain management was used more frequently than intravenous pain
medication (66%), pain injections (62%), relaxation (33%), touch (19%), and massage (9%)
(Robert et al, 1997).

When asked what helped them cope with their gynecologic cancer, 93% of 108 women cited
spiritual beliefs. In addition, 75% of these patients stated that religion had a significant place
in their lives, and 49% said they had become more spiritual after their diagnosis (Robert et al,
1997)).

Among 90 HIV-positive patients,those who were spiritually active had less fear of death and
less guilt (Kaldjan et al, 1998).

Contd

Spirituality also can provide reserves that enhance

endurance. In a qualitative research study of men
hospitalized with prostate cancer endurance through
difficult illness, treatments, and unknown outcomes

The metaphor men of prayer because all of the patients

identified the use of prayer as vitally important. The
patients reported that prayer provided strength,
assurance, comfort, and inner strength, trusting and living
day by day.

(Walton and Sullivan, 2004 in Smith, 2006)

Contd

A random Gallup poll asked people what concerns they would have if they were
dying. Their top issues were finding companionship and spiritual comfort
chosen over such things as advance directives, economic/financial concerns,
and social concerns. (Pulchaski, 2001)

Those who were surveyed cited several spiritual reassurances that would give
them comfort. The most common reassurances cited were beliefs that they
would be in the loving presence of God or a higher power, that death was not
the end but a passage, and that they would live on through their children and
descendants (George, 2001).

Bereavement is one of lifes greatest stresses. A study of 145 parents whose

children had died of cancer found that 80% received comfort from their
religious beliefs 1 year after their childs death. Those parents had better
physiologic and emotional adjustment. In addition, 40% of those parents
reported a strengthening of their own religious commitment over the course of
the year prior to their childs death (Cook and Wimberly, 1981 in Pulchaski,
2001).

Recovery

Spiritual commitment tends to enhance recovery from illness and surgery. For
example, a study of heart transplant patients showed that those who participated
in religious activities and said their beliefs were important complied better with
follow-up treatment, had improved physical functioning at the 12-month follow-up
visit, had higher levels of self-esteem, and had less anxiety and fewer health
worries (Harris et al, 1995).

In general, people who dont worry as much tend to have better health outcomes.
Maybe spirituality enables people to worry less, to let go and live in the present
moment.

Related to spirituality is the power of hope and positive thinking. In 1955, Beecher
showed that between 16% and 60% of patientsan average of 35%benefited from
receiving a placebo for pain, cough, drug-induced mood change, headaches,
seasickness, or the common cold when told that the placebo was a drug for their
condition. Study of the placebo effect has led to conclusions that our beliefs are
powerful and can influence our health outcomes (Pulchaski, 2001)

Spirituality in general
Various investigations have shown religious involvement to
be positively correlated with well-being, happiness, life
satisfaction, hope, optimism, purpose and meaning in
life, higher self-esteem, greater social support and less
loneliness, lower rates of suicide and fewer positive
attitudes toward suicide, less anxiety, less psychosis and
fewer psychotic tendencies, lower rates of alcohol and drug
use/abuse, less delinquency and criminal activity, and
greater marital stability and satisfaction
(Koenig, 2009; Koenig, McCullough, & Larson, 2001).

Spiritual Care is not

just about religious beliefs and practices about

imposing your own beliefs and values on another

using your position to convert

a specialist activity

the sole responsibility of the chaplain.

(RCN, 2011)

The value of understanding Spiritual

care

Spirituality may be a dynamic in the patients understanding of the disease.

Religious convictions may affect health care decision making

Spirituality may be a patient need and may be important in patient coping.

An understanding of the patients spirituality is integral to whole patient

care.

ASPECTS OF SPIRITUAL CARE

Practicing compassionate presencei.e., being fully presentand

attentive to their patients and being supportive to them in all of
their suffering: physical, emotional, and spiritual

Listening to patients fears, hopes, pain, and dreams

Obtaining a spiritual history

Being attentive to all dimensions of patients and their families: body,

mind, and spirit

Incorporating spiritual practices as appropriate

Involving chaplains as members of the interdisciplinary health care

team

Practising spiritual care

In our survey a member said Spiritual care is a fundamental
part of nursing currently much neglected through ignorance and
misunderstanding. (RCN, 2011)

The practice of spiritual care is about meeting people at the

point of deepest need.

It is about not just doing to but being with them.

It is about our attitudes, behaviours and our personal qualities

i.e. how we are with people.

It is about treating spiritual needs with the same level of

attention as physical needs.

3 actions as indicators of the quality of

spiritual support

Assess and document spiritual needs of patients and

patients families on an ongoing basis;

Encourage access to spiritual resources; and

Elicit and facilitate spiritual and cultural practices that

patients and their families find comforting

(Levy, Nelson, Solomon, 2003 in Smith, 2006)

What is needed from a Nurse?

Adopting a caring attitude and disposition.

Recognising and responding appropriately to peoples needs.

Using observation to identify clues that may be indicative of

underlying spiritual need e.g. peoples disposition
(sad/withdrawn), personal artefacts (photographs,
religious/meditational books and symbols).

Giving time to listen and attend to individual need.

Being aware of when it is appropriate to refer to another

source of support e.g. chaplain, counsellor, another staff
member, family or friend.

Preparing to give spiritual care

Just as you would assess your patients physical needs, an

initial assessment of their spiritual concerns is also
important. You may find questions such as these helpful:

do you have a way of making sense of the things that

happen to you?

what sources of support/help do you look to when life is

difficult?

would you like to see someone who can help you?

would you like to see someone who can help you talk or
think through the impact of this illness/life event? (You
dont have to be religious to talk to them).

(RCN, 2011)

Integrating personal beliefs and professional

practice
It may become apparent that the client requires some intervention to support them with
their spiritual or religious beliefs. Before taking any action you should consider the following:

has the intervention been initiated by the patient/client?

has clear consent been given?

does it comply with your professional codes of practice?

does it comply with your employers codes of practice?

is it safe and appropriate?

is it likely to cause offence?

do you feel comfortable?

do you have sufficient knowledge and skills?

is there adequate support and supervision for you and your patient/client?

(RCN, 2011)

Where do I go when I feel out of my depth?

It is about knowing your strengths, limitations and when to seek

help. You may consider the following:

another colleague, someone you trust (mentor or preceptor)

the Chaplaincy team (who are there for staff and patients of all
faiths and none)

local contacts specific to your workplace

psychosocial team (e.g. social worker, counsellor, psychologist)

your own faith groups and/or other support network

(RCN, 2009)

Why spirituality is essentials for nurses?

engaged spirituality' is the key to preventing further cases of patient abuse and neglect
(Stephen Wright and Julia Neuberger, 2013)

All belief systems, whether religious or otherwise, have something to say about what it is
to be human. We are all much more than our jobs or roles or personalities.

Spiritual practices such as prayer, meditation and reading scriptures cultivate deep
reflection on the nature of 'I' and how best to be and act in the world.

They seek to encourage a less egocentric view of ourselves in the world, to make us a part
of the creation, with responsibilities towards the world we live in and to each other.

If we come to identify too strongly with 'I am a nurse' and then something happens to our
role, such as redundancy or a complaint, it can feel as though our whole life is under
attack. Similarly, labels such as 'patient' can sometimes lead us to forget that he or she is
a human being, just like us.

References

Editorial Board. Journal of Psychosocial Nursing Vol. 49, no. 6, 2011

Pulchaski, C. (2001). Role of Spiritual Care in Health Care Settings

Royal College of Nursing (2011). Spirituality in Nursing Care. A pocket

guide

Smith. A.R. (2006). Using the Synergy Model to Provide Spiritual

Nursing Care in Critical Care Settings. Journal Critical Care Nursing,
26(4), 42-47

Walter, S & Neuberger, J, 2012. Why Spirituality is essential for

nurses?. Nursing Standard, 24(40)