Spirituality_Nursing2.pdf
Journal of Holistic Nursing American Holistic Nurses Association
Volume XX Number X XXXX 201X 1 –14
© The Author(s) 2016 10.1177/0898010115626777
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As an inherent component of human beings, spirituality is an intangible and multidimensional concept that is subjective in nature. It is a universal phenomenon felt by a person according to his or her experiences and beliefs (Galvis & Pérez, 2011). It is a personal inquiry into the meaning and purpose of life and may or may not be related to religion. In addition, it can be influenced by social, cultural, biological, psychological, and religious factors (Batcheller, Davis, & Yoder-Wise, 2013; Sánchez, 2010; Tanyi, 2002). In cases of illness, the demand for spiritual support depends on the severity of the
illness or the impairment it has caused, the social and family support, and the experiences of loss and pain (Castelo-Branco, Brito, & Fernandes-Sousa, 2014).
From the perspective of nursing practice,
626777 JHNXXX10.1177/0898010115626777Journal of Holistic NursingVeloza-Gómez et al. research-article2016
Authors’ Note: Please address correspondence to Mónica Veloza, MSc, Universidad de La Sabana, School of Nursing and Rehabilitation, Campus del Puente del Común, Km. 7, Autopista Norte de Bogotá, Chía, Cundinamarca, Colombia; e-mail: mon- [email protected].
The Importance of Spiritual Care in Nursing Practice
Mónica Veloza-Gómez, MSc Lucy Muñoz de Rodríguez, MSc University of La Sabana, Chía-Cundinamarca, Colombia
Claudia Guevara-Armenta, MSc National Vocational Training Service (SENA), Bogotá-Cundimarca, Colombia
Sandra Mesa-Rodríguez, MSc University Foundation of Navarra, Neiva-Huila, Colombia
Purpose: Explore what spiritual care means to nurses who work in emergency care units. Design and Method: Nine nursing professionals from an emergency care unit at a private health institution affili- ated with the Universidad de La Sabana participated in this descriptive qualitative study. Nonparticipant observation, field notes, and in-depth interviews with a question guide were used to collect the data, which were analyzed by means of content analysis. Results: Three themes and their corresponding subthemes were identified with respect to the significance of spiritual care: (1) interpretation of spir- itual care, (2) the patient and the family in spiritual care, and (3) the role of the nurse in spiritual care. Conclusions: These findings provide a deeper understanding of spiritual care in terms of its signifi- cance. They also acknowledge its importance to nursing practice in emergency care units. The signifi- cance of spiritual care is based on theoretical, scientific, and humanistic points of reference (the discipline of nursing) that strengthen the therapeutic relationship between the patient/family–nurse dyad. The study also offers evidence for holistic nursing practice that requires theoretical-academic, administrative, and assistance support.
Keywords: nursing care; spirituality; nursing; holistic nursing; evidence-based nursing; hospital emer- gency care units; qualitative research
Qualitative Research
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Spirituality is related to the holistic notion of care. This idea encompasses all human dimensions and the intensive efforts made to include new approaches that meet the technological skills and the ontologi- cal capabilities that are essential to the maturity and survival of nursing as a profession. (Dezorzi & Crossetti, 2008, p. 213)
Nursing is a practice-based discipline that is inter- ested in the human being (Batcheller et al., 2013). Accordingly, spiritual care promotes the development of therapeutic relationships characterized as being the context and environment where the innate dignity and integral nature of each and every person are recog- nized, as is the vital importance of sensitive and com- passionate practice (Biro, 2012; Meehan, 2012).
Background and Significance
Nursing literature contains studies on the impor- tance of spirituality, spiritual care for nurses and nursing students, and spiritual care in high-depend- ency care settings, such as intensive care units and those dedicated to palliative care. With regard to the importance of spirituality and spiritual care and in light of their broad conceptualization in relation to nursing, further research is needed to clarify and strengthen the practice of spiritual care (Swinton & Patison, 2010). Moreover, the literature on this dis- cipline recognizes that including spirituality in organ- izations helps preserve the meaning of person-centered care in nursing and the assimilation of physical, psychological, and spiritual needs (Batcheller et al., 2013). It is imperative to clarify how nurses can offer spiritual care in practice and to arrive at a model of spiritual values that can be a learning source and help nurses to achieve a common understanding of spirituality and give them a spiritual focus for nurs- ing practice (Meehan, 2012). Spiritual care, as part of holistic nursing, requires a personal spiritual per- spective on the part of clinical nurses who support the needs of patients in their search for meaning and purpose in life. An educational effort supported by continuing education programs is needed to facilitate this process (Wu & Lin, 2011).
With respect to spiritual care in high-depend- ency care settings, such as intensive care units, a multiplicity of meanings as part of the multidimen- sional nature of spirituality and its influence on the practice of care has been identified when studying
the significance of spirituality in these scenarios (Penha & Silva, 2012). Therefore, taking spirituality into account is important in order to unify scientific knowledge, in practice, with an expression of human sensitivity and a deep awareness of the human being (Dezorzi & Crossetti, 2008).
A group of nurses in Thailand who work in intensive care units offer spiritual care through psy- chological support. This is done by facilitating reli- gious rituals and cultural beliefs, communicating with the patient and the family, valuing the spiritual needs of patients, showing respect, and facilitating the family’s participation in patient care (Lundberg & Kerdonfag, 2010).
A comparative study on the practice of spiritual care in palliative and intensive care units identified two differentiating factors with respect to empathy in the delivery of spiritual care: the nurse’s educational profile and age. More of a spiritual perspective and advanced practice of this type of care were identified in the group of nurses from palliative care units. The highlights included more available time and privacy to offer spiritual care and other aspects in this pallia- tive care scenario, such as end-of-life care. The situ- ation can be different in high-dependency care units, such as intensive care units or emergency care units, where barriers such as a lack of privacy with the patient and limited time for care were identified (Ronaldson. Hayes, Aggar, Green, & Carey, 2012). However, the study suggests that nurses who have far more time with patients demonstrate integrity and awareness of the importance of spiritual care as part of professional practice (Chan, 2009).
Regarding education, the participants in a study conducted with nurses working in low-dependency care settings in Hong Kong expressed feelings associ- ated with their inability to offer spiritual care due to increased workloads, lack of time, inadequate resources, and insufficient knowledge in that regard (Wong & Yau, 2010). However, in another study undertaken with nursing students, a broad vision of spirituality related to greater capacity to offer spirit- ual care was reported. This level of competence can be achieved at the undergraduate level by taking into account the factors that contribute to the acquisition of skills and aptitudes for spiritual care (Ross et al., 2014).
A study conducted with a group of Turkish nurses regarding their perception of spirituality and spiritual care identified demographic variables,
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cultural beliefs, years of work experience, level of training, and the area of work as factors that influ- ence the way spiritual care is provided. Educational level was the variable with the greatest positive impact on their perception of spirituality and spiritual care (Ozbasaran, Ergul, Temel, Aslan, & Coban, 2011).
The importance of spiritual care in nursing and its impact on the quality of care and the promotion of best practices are recognized at the administrative level in health care institutions. There is ample knowl- edge of this theme, and nurses’ involvement to make use of that knowledge and thereby empower motiva- tion in this respect and identify adequate training in spiritual care is recommended (Cockell & McSherry, 2012). The development of nursing education pro- grams on spiritual care can have positive effects, not only in terms of the care nurses provide but also in eliciting greater satisfaction in the exercise of their profession. The development of these types of pro- grams also allows for recognition of the importance of spiritual care as part of the “identity” of a health insti- tution (Vlasblom, Steen, Knol, & Jochemsen, 2011).
The advancement of knowledge on spiritual care is evident, as is the nature of how nurses provide holistic care through a therapeutic relationship that is person and family-centered, namely, one that consid- ers their physical and psychological needs. The litera- ture also suggests the need for spiritual care in practice scenarios where the therapeutic relationship might be compromised, as in the case of high- dependency settings, taking into account the specific technologies involved, the complexity of the contexts, the dependency on care, the patient’s privacy, and education on this topic. Spiritual care is necessary to achieve a positive impact on the well-being of patients, families, nurses, and health institutions. Thus, researching the significance of spiritual care to nurses in emergency care units, which are characterized by high-dependency care, a hi-tech environment, and a context that limits privacy and individuality in care, is necessary. This study also is required because a better understanding of the practice of spiritual care will benefit nursing education and research.
Materials and Method
Design, Sample, and Scenario
A descriptive qualitative study was conducted (Guba & Lincoln, 2005; Sandelowski, 2000). The
sample was intentional, and nine professional nurses assigned to three shifts in the emergency care unit of a private university health care institution affili- ated with the Universidad de La Sabana took part. The participants, two men and seven women, ranged in age from 23 to 38 years and had emergency care unit experience ranging in length from 11 months to 3 years. The nurses’ participation was voluntary. The interviews, each lasting 50 minutes on average, were held in an area adjacent to the emergency care unit, ensuring the possibility of conducting the interviews in a private and comfortable setting, without inter- ference.
Ethical Considerations
This article is part of a master’s degree research project that was approved by the research and ethics committees of the Universidad de La Sabana and the Universidad de La Sabana Clinic, where this study was conducted. The privacy and confidentially of the information provided by the participants were protected, and their agreement to participate in the study voluntarily was obtained on the basis of their understanding and written informed consent.
Data Collection
Data collection was accomplished through non- participant observation, field notes, and in-depth interviews that were guided by the following ques- tion: What does spiritual care mean to you? Each recorded interview was transcribed textually and analyzed immediately, in conjunction with the obser- vations in the field notes, in order to keep the infor- mation as reliable as possible. The sample was collected up to data saturation, based on an analysis of the information provided by the participants, with a follow-up of 90 days.
Data Analysis
The data were analyzed using the qualitative con- tent analysis method, which implies a subjective textual interpretation of the content of the data through a process of systematic classification (Hsieh & Shannon, 2005; Munhall & Oiler-Boyd, 1993). Mainly inductive reasoning was used in this process and coding was done through an analysis of the inter- views, which were read in detail, line by line. Relevant
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statements were identified and complemented with information from the field diary. Then, categories were formed to support the establishment of themes and subthemes (Hernández & Fernández, 2010).
The rigorous criteria adopted to assess the scien- tific quality of the study focused on credibility, audit- ability, and transferability (Guba & Lincoln, 2005). Credibility was achieved through new contacts with each of the informants to confirm the findings by acknowledging the information provided as being true and authentic. Auditability is referred to by other authors as confirmability. This criterion was met through the intervention of other researchers whose perspectives allow for reaching conclusions that are similar to those outlined by the researchers in this study. The director and codirector of the study provided constant guidance during the course of the research. They both intervened in the process, as required, to ensure the confirmability and useful- ness of the information that was produced. Transferability or applicability was achieved through socialization of the research results as a possible reference for expert readers, who will consider whether or not they can be transferred to other similar contexts represented by emergency care units at other health institutions. The interviews were recorded digitally and transcribed verbatim to meet the criteria of reliability and adaptability.
Results
The significance assigned to spiritual care by the nurses who took part in this study centers on three themes and their respective subthemes:
1. Interpretation of spiritual care from the standpoint of its particularities, its end goal, and the sense of religion in spiritual care
2. The patient and family in spiritual care, with the patient perceived as an integral being and a subject of care and the family, as a source of support and subject of care
3. Role of the nurse in spiritual care, high- lighting nurses’ qualities, nursing inter- vention, and the scenario of nursing practice
The themes and subthemes are described below, supported by the research findings.
Theme 1: Interpretation of Spiritual Care
Interpretation of spiritual care is supported by three subthemes: the particularities of spiritual care, its end goal, and the sense of religion in spiritual care. Sequentially, they allow us to consider each on its own terms and in relation to the ultimate goal. Aspects related to beliefs and religion that generate a rich interpretation and strengthen nursing care are considered as well.
With respect to interpretation of spiritual care (Figure 1), starting with its particularities, the study participants consider this type of care to be a funda- mental aspect of human life, something that belongs to and is representative of nursing, a facet in which the individual perspective and integrity of the person in his or her totality are present.
“What is spiritual is basic, because it is fundamental to life, like breathing or all that concerns what is physiological.” “Spirituality is something that human beings need in order to live.” “It is care focused more on the person; in other words, the patient comes first.” “Each person is unique, a complete whole.”
Emotional support, open-mindedness, and active listening also are part of these particularities. Active listening and an open mind are the prelude to being attentive to what patients express or convey, without judgment or blame, listening to them when needed and always being available to them, with an unbi- ased attitude and respect for their dignity and indi- viduality. These particularities constitute guides to spiritual care, with emotional and holistic support being emphasized as strategies for approaching humans as complete beings and, thus, identifying what they need in terms of care:
“How is spiritual care provided in your daily activities? It’s done by offering moral support, emotional support, active listening, in silence, too . . .” “One must have an open mind, but be highly focused as well.” “I listen to them and don’t say anything. I don’t assign blame and don’t judge them.” “Basically, it’s giving emotional sup- port and holistic care.” “Holistic care is being able to see all the situations the patient is involved in and to find a solution when things fall apart.”
Regarding the educational component or nurs- ing training, the lack of a definition, guidelines or
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related training leads to uncertainty in terms of expectations for offering spiritual care. However, the need to consider a person’s individuality and integral nature is recognized:
“Well, I don’t think there is a protocol for helping and offering spiritual care. It’s done differently with each person, depending partly on the moment and their beliefs.” “We’re not trained for this. Oftentimes, we are not even prepared to say a patient has died, much less to be able to address the spiritual component.” “There is no defined protocol on how to start, as there is with a nursing procedure.” “In spiritual care as such, there are no defined characteristics or, if so, I don’t know them. And, I’m not sure we are prepared for this.”
As for the end goal, the study participants indi- cated that spiritual care is given not only in response to a particular need but also to make patients feel better and to offer relief, advice, and well-being. Counseling can be provided in light of the patient’s beliefs:
“You should respond to more than just a need. This type of care is given with the idea of offering some- thing more, something that makes patients feel bet- ter.” “Counseling must take into account the patient’s beliefs.” “We can offer this little bit of spirituality that is going to help the patient recover satisfactorily.”
Concerning the sense of religion in spiritual care, the participants in the study regard the reli- gious beliefs of patients and nurses as part of spirit- ual care, allowing for expression of and respect for those beliefs by responding to religious requests such as support in prayers to assist with recovery. Similarly, respect is afforded to patients in situations where there are no religious beliefs involved.
“My beliefs as a woman and as a person are impor- tant in this instance.” “With my beliefs, I’m giving them a different type of care.” “Spiritual care is offered according to religious beliefs.” “It allows a person to express their feelings about beliefs and to respect them.” “We offer them nursing care and, if they want someone to talk to, we help them with a priest who accompanies them during the difficulty they are experiencing.” “With patients who don’t believe in God, it is very difficult to get involved, because it would be a lack of respect for their beliefs.” “The closeness the patient has with a special being, that belief is what helps the patient to pull through.”
Theme 2: The Patient and Family in Spiritual Care
The theme “patient and family in spiritual care” (Figure 2) is supported by two subthemes: the patient as an integral being and subject of care and
Figure 1. Interpretation of spiritual care. Source: Data taken from the research: Significado del cuidado espiritual en el profesional de enfermería que se desempeña en un ser- vicio de urgencias [Significance of spiritual care to the nursing staff in an emergency care unit]. C. P. Guevara & S. M. Mesa— Diagram derived from the research.
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the family as a source of support and subject of care. These play an important role in the meaning of spir- itual care and strengthen the dyad that is formed with the nurse in a therapeutic relationship.
For nurses, considering the patient as a complete person and subject of care implies getting to know the patient and their needs through observation and com- munication conducted in a prudent and convenient manner, inquiring about their feelings, and identify- ing the situation that is being experienced, not only from a physiological standpoint but also from an emotional perspective. Loneliness is one example.
“You have to consider the type of patient you are deal- ing with and try to intervene on their behalf in a prudent and convenient way.” “I believe in simply going to ask them how they feel emotionally, spiritu- ally, and physically.” “When offering spiritual care as part of your daily activities, you define the patient and provide that kind of care, depending on how the person sees it.” “If you see a situation where a patient wants and needs spiritual care, then you simply try to provide it by blocking out external influences that do not contribute to the patient’s commitment and to his or her improvement.” “Patients don’t get sick just because of illness per se, but also due to loneliness.” “Patients in a lot of pain or patients who are without pain, but anxious about knowing their diagnosis, they also need spiritual support.”
The participants in the study highlighted the relevance of the family in spiritual care, both as a source of support and the subject of care. This is because emotional and spiritual aspects surface as a consequence of their experiences when a family is confronting an illness, either through the support it can offer or in response to their requirements for care. Family love is a component of family support that helps patients to cope with their situation.
“I think the family group at the patient’s side and at the side of the person offering care makes for a good contribution.” “I like to mix the family part and the individual part, because it forms an entire cycle that helps the patient to pull through. Mixing is like tak- ing a little bit of the patient, of the family, and knowing them that way.” “Families are the ones who request more spiritual help; it´s not only the patient. Families seek us out.” “Care is provided across the family.” “One could say spirituality is only praying, but a person’s spirit is overwhelmed suddenly by their emotional side.” “Affection can be offered as a resource for spirituality.” “At times, I see love among family members and I realize how it helps me with the spiritual part.” “When someone is affectionate, it helps with spiritual support and particularly when it comes from the family.” “I believe in working on the morale and mood of the family and patient to help improve the patient’s health, taking into account family love.”
Theme 3: The Role of the Nurse in Spiritual Care
The role of the nurse in spiritual care (Figure 3) is present in three differentiating and complemen- tary aspects: the qualities of the nurse, nursing intervention, and the scenario of nursing practice. These qualities give nursing care its own particular characteristics that simultaneously impact the set- ting where spiritual care is offered.
The qualities professional nurses say are required to exercise spiritual care are capacity, comprehension, vocation, and commitment, that is, expressions of themselves and their therapeutic role as caregivers:
“We are in a position to tell a patient to hold on to God and that spiritual part will help them.” “I work with my patients in terms of their spiritual needs.” “One’s duty is to listen to them and give them a reason to live.” “[It’s] having some honor and strengthening
Figure 2. Patient and family in spiritual care. Source: Data taken from the research: Significado del cuidado espiritual en el profesional de enfermería que se desempeña en un servicio de urgencias [Significance of spiritual care to the nurs- ing staff in an emergency care unit]. C. P. Guevara & S. M. Mesa—Diagram derived from the research.
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them in the face of trouble.” “I am a nurse; it is one’s vocation to give care.” “It’s doing what has to be done.” “If one has that helping spirit, one must have a good heart and must be a good person.”
Another aspect that is underscored as part of the nurse’s role when providing spiritual care is his or her intervention in a therapeutic nurse–patient/fam- ily relationship. The authentic presence of the nurse in that relationship is manifest and characterized by generous companionship, responding to the call for help and being available to others, which result in satisfaction and mutual benefit.
“Spiritual care is having constant and sincere com- munication with the patient.” “It’s putting oneself in the other person’s shoes.” “Spiritual care means giv- ing words of encouragement.” “If the patient needs companionship, a prayer or something spiritual at any point in time, keeping them company is also basic.” “There are times when patients feel very lonely, and we’re the only ones who can help to give them strength.” “Spiritual care gives me a greater sense of tranquility and more satisfaction than other kinds of care that are equally important.” “I feel good about it and I enjoy having time to talk with patients.” “One is satisfied at having made someone feel better.” “It is rewarding to feel that I have helped someone with a comforting word or expression of encouragement.” “I feel very good. I’ve gotten to
know the family; it’s important to them and to the patient.” “I was pleased to see her go calmly into God’s care.” “I’m at peace. I feel I did something important for myself and for the patient.”
The practice scenario is an important factor in the role of the nurse when offering spiritual care. In the case of an emergency care unit, nurses recognize the possibility of offering well-timed spiritual care when needed, despite the condition of the patients and the complexity of the service. Naturally, consid- eration is given to the importance of the work to be done and time management.
“One can provide spiritual care at any time, from the moment the patient arrives in triage. If a patient comes in anxious, afraid, worried, in pain, not knowing or unaware of things, we can offer spiritual care as of that point and until the patient goes home.” “I believe in offering timely care when patients want it and need it.” “It is beautiful when someone calls for you and says, ‘I would like you to hold my hand; I want to go.’” “In the emergency care unit, one could say we might not be able to offer spiritual care because of the daily chaos. Everything has to be done quickly.” “There is a lot to do, but there are times like yesterday and today when there were opportunities. For example, you can talk to the patient while administering medication. These are brief moments, but they can be very substantial for
Figure 3. Role of the nurse in spiritual care. Source: Data taken from the research: Significado del cuidado espiritual en el profesional de enfermería que se desempeña en un ser- vicio de urgencias [Significance of spiritual care to the nursing staff in an emergency care unit]. C. P. Guevara & S. M. Mesa— Diagram derived from the research.
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a person and for the nurse.” “Care like this is pos- sible when the volume of patients is low, when there is a bit of privacy and we’re not under so much pres- sure.”
Discussion
The significance of spiritual care, as represented by the three themes identified in this study (inter- pretation of spiritual care, the patient and the family in spiritual care, and the role of the nurse in spiritual care), has not been recognized in the literature in a comprehensive way. Therefore, the following discus- sion is based on the findings for each of the themes proposed in the study, considering how they are related and complementary.
Theme 1: Interpretation of Spiritual Care
The results of this study show spirituality is envi- sioned as one of the central points of the integral care that is part of nursing practice (Wu & Lin, 2011). It is a condition for spiritual care that requires knowledge, skill, and aptitude (Ross et al., 2014), in addition to an open mind and active listen- ing. These aspects are present in a therapeutic rela- tionship.
As to the interpretation of spiritual care based on its particularities and end goal (see Figure 1), the findings of this study are consistent with those of several other authors (Barnum, 2003; Burnard, 1998; Carson, 1989; O’Brein, 2007) with respect to spiritual, integral, and holistic care, and particularly its complexity and importance in addressing human responses of a biological, psychological, social, and spiritual nature. Theses aspects are also viewed as separate and synergistic components, that is, as a hallmark and legitimate activity within the scope of nursing (Biro, 2012; Chan, 2009; Wu & Lin, 2011).
A person’s spirituality can be determined by aspects of life that are profoundly personal and spe- cific, such as values, beliefs, and relationships (Wu & Lin, 2011). It is constructed differently, accord- ing to religious traditions, spiritual movements, belief systems, cultures, contexts, and, not least of all, the particular circumstances in a person’s life (Sheldrake, 2007). These elements are comple- mented by the spiritual attributes identified by the Royal College of Nursing: hope and strength, trust,
meaning and purpose, forgiveness, beliefs and faith in oneself, in others, and in a God or higher power, personal values, love and relationships, morality, creativity, and personal expression (Baldacchino, 2006; Batcheller et al., 2013; Ross et al., 2014).
Spiritual care, from the perspective of compre- hensiveness of the human being in the therapeutic relationship, can be related to certain aspects of the “caritas process” based on Jean Watson’s Theory of Human Caring (Duffy, 2011; Watson & Woodward, 2010). According to that theory, nursing interven- tion should work on
being authentically present and enabling and sustain- ing the deep belief system and subjective life world of self and one being cared for. Allowance for existential- phenomenological-spiritual forces becomes opening and attending to spiritual-mysterious and existential dimensions of one’s own life-death; soul care for self and the one being cared for. (Watson & Woodward, 2010, p. 355)
This concept also relates to what the Royal College of Nursing has identified regarding spiritual care in terms of how one recognizes and responds to the needs of the human spirit when confronting trauma, illness, or sadness, and can include the quest for meaning, self-esteem, self-expression, and support through faith, ritual, prayer, sacraments, or simply empathetic listening (Ross et al., 2014).
Spiritual care is part of good nursing practice, although spirituality is a dimension of health that nurses are less certain of and less consistent in deliv- ering within nursing care (Biro, 2012). This situa- tion leads to a lack of familiarity with spiritual care in the nursing profession, and some nurses may not feel prepared to provide spiritual care (Batcheller et al., 2013; Lundberg & Kerdonfag, 2010; Swinton & Patison, 2010; Vlasblom et al., 2011). Some stud- ies in this respect are clear about this lack of train- ing, translated as personal concern, which has a significant impact on exercise of the profession (Biro, 2012; Ronaldson et al., 2012).
Specifically, in relation to some of the particu- larities of spiritual care, the study participants say its provision suffers from a lack of definition, guide- lines, and prior training (see Figure 1). This invites readers to reflect on the professional training nurses receive in light of the concept of spiritual care, which is personal, broad, and complex and cannot be addressed through a rigid and limiting process.
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What it does allow for is a wide and dynamic con- ceptualization that encourages a personalized approach implicit in the ability to offer spiritual care as part of what nurses do (Baldacchino, 2006; Carson, 1989; Vlasblom et al., 2011). Clinical nurses need a personal spiritual perspective if they are to support patients in their search for meaning and purpose in life and thus provide spiritual care at times of illness or hospitalization (Wu & Lin, 2011).
Regarding the sense religion in spiritual care (see Figure 1), which is one of the subthemes, it is important to consider how the term religion is used generally to describe a fixed system of ideological commitments that regulate the behavior of its members and the rites and practices used in the system of worship (Chan, 2009). Religion helps people find meaning in life, according to their own vision of the world, and it can be a resource to com- ply with their spiritual purpose (Castelo-Branco et al., 2014; Galvis & Pérez, 2011). From a differ- ent perspective, Cohen (1993) and Moller (1999) say spirituality is a broader concept than religious- ness, even though religion can be an expression of spirituality. However, a person’s spiritual dimension may be totally separated from religion and not be expressed as a religious practice (as indicated in Sánchez, 2010).
The foregoing adds to what the study found in terms of the importance of taking the patient’s reli- gious beliefs into account and showing respect for freedom of worship when offering spiritual care. This has an impact on the personal interpretation of health care when the spiritual dimension is present.
Theme 2: The Patient and the Family in Spiritual Care
From the perspective of nursing as a professional discipline, the human being is considered the focus of the discipline (Newman, Smith, Pharris, & Jones, 2008), the guiding point of reference that continu- ously vitalizes the practice of nursing care. The human being also is regarded conceptually as a per- son, a subject and recipient of care, a client, and a patient. Based on these notions and in this particu- lar study, human beings as patients are characterized by their comprehensiveness, complexity, and aware- ness (Newman et al., 2008), and also as subjects of care who have the ability to know themselves; who are capable of using ideas, words, and symbols to think; who can communicate with other beings and
with God; and who preserve beliefs and customs (Carvajal & Caro, 2009). These considerations spec- ify their nature in terms of dignity, wholeness, and individuality.
As part of the dynamic notion of the human being, from a patient’s perspective, the family is regarded as a component of the nurse and patient– family dyad. This phenomenon is of particular inter- est in nursing. The family is the basic unity of society; it shares ties of collaboration, emotional closeness, and its members can identify themselves as part of it (Roy, 2009). This is because they share a project for life in which a variety of feelings cen- tered on the meaning of belonging and unity are generated, allowing them ideally to adjust to change and circumstances specific to family dynamics. Illness can be part of those circumstances and can generate some degree of dysfunctionality. The fam- ily, as a system, consists of an organized set of ele- ments that are related and interact. This means any action, alteration, or change in one of those ele- ments affects all the others (Membrillo, Fernández, Quiroz, & Rodríguez, 2009).
Research findings (see Figure 2) coincide with the idea of the family as a subject of care and source of support, as a unit of care or totality (Leon & Knapp, 2008). As the focal phenomenon in the dis- cipline, the family also requires spiritual care through which nurses can identify specific needs and empower resources in their role as caregivers (Carvajal & Caro, 2009; Silveira & Angelo, 2006).
Nurses, based on their caregiving experience, say support from the family is important to improving the patient’s health, given the emotional, physical, and spiritual assistance family members can provide and the tranquility, help, and encouragement they offer in the face of stress caused by illness. Similarly, this study emphasizes that the family, as a subject of care, experiences satisfaction when it feels it can count on health professionals not only for care but also in terms of depending on their skills and poten- tial to attend to the needs of the family as a whole (Galvis & Pérez, 2011).
In this study, family love (see Figure 2) is observed to be a component of family support, because it helps in coping with health situations. Love, as a form of care, is an emotion accompanied by feelings of compassion or empathy; it is a two-way effort that benefits the patient as much as the nurse, depending on the patient’s situation. As a comple- ment to love, there is the idea that communication,
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respect, and commitment are present in every care relationship (Vázquez & Eseverri, 2010). These aspects were expressed by the study participants as part of their response to patients and families during spiritual care.
Theme 3: The Role of the Nurse in Spiritual Care
The role of nurses in spiritual care, as identified in this study, coincides with two areas related to “quality care” that are found in research findings: (1) personal attributes and values (being kind, lov- ing, gentle, polite, respectful, compassionate, understanding, sensitive, and honest) and (2) pro- fessional attributes (knowledge, competence and technical skills, the ability to explain things to patients, and effective management of responsi- bilities), in addition to active listening and open mindedness, as complementary attributes of qual- ity care (Batcheller et al., 2013; Biro, 2012; Castelo- Branco et al., 2014; Lundberg & Kerdonfag, 2010; Ozbasaran et al., 2011).
Additionally, as part of this role and in nursing intervention, trust and honor constitute important aspects that are relevant to all effective therapeutic relationships, because they help build truth, give hope, and act as a catalyst (Lundberg & Kerdonfag, 2010). Thus, spiritual care represents a combination of the art of the nursing profession and human sci- ence (Galvis & Pérez, 2011).
The work of nursing is related to specific aspects of professional practice where certain qualities are expressed, such as the ability to feel compassion, which the nurse experiences and needs to grow. Dedication is another important aspect. It gives strength and special character to those who care for people and involves being there for another person, with courage and consistency (Estefo & Paravic, 2010; Novoa et al., 2005; Páez, 2000).
According to the views expressed by the study participants regarding the qualities of nurses and the practice scenario (see Figure 3), nurses who provide spiritual care have the ability, commitment, and vocation required to do their job, considering the situation and the health care required by the patient’s condition and depending on its complexity (Páez, 2000). Thus, personal and professional attributes are embedded in care and allow us to recognize the
person’s human condition and vulnerability, taking into consideration biomedical science and technol- ogy (Penha & Silva, 2012).
One of the main components of good nursing is the nurse–patient relationship, as an act of open and spontaneous interaction with the other person in favor of well-being and quality of life. The nurse– patient relationship is identified in the literature on spiritual care as the context and medium where nurses can provide this type of care (Biro, 2012; Páez, 2000; Watson & Woodward, 2010; Wong & Yau, 2010; Zárate, 2004). The therapeutic relation- ship is a mutual and emotional learning experience in which cultural differences are respected and accepted. In this relationship, the nurse uses per- sonal attributes and clinical techniques to benefit the patient (Cutcliffe & McKenna, 2005).
Considering the results of this study, and from the perspective of nursing intervention and the prac- tice scenario (see Figure 3), specific research sup- ports the benefits of the nurse–patient relationship based on its multidimensional vision (biological– psychosocial–spiritual). However, nurses and patients report there is not sufficient time to partici- pate in a relationship, mostly because of an organi- zational culture that prioritizes physical over spiritual care (Biro, 2012). Additionally, the importance of having enough time to develop a good nurse–patient relationship (Biro, 2012) was identified as an impor- tant point in research on spiritual care.
A spiritual, care-based therapeutic relationship requires a personal perception of the nurse’s own spirituality, which influences the degree to which the patient’s spiritual needs are perceived. This per- ception contributes to planning and implementing interventions in such a way that the consequences of a nurse’s actions generate mutual benefit (Vlasblom et al., 2011; Wu & Lin, 2011). This approach partly supports what was expressed by the study partici- pants regarding the consequences of a nurse’s inter- vention (see Figure 3), as represented by his or her contribution, the satisfaction that is generated, and the resulting mutual benefit.
One of the findings of this study (mutual benefit in the nurse/patient–family relationship) refers to the satisfaction the participants experienced when performing different interventions that responded to a proposed care plan, thanks to the development of an effective therapeutic relationship. A strong link most likely exists between the personal focus related
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to spiritual care and the rewarding experience felt by nurses (Vlasblom et al., 2011).
In effect, this satisfaction reaffirms Zarate’s idea that nurses express satisfaction because they are the first to attend to patients, spend more time with them, administer pharmacological care and treat- ment, and constantly evaluate their response to med- ication and nursing care. Moreover, nurses attend to patients through a proposed course of therapy and have more interaction with them and their families, meaning they can easily recognize their dissatisfac- tion and incomprehension (Zárate, 2004). Offering care in line with this notion of nursing best practices implies considering the human being as holistic, with the consequences of spiritual care resulting in a posi- tive impact on the patient’s health and greater satis- faction among nurses in the development of their professional practice (Cockell & McSherry, 2012; Hsiao et al., 2012; Vlasblom et al., 2011).
Another aspect to consider in the work of nurses who provide spiritual care refers to the practice sce- nario where different circumstances occur, depend- ing on the complexity of the service and the patient’s condition. Understanding spiritual care and its rela- tionship to good nursing practice is important, because this kind of care has been recognized as the most neglected area of nursing practice (Biro, 2012). Spirituality in health–illness processes has been rec- ognized by health professionals, and there is scien- tific evidence of its relevance to practice, even though this situation remains forgotten in nursing care (Castelo-Branco et al., 2014).
Nurses who work in an emergency department often must spend a considerable amount of time with people who are troubled and in need of crisis intervention, either because of their medical condi- tion or due to their psychological needs (Novoa et al., 2005). Therefore, it is important to consider the high-dependency care scenarios in which spirit- ual care is provided, since these are contexts where nurses are embedded in extremely complex situa- tions in which it is necessary to prioritize needs that are relevant at any given moment in terms of physi- cal, physiological, and biological components, with subsequent attention to spiritual needs. This places a tremendous emotional burden on nurses and makes them more cautious when resolving situa- tions efficiently by providing optimal quality time for the well-being of the patient and the family (Novoa et al., 2005; Zárate, 2004). However, both patients
and nurses cite the amount of time nurses are required to spend on administrative work as a factor that adversely affects the ability to provide good care, making the provision of spiritual care even more complex (Biro, 2012).
Other circumstances unique to the practice sce- nario such as time, administrative versus caring activities, the prevalence of technology and cost-sav- ing in health services, the increase in the number of patients related to the increased complexity of care, and patient privacy also can be interpreted as decisive aspects that undermine the quality of spiritual care (see Figure 3; Biro, 2012; Cockell & McSherry, 2012; Meehan, 2012; Ronaldson et al., 2012). Patients and nurses refer to these circumstances as factors that hinder the ability to provide good nursing care that is sensitive and compassionate (Chan, 2009; Dezorzi & Crossetti, 2008). In addition, other difficulties associ- ated with providing spiritual care refer to increased workload, lack of time, professional and personal training, and inadequate resources (Castelo-Branco et al., 2014; Galvis & Pérez, 2011; Hsiao et al., 2012). It also has been found that spiritual care is viewed as a low priority compared to other methods for saving lives (Hsiao et al., 2012).
In effect, based on the findings of the study and in relation to the significance of spiritual care, good nursing practice requires constantly building and rein- forcing care scenarios and therapeutic relationships in which the momentum is focused on the ongoing pres- ence of complete human beings who share moments of care when their spiritual self is present.
Implications
Implications for the Practice of Holistic Nursing
The results of this study verify the significance of spiritual care as a reference for nursing practice sup- ported by humanistic, theoretical, and scientific dimensions. The voices of the study participants ech- oed this significance. Based on their own experience as caregivers of patients and vulnerable families in a highly complex service environment, such as an emer- gency care unit, they emphasized the value and impor- tance of spiritual care, understood here as the need to view patients as integral beings and subjects of care and the family as a source of support and subject of care, highlighting the role of nurses in nurse–patient
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interaction in which their qualities, commitment, vocation, knowledge, and capacity are present.
Implications for Education
This research unquestionably contributes to nursing education at the various undergraduate and postgraduate levels where spiritual care must be included as part of humanistic training to acquire certain abilities, such as being therapeutic. These abilities are reflected in the nurse’s values, principles, dignity, and humanization and harmo- nize with the ability to know and act, as represented in knowledge, skills, and attitudes. All this consti- tutes a totality aimed at the exercise of holistic nursing practice.
Implications for Research
This study offers conceptual clarity to support holistic care drawn from the evidence on the signifi- cance of spiritual care, with complementary descrip- tions of each theme, supported by the statements of the participants. These statements were discussed in conjunction with related research, providing descrip- tive knowledge on the phenomenon under study and laying the groundwork for new research topics directed toward studies of an explanatory and predictive nature with regard to spiritual care and its relationship to nursing practice. This study also paves the way for methodological research to generate new instruments and evaluate existing ones related to the topic.
Limitations
The phenomenon under study was described from the standpoint of nursing practice, but was not related to other variables that could widen the per- spective. This is because a qualitative design was used for the study.
References
Baldacchino, D. (2006). Nursing competences for spiritual care. Journal of Clinical Nursing, 15, 885-896. doi:10.1111/ j.1365-2702.2006.01643.x
Barnum, B. (2003). Spirituality in nursing: From traditional to new age (2nd ed.). New York, NY: Springer.
Batcheller, J., Davis, J., & Yoder-Wise, P. (2013). Hope for the future: Intensifying spirituality in the workplace. Nursing Administration Quarterly, 21, 261-264. doi:10.1097/ NAQ.0b013e3182a2f9ae
Biro, A. (2012). Creating conditions for good nursing by attending to the spiritual. Journal of Nursing Management, 20, 1002-1011. doi:10.1111/j.1365-2834.2012.01444.x
Burnard, P. (1998). The spiritual needs of atheists and agnostics. Professional Nurse, 4, 130-132.
Carson, V. (1989). Application of nursing theory to spiritual needs. In V. Carson (Ed.), Spirituality dimensions of nursing practice (pp. 148-179). Philadelphia, PA: W. B. Saunders.
Carvajal, G., & Caro, C. (2009). Soledad en la adolescencia: Análisis del concepto [Loneliness during adolescence: Analysis of the concept]. Aquichán, 9, 281-296.
Castelo-Branco, M., Brito, D., & Fernandes-Sousa, C. (2014). Necessidades espirituais da pessoa doente hospitalizada: Revisão integrativa [The spiritual needs of ailing hospitalized patients: An integrative review]. Aquichán, 14, 100-108.
Chan, M. F. (2009). Factors affecting nursing staff in prac- ticing spiritual care. Journal of Clinical Nursing, 19, 2128-2136. doi:10.1111/j.1365-2702.2008.02690.x
Cockell, N., & McSherry, W. (2012). Spiritual care in nurs- ing: An overview of published international research. Journal of Nursing Management, 20, 958-969. doi:10.1111/ j.1365-2834.2012.01450.x
Cutcliffe, J., & McKenna, H. (2005). The essential concepts of nursing. London, England: Elsevier.
Dezorzi, L. W., & Crossetti, M. D. (2008). La espiritualidad en el cuidado de si para profesionales de enfermería en terapia intensiva [Spirituality in self-care for intensive care nursing professionals]. Revista Latino-Americana de Enfermagem, 16, 212-218.
Duffy, J. R. (2011). Theories focused on caring. In A. B. Butts & K. L. Rich (Eds.), Philosophies and theories for advanced nursing practice (pp. 507-523). Mississauga, Ontario, Canada: Jones & Bartett Learning.
Estefo, S., & Paravic, T. (2010). Enfermería en el rol de gestora de los cuidados [Nursing in the role of health care manager]. Ciencia y enfermería, 16, 33-39. Retrieved from http://www.scielo.cl/scielo.php?script=sci_arttext& pid=S0717-95532010000300005
Galvis, M., & Pérez, B. (2011). Perspectiva espiritual de la mujer con cáncer [Spiritual perspective of women with cancer.]. Aquichán, 11, 256-273.
Guba, E., & Lincoln, Y. (2005). Paradigmatic controversies, contradictions and emerging confluences. In N. Denzin & Y. Lincoln (Eds.), The Sage handbook of qualitative research (pp. 191-215). Thousand Oaks, CA: Sage.
Hernández, R., & Fernández, C. (2010). Metodología de la Investigación [Investigation methodology]. Mexico City, México: McGraw-Hill.
Hsiao, Y.-C., Wu, H.-F., Chien, L.-Y., Chiang, C.-M., Hung, Y.-H., & Peng, P.-H. (2012). The differences in spiritual health between non-depressed and depressed nurses. Journal of Clinical Nursing, 21, 1736-1745. doi:10.1111/ j.1365-2702.2011.03962.x
Hsieh, H.-F., & Shannon, S. E. (2005). Three approaches to qualitative content analysis. Qualitative Health Research, 15, 1277-1288. doi:10.1177/1049732305276687
at MINNESOTA STATE UNIV MANKATO on February 27, 2016jhn.sagepub.comDownloaded from
Spiritual Care and Nursing Practice / Veloza-Gómez et al. 13
Leon, A. M., & Knapp, S. (2008). Involving family systems in critical care nursing: Challenges and opportunities. Dimensions of Critical Care Nursing, 27, 255-262. doi:10.1097/01.DCC.0000338866.47164.6d
Lundberg, P. C., & Kerdonfag, P. (2010). Spiritual care provided by Thai nurses in intensive care units. Journal of Clinical Nursing, 19, 1121-1128. doi:10.1111/ j.1365-2702.2009.03072.x
Meehan, C. (2012). Spirituality and spiritual care from a care- ful nursing perspective. Journal of Nursing Management, 20, 990-1001. doi:10.1111/j.1365-2834.2012.01462.x
Membrillo, A., Fernández, M. A., Quiroz, J. R., & Rodríguez, J. L. (2009). Familia introducción al estudio de sus ele- mentos [Family: Introduction to the study of its ele- ments]. México City, Mexico: Editores de Textos Mexicanos.
Munhall, P., & Oiler-Boyd, C. (1993). Nursing research: A qualitative perspective (2nd ed). New York, NY: NLN.
Newman, M. A., Smith, M. C., Pharris, M. D., & Jones, D. (2008). The focus of the discipline revisited. Advances in Nursing Science, 31(1), E16-E27. doi:10.1097/01. ANS.0000311533.65941.f1
Novoa, M., Nieto, C., Forero, C., Caycedo, C., Palma, M., Montealegre, M. D., . . . Sánchez, C. (2005). Relación entre perfil psicológico, calidad de vida y estrés asistencial en personal de enfermería [Relationship between psycho- logical profile, quality of life and welfare stress on nursing staff]. Universitas Psychologica, 4(1), 63-76.
O’Brein, M. E. (2007). Spiritual care: The nurses role. In M. E. O’Brein (Eds.), Spirituality in nursing: Standing on holy ground (2nd ed., pp. 129-154). London, England: Janes & Bartlett.
Ozbasaran, F., Ergul, S., Temel, A. B., Aslan, G. G., & Coban, A. (2011). Turkish nurses’ perceptions of spiritu- ality and spiritual care. Journal of Clinical Nursing, 20, 3102-3110. doi:10.1111/j.1365-2702.2011.03778.x
Páez, R. (2000). La ética de las virtudes y enfermería [The virtue ethics and nursing]. Revista Mexicana de Enfermería Cardiológica, 8(1-4), 60-68.
Penha, R. M., & Silva, M. J. (2012). Significado de espiritu- alidade para a enfermagem en cuidados intensivos [Meaning of spirituality for critical care nursing]. Texto Contexto Enferm, 21, 260-268. doi:10.1590/S0104- 07072012000200002
Ronaldson, S., Hayes, L., Aggar, C., Green, J., & Carey, M. (2012). Spirituality and spiritual caring: Nurses perspectives and practice in palliative and acute care environments. Journal of Clinical Nursing, 21, 2126-2135. doi:10.1111/ j.1365-2702.2012.0418
Ross, L., Leeuwen, R. V., Baldacchino, D., Giske, T., McSherry, W., Narayanasamy, A., . . . Schep-Akkerman, A. (2014). Student nurses perceptions of spirituality and competence in delivering spiritual care: A European pilot study. Nurse Education Today, 34, 697-702. doi:10.1016/j. nedt.2013.09.014
Roy, C. (2009). The Roy adaptation model. Boston, MA: Pearson.
Sánchez, B. (2010). ¿Qué significa dar cuidado espiritual? Un aporte desde el cuidado a las personas con enfermedad crónica. In Avances en el cuidado de enfermería (pp. 171- 195). Bogotá, Colombia: Grupo de Cuidado, Facultada de Enfermeria, Universidad Nacional de Colombia.
Sandelowski, M. (2000). Focus on research methods: Whatever happened to qualitative description? Research in Nursing & Health, 23, 334-340.
Sheldrake, P. (2007). A brief history of spirituality. London, England: Blackwell.
Silveira, A. O., & Angelo, M. (2006). La experiencia de interac- ción de la familia que vive la enfermedad y hospitalización del niño [Interaction experience for families who lives with their child’s disease and hospitalization]. Revista Latino-Americana de Enfermagem, 14, 893-900. Retrieved from http://www. scielo.br/scielo.php?script=sci_arttext&pid=S0104- 11692006000600010&lng=en&tlng=es.10.1590/S0104- 11692006000600010
Swinton, J., & Patison, S. (2010). Moving beyond clarity: Towards a thin, vague, and useful understanding of spir- ituality in nursing care. Nursing philosophy, 11, 226-237. doi:10.1111/j.1466-769X.2010.00450.x
Tanyi, R. A. (2002). Towards clarification of the meaning of spirituality. Journal of Advanced Nursing, 39, 500-509. doi:10.1046/j.1365-2648.2002.02315.x
Vázquez, M., & Eseverri, M. (2010). El cuidado de las familias en las unidades de cuidados intensivos desde la perspectiva de Jean Watson [The caring of family members in the inten- sive care units from the Jean Watson perspective]. Enfermería Intensiva, 21, 161-164. doi:10.1016/j.enfi.2010.03.004
Vlasblom, J. P., Steen, J. V., Knol, D. L., & Jochemsen, H. (2011). Effects of a spiritual care training for nurses. Nurse Education Today, 31, 790-796. doi:10.1016/j. nedt.2010.11.010
Watson, J., & Woodward, T. (2010). Jean Watson’s theory of human caring. In M. C. Smith & M. E. Parker (Eds.), Nursing theories and nursing practice (pp. 351-369). Philadelphia, PA: A. Davis.
Willis, D. G., Grace, P. J., & Roy, C. (2008). A central unify- ing focus for the discipline: Facilitating humanization, meaning, choice, quality of life, and healing in living and dying. Advances in Nursing Science, 31(1), E28-E40. doi:10.1097/01.ANS.00003115
Wong, K. F., & Yau, S. Y. (2010). Nurses’ experiences in spir- ituality and spiritual care in Hong Kong. Applied Nursing Research, 23, 242-244. doi:10.1016/j.apnr.2008.10.002
Wu, L.-F., & Lin, L.-Y. (2011). Exploration of clinical nurses’ perceptions of spirituality and spiritual care. Journal of Nursing Research, 19, 250-256. doi:10.1097/ JNR.0b013e318236cf78
Zárate, R. A. (2004). La gestión del cuidado de enfermería [Management of nursing care]. Index Enferm, 13(44-45), 42-46. doi:10.4321/S1132-12962004000100009
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Mónica Veloza-Gómez, Assistant Professor - Professor and researcher - Master Program advicer - Practice area chief of School of Nursing and Rehabilitation, Universidad de La Sabana. Sigma Theta Tau - Upsilon Nu Chapter member.
Lucy Muñoz de Rodríguez, Emeritus Professor Universidad Nacional de Colombia. Full Professor - Professor and researcher - Master Program advicer of School of Nursing and Rehabilitation,
Universidad de La Sabana. Sigma Theta Tau - Upsilon Nu Chapter member.
Claudia Guevara-Armenta, Training in vocational nursing technician professor. Research professor in National Vocational Training Service (SENA).
Sandra Mesa-Rodríguez, Nursing Program Director, Fundación Universitaria Navarra - Wide clinical care experience.
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