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Nursing - A Caring Spirituality Professor Susan Ronaldson Chair in Nursing, Australian Catholic University; Director, St Vincent’s Healthcare Campus Nursing Research Unit

In this paper Nursing as a Caring Spirituality  will  will be explored within the context of nursing as a caring profession. The importance of the maintenance of hope in nursing care will be highlighted. Through identifying and providing spiritual caring caring both the nurse and the person in need of care will benefit and grow. Nursing and Caring Health professionals, in particular nurses, have paid much attention in recent times to the concept of caring, which is a central theme to the practice of nursing. Nurses must claim ownership of caring in order  to define their professional discipline. Milton Mayeroff in his writings, On Caring  (1971),  (1971), outlined eight major ingredients of caring. Two of these ingredients are Hope and Courage. Nurses in their caring facilitate hope in the people for whom they care and are the personal witnesses of enormous courage as people live through their health/illness experiences. Nurses also display notable courage in providing exquisite care in difficult and challenging situations. The experience of caring is not formula based. The essence of caring provides a deep reservoir for clinical nursing research in our search for truth - truth which articulates the decision making process for the delivery of patient care. There is a paramount need for meaningful communication in order to pursue such truth. That is, communication which exchanges each person’s experience of caring. The Meaning of Hope in Nursing 1997), ), one of the themes In an Australian nursing text, Spirituality, The Heart of Nursing  (Ronaldson,  (Ronaldson, 1997 which emerges from the writings of contributing authors is the need for nurses to foster and maintain hope for individuals in need of nursing care. Nurses are often witness to people’s personal experience of spirituality and their endeavours to understand the meaning and worth of their life pa particularly rticularly when confronted by an incurable condition or chronic illness. Spirituality, as defined by Elizabeth McKinlay (1992) 1992) is ‘that which lies at the core of each person’s being, an essential dimension which brings meaning to life. It is acknowledged that spirituality is not constituted only of religious practices, but must be understood more broadly, as relationship with God,1997, however God relationship with other people’ (cited inRonaldson, inRonaldson, p.101 p.101). ). is perceived by the person, and in Susan Gaskins' 1995 research, The Meaning of Hope: Implications for Nursing Practice and Research, Research , gives us some insight into the themes which define hope for people who have a chronic illness. Three of the most common themes defining hope were spirituality, relationships relationships with others, and h having aving one’s health. ), While acknowledging that hope is difficult to define and which is context based, Carol Farran et al . (1992 (1992), in their nursing paper Clinical Assessment of Hope, Hope , state that hope is ‘an expectation about attaining some desired goal in the future, a necessary condition for action, a subjective state that can influence realities to come, and a knowledge that as human beings we can somehow manage our internal and external realities’ (p. 130). For this research on the clinical assessment of hope they identify four central attributes of an acronym of hope: H-health, O-others, P-purpose, and E-engaging process. Hope and Health

 

Hope is opposed by despair for people who are ill, but also for well individuals. A person’s sense of hope is challenged in everyday living and it is quite an obvious dimension when confronted by challenges to health. Hope is related to people’s desire to achieve a goal in life. As nursing professionals we are regular  witness to statements of hope. You hear patients say, "I hope to feel well again", "I hope to walk again" and "I hope to live until Christmas". Within the perspective of health and well-being hope is a fragile reality. Nursing research is broadly based on issues surrounding health. Our hope is to optimise each person’s health and their innate resources. We can benefit investigations of health status by framing such research on patient and carer concepts and their understandings of hope and of health. Hope and Others  As humans are a social social being, our hopes hopes and expectations of others and of ourselves ourselves are inextricabl inextricably y interwoven. As nursing professionals we must assess other’s context of hope and its value in their lives. Nurses are in a strategic position to foster and maintain hope in individuals. To be adequate here we must also recognise our own sense of hope. ‘Hope in its mature form becomes a sense of certainty about the coherent nature of human life and an acceptance of one’s lifestyle as worthwhile’ ((Fa Farr rran an et al. ,  , 1992, p.134.) p.134 .) Central to hope and others is the establishment of a trusting relationship. Nurses must endeavour to pursue trusting relationships with those for whom they care and their significant others, and also with the wider community. Society expects and deserves that they can place their trust in nursing professionals. Importantly, nursing research of a high quality needs to be conducted, and where appropriate, be focused on client outcomes and not just our aims. Hope and Purpose Purpose involves a person’s concept of raison d’etre d’etre - their reason for being, their spiritual being. A person’s sense of spirituality must be identified and respected. In everyday life, and particularly in ill health, spirituality is explored by individuals as they define their life’s meaning. The individuality of spirituality is the antithesis of a person’s daily work and lifestyle. Nursing professionals need to respect the spiritual elements of each person’s life. In acknowledging and supporting spirituality, a person’s sense of self is both affirmed and respected. Hope as an Engaging Process People have goals in life which at the same time may be quite simple and complex. A person’s hope for the future involves goals to be achieved and actions to be explored. Nurses, because of their knowledge base and their experience, often have clearly defined health goals and outcomes which may be foreign and even unacceptable to the individual. While we work with them to explore and accept our therapeutic goals we must carefully recognise the goals of the individual. Nursing and its research need to respect each person’s goals in life and their hopes. Here I am reminded of the many occasions in my career when patients have opened my eyes and taught me. These significant events have guided my practice. The elderly man living with dementia who was physically withdrawn and verbally uncommunicative, yet on a special social occasion singing that beautiful Irish ballad, Danny Boy , word perfect and full of emotion; the young man’s fears of dying as he waited for a relatively straightforward investigation of his cerebral blood flow and who subsequently died before he regained consciousness; and the elderly woman’s desire to return to her home and to her only companion, her dog, before she died from her next heart attack.

 

These people taught me to listen to every word expressed and to seek an understanding that people have much insight when confronted by serious illness and impending death. It also taught me to recognise what was important to them and to their life. Nursing and Spirituality Interest in the concept of spirituality has increased markedly over the past decade and is reflected in both general and health care literature. Nurses, in their many and varied roles, are in a pivotal position to provide spiritual caring. An understanding of the spiritual self will carve a niche in nurses’ abilities to provide truly holistic care. Recently at a public forum I was surprised to hear the question asked: Is it really the nurse’s role to  provide spiritual care? This care? This represents a limited view of both nursing and spirituality. If spiritual care is not provided by nurses, both the nurse and the person in need of such care, are impoverished. Nurses do provide spiritual care often as a subtext to their caring role. It is now time to recognise, articulate and claim this important element of nursing. These concepts can be articulated through our clinical nursing research. While spiritual beliefs are generally considered to be a private concern, the need for spiritual caring is often foremost for individuals when challenges to health occur. The meaning of one’s life and purpose, sense of hope, and belief in oneself and a power beyond self are confronted and questioned. Nurses have a ‘presence’ in these times of significant stress and turmoil. They are there to listen, to reflect, to clarify and importantly, to foster hope.  According to Thomas Thomas Moore, in hi his s book, Care of the Soul , ‘Spirituality is seeded, germinates, sprouts and blossoms in the mundane. It is found and nurtured in the smallest of daily activities... a ctivities....the .the spirituality that feeds the soul and ultimately heals our psychological wounds may be found in those sacred objects Moore, 1994: 219 219). ). that dress themselves in the accoutrements of the ordinary’ ((Moore,  A single event that that occurred early iin n my nursing career I now recognise as a spiritual one - an awakening which emerges periodically in my work and which holds great meaning for me. This spiritual awakening occurred as I was drying the feet of an elderly man residing in a large aged care facility in rural Victoria. I was working as an educator of student nurses. For a brief moment in time I was struck by the translucency and radiance of the thin, pale, aged skin on this man’s feet. This caring act represented to me the service role of nursing. I then understood at a very deep level that I was both immensely privileged and humbled to possess the skills to perform such a relatively simple, yet enormously important act of caring. It was a most valuable of human - being at one with needs ofofthis undemanding and vulnerable elderly man. Much later I wastasks to recognise this was an the experience ‘vernacular spirituality’, an appreciation of the sacred in the ordinary (Sexson ( Sexson in Moore, 1994, p. 215) 215) which, according to Moore, as a spirituality, while being ‘ordinary and close to home, is especially nourishing to the soul’ (p. 215). At that time in my career it awakened my identity as a gerontic nurse and confirmed the meaning and value of nursing in my life. Spirituality Spiritualit y and nursing are historically and inextricably interwoven. ‘The soul needs spirit, but our spirituality also needs the soul - deep intelligence, a sensitivity to the symbolic and metaphoric life, genuine community, and attachment to the world’ ( Moore, 1994, p. 229 229). ). Nursing’s philosophy of caring and its founding beliefs are commensurate with these concepts. In addition, nursing research can benefit from recognising this important element in each person’s life. Spirituality, Spiritualit y, in its truest sense, is not contained by any cultural boundaries. Nursing can be considered a Caring Spirituality  to  to which each of us contribute through our individual nursing work. Such a contribution will add new meaning to our nursing care and from which our spiritual self may grow. The way forward is to acknowledge that each person has a spiritual self and to recognise the spiritual

 

expressions of those in need of nursing care. Simple affirmation of people’s spiritual needs, such as their search for meaning and the need for love, will enhance spiritual caring in nursing. People’s hopes are an expression of their spirituality.

Nurses may be aware that patients have spiritual needs, but in many cases are unable to respond to these needs. This may result from an inadequacy in nurse education that does not prepare nurses to provide spiritual care. In addition, spiritual care is seen as part of the psychosocial assessment assessment or in the domain of the pastoral care workers. In reality though, nurses are in the best position to deliver this important aspect of nursing care, particularly when caring for the patient with a life-threatening illness. Nurses learn early to become good listeners and communicators. By helping patients express their beliefs and by staying with them during the events of their illness, they are providing spiritual care. The challenge for nurses is to embrace holism and a holistic view of life and self and then convey this into caring for others. [top] top]

Nurses strive to incorporate holistic care that includes spiritual care into their nursing practice. The concept of providing spiritual care is derived from nursing theory, that states humans are biological-psychological-spiritual biological-psychological-spiritual beings. Although nursing has recognised that patients have spiritual needs, the practice of spiritual care by nurses is often infrequent and an underutilised facet of care. This may be due to the assumption by many nurses that this domain should be dealt with by pastoral care workers. In reality, however, it is the nurse who is ideally placed to comfort and support the patient in spiritual distress, particularly those suffering a life-threatening illness. These patients are often more concerned with issues of a spiritual, rather than a physical nature. Thomas (1993: 12) believes these patients are not so afraid of death, as they are of being left alone, and describes the very act of maintaining a bond with the patient in distress as an extension of 'unconditional love'. As nurses we cannot prevent death from occurring, but we can accompany the patient some of the way just by staying, watching and being there. The term 'spirituality' is derived from the Latin word 'spirare' meaning 'to breathe life', expressing one's values and beliefs about self, humanity, life and God. In defining spirituality, much of the literature equates spirituality with religion. Labum (1988: 314) broadly defines spirituality as 'that which inspires in one the desire to transcend the realm of the material', which Labum believes can be interpreted as a reference to religion and deeper philosophies that contemplate the meaning of life. This explanation is reinforced by a strong belief among nurses that the only patients with spiritual issues are those who articulate using such words as 'God', 'church' and 'heaven'. While religious life and experience are a significant part of one's spirituality, other parts must not be overlooked, particularly those that search for meaning, hope or love. Some spiritual issues are raised in anger and disbelief, e.g. 'Why did God pick me?', 'I don't deserve this end; I've lived a good life'. The nurse is there to support the patient and not to defend God and can quietly acknowledge; therefore, 'Yes, I don't understand either'. To many, spirituality is a journey, a discovery, a response to life, a search for ultimate meaning, an engagement in relationships, becoming whole in holiness, developing capacity in faith, hope and love. Religion may or may not be part of one's spirituality. Murray and Zenter (1989: 259) describe spirituality as:

 

... a quality that goes beyond religious affiliation, that strives for inspirations, reverence awe, meaning and purpose, even in those who do not believe in God. The spiritual dimension tries to be in harmony with the universe, strives for answers about the infinite, and comes into focus when the person faces emotional stress, physical illness or death. Milne (1984) interprets spirituality from a pastoral perspective, referring to the 'vital expression of a person's total being, the wholeness of the spirit'. This wholeness is also inextricably entwined in the concept of holistic nursing, in which the patient is allowed to deal with their situation in a wholeness of spirit. Other definitions of spirituality encompass 'the radical truth of things', 'a sacred journey' and 'a life relationship with mystery, higher power, god or the universe' (Narayanasamay, (Narayanasamay, 1993: 197). Spirituality embraces the needs of the believers and the nonbelievers; therefore, it is not confined within a religious context. Transcendence, Transcendenc e, writes Conrad (1985: 416), is integral to spirituality and focus on spiritual values that can sustain an individual as the physical body deteriorates. Nurses are easily accepted into the patient's initial sphere during the course of their illness and should be able to address spiritual issues comfortably. As Jacik (1989: 278) writes, this spiritual care can take the form of Scripture reading, prayer or reassuring the patient that God is listening, loving and caring. Besides the significance of active listening and being present, spiritual support may also take the form of sitting with the patient during a religious ritual, joining in prayer, reading or providing inspirational literature. In addition, Thomas (1993: 16) adds meditation, guided imagery, art and music or calling a long-lost friend as important aspects of spiritual care. Conrad (1985: 419) believes when providing spiritual care to the patient, the nurse must be comfortable in spiritual matters, have good communication skills and be able to demonstrate empathy. An opportune time to assess the patient's individual spirituality is during the nursing assessment and subsequent documentation on the nursing care plan. Conrad cites Stoll (1985: 20) who outlines four effective interviewing techniques in four areas: the person's concept of God or deity, the source of strength and hope for the person, the significance of religious practices and rituals to the person, and what the person believes is the relationship between his or her spiritual belief and their state of health. Narayanasamay (1993: 196) supports Conrad's claim and posits there is concern within Narayanasamay nursing that spiritual care of the patients is inadequate and suggests this is due to the lack of sufficient educational preparation of nurses in the provision of holistic nursing care. Jacik (1989: 276) agrees and adds that nurses can only adequately provide the spiritual care if they have examined their own beliefs and discovered how the truths and religious principles have guided their own lives. Fitzgerald (1987: 15) offers the motto 'know thyself' to any nurse who wishes to be more comfortable with spiritual matters. The challenge, adds Jacik (1987: 15), is to listen for the call for wholeness and embrace holism and a holistic view of life and self and then convey this into caring for others. One must be able to face the reality of one's own mortality, believe that they can help another die well by realising human life is temporary and human beings are mortal, and accept life as transient. If the spiritual care is inept, the patient is left on their own to struggle with their spiritual needs. Hamner (1991: 3) also expresses concern that spiritual needs are not necessarily included in the nursing assessment, despite the fact that nurses take great pride in delivering holistic care. Many nurses believe spirituality is intertwined with the psychosocial psychosocial dimensions. However, Piles (1990: 37) explains that the psychosocial dimension involves man's relationship to himself, others or to being, his environment, while the dealsto with man's relationship to a higher or God, depending onspiritual how thedimension person wishes

 

define it. Many nurses have never been exposed to, questioned the relevance of, or indeed, investigated, the spiritual needs of their patients. However, despite not having had a formal introduction to the concept of spirituality, nurses have spent many hours holding a dying patient's hand, and reassuring them that they will not die alone. Spiritual support is essential to the holistic care of any patient. Although Fitzgerald (1987: 14) emphasises that the dying patient does not have special spiritual needs, those with a life-threatening illness are more conscious of time and may feel an urgency to look at life more deeply. Spiritual support can foster richness of meaning, hope, love and satisfaction in their final days of living. Labun (1988: 316) reinforces this view, by stating patients who are facing death or crisis, encounter intense spiritual events described as a 'near death experience'. According to Mackenzie (1992: 44), people who have experienced near-death become more spiritual, love people in a totally different way, retain a deep sense of God and a spiritual hunger to discover how best to live life in the future. Spiritual healing, states Thomas (1993: 3), occurs when we attempt to meet the following spiritual needs: the search for meaning and transcendence; the sense of forgiveness both given and received; the maintenance of hope and the sustenance of love and relationships. The nurse can provide spiritual care by attempting to provide some meaning in experiences that are lived as meaningless, or appear as meaningless. Fitzgerald (1987: 15) believes nurses are privileged to be allowed to witness the vulnerability of another's death. Spiritual care of the dying heightens our awareness, promotes understanding and assists us to overcome hurdles in our search for meaning. Pain, death and suffering can be given meaning by guiding the dying to ask of themselves 'now that I am dying, what am I going to do about it?' The dying patient may sometimes experience guilt and anxiety as they consider unfulfilled expectations or acts of omission towards others. The sense of guilt can be relieved by merely talking with someone who cares. Thomas (1993: 11) states that by providing this opportunity for reconciliation, our awareness of human nature as vulnerable, limited, imperfect and humble, is heightened. The patient will realise acceptance of self and others regardless of past mistakes and their spiritual pain will be eased. Hope, says Aristotle, is a waking dream. As nurses, we become the source of spiritual hope for the dying patient by ensuring e nsuring freedom of pain, a good night's sleep, a nice hot bath and at all times emphasising that there is always something, no matter how small, to look forward to. This provides a powerful barrier against despair, and the patient can be assured they will not die alone. Cassidy (1988: 5) interprets the spirituality of caring: The spirituality of those who care for the dying must be the spirituality of the companion, of the friend who walks alongside, helping, sharing, and sometimes just sitting empty-handed, when we would rather run away. It is the spirituality of presence, of being alongside, watchful, available of being there... we who would be a companion to the dying therefore must enter into their darkness, go with them at least part of the way, along their lonely and frightening road... enter into the suffering and share in some small way their pain, confusion and desolation. Spiritual support is essential to the total nursing care of the dying patient. They should not die without meaning, guilt-ridden, lonely or suffer feelings of hopelessness when being cared for by nurses. The dying patient does not expect theological answers to all their questions, but rather a comforting supportive listener. Despite a lack of formal educational preparation. on spirituality, nurses learn early to become good listeners, and can rely on

 

their own skills in communication to provide specific spiritual interventions. Because of their clinical practice and lived experience, nurses are able to give total, quality care. The nurse is able to help patients express their beliefs, and by staying with them during the e events vents of terminal illness, the nurse provides spiritual care. The simple act of being there is, in many ways, the hardest part. [top] top]

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