Historically, a strong relationship has existed between institutional religion and nursing. In the past two decades, however, concerns have been raised over the placement of such topics as religious awareness, spiritual care, and ethics in the nursing curriculum. This has resulted from a variety of factors including the shift from a predominance of private hospital-based Diploma Programs to Associate and Baccalaureate Degree Programs in public institutions of higher learning and the resulting time constraints. In this article we shall describe the way in which religious awareness, spiritual care and a process for ethical decisionmaking have been integrated into the ADN Program at Wesley College, Dover, Delaware.
At the very time that nursing education was shifting from hospital to college, two trends were influencing the way in which the religious needs of persons were perceived. On the one hand, Vatican II, the ecumenical movement and the general pluralism of the 1960s led many to question the parochial models that had often been utilized in nursing education (Fish & Shelley, 1983). Concurrently, a variety of factors in personality were beginning to be seriously considered in models of "holistic" health care. A number of articles were written in the 1960s suggesting that spiritual care be included in nurses' education as part of the broadened holistic approach (Piles, 1980).
Two surveys carried out in the late 1970s indicate a continued recognition of this need. Banks carried out extensive research on the opinions of three groups of health education professionals: active experts, graduate teaching associates and retired health care educators. Her study revealed positive support for the assertion that there is a spiritual dimension to health and that there should be a spiritual dimension to health care. In fact, 61% of her respondents felt that some component of spiritual care was of "critical" importance for the next 25 years of health care education (Banks, 1980). Among the concerns this group had in meeting this need were: 1. recognizing the diversity of beliefs of both the students being taught and the patients for whom care was being provided; 2. acknowledgment of the fact that the spiritual dimension is of greater or lesser importance for various individuals; 3. the inclusion of the spiritual dimension in a way that makes it a part of the general holistic approach; and 4. in public institutions, proper regard for the separation of church and state (Banks, 1980).
Piles surveyed 120 randomly selected National League of Nursing (NLN) programs, evenly divided between Baccalaureate (BSN) and Associate Degree (ADN) programs. She found that while there was general agreement that humankind is holistic and that the spiritual dimension should be included in nursing curricula, this area was being addressed only tangentially, or treated as a subcategory of the psychosocial nature of persons which needed little explication (Piles, 1980). Her concern was that "Interventions appropriate for one dimension will not help a patient manifesting needs in another (Banks, 1980).
In January 1984, the Wesley College Division of Nursing and Chaplain's Office devised a survey which was intended to update rather than reproduce earlier results. It deliberately focused on programs comparable to our own, namely the 47 NLN accredited Associate Degree Nursing programs in private American institutions of higher education. The survey was designed to ascertain what facets of religious awareness, spiritual care and ethics, if any, are included in the various nursing curricula; at what point in each curriculum this material is introduced; and how much time is devoted to it at each school. Six of the respondents indicated that their section on spiritual concerns was focused in the first semester or quarter course (Fundamentals of Nursing or Introduction to Nursing), with the remainder of schools placing it at various points in the curriculum. The amount of nursing classroom time devoted to topics related to religious awareness and spiritual care is given in the Table.
The survey underscored the limited time available for religious topics within the crowded ADN setting. We were not satisfied with the often suggested alternative of leaving this area of study for later inservice education. Our goal was to integrate concepts of spiritual care and ethics into the existing Associate Degree Nursing Curriculum in ways that would make students more aware of patients' spiritual needs and able to implant appropriate interventions. We sought to carry this out in a way that would relate to the nursing process and the holistic understanding of patients while honoring curricular time constraints.
TIME DEVOTED TO RELIGIOUS AWARENESS AND SPIRITUAL CARE IN NLN SCHOOLS RESPONDING TO THE WESLEY COLLEGE SURVEY
The holistic approach to nursing education places great stress on self-awareness. It has been well documented that there is considerable variety in religious attitudes in America today, in spite of the fact that the vast majority of Americans assent to such generalization as "I pray to God" or "I believe in God" (Roozen, 1978). The Crane-Coffer Religious Attitudes Inventory was administered to students beginning their Nursing Fundamentals (NR 100) course for two reasons: to encourage them early to reflect upon their own religious attitudes and biases and to permit the investigator to compile a composite of the class in order to address their needs and attitudes specifically in the various presentations.
The 107-item Crane-Coffer Religious Attitudes Inventory (CCRA) provides a quick and thorough assessment of religious beliefs (Compton, 1983), yet it can be completed in approximately 30 minutes. This reasonably priced instrument is available directly from the publisher. A detailed profile is available which is designed to be used in the context of a one-on-one counseling relationship (Crane & Coffer, 1964). Rather than using this detailed profile, the CCRA was administered to the nursing students and interpreted using an abbreviated profile prepared by selecting items from the CCRA as used on the standard profile and classified by the manual. Items were chosen to interpret eight general religious attitudes: 1. God is personal; 2. God is benevolent; 3. God can be known through Christ; 4. God can be known through the Bible; 5. The respondent expresses positive regard for the Church; 6. The respondent expresses positive regard for Prayer; 7. Religion permits and/or encourages growth; and 8. The respondent expresses an orthodox view of death according to generally accepted Judeo-Cristian norms.
The inventory did stimulate reflection by students on their own religious attitudes. Some students discussed the instrument formally with the college chaplain, while other discussed it informally with their clinical nursing instructors. The composite profile was used in presentations to the Nursing Fundamentals class. It revealed that while there was a positive feeling overall about God's personal and benevolent nature, there was little positive regard for the church. An item analysis of attitude (Compton, 1983) revealed an orthodox view of death overall, but discomfort in facing one's own death. This led to more time devoted to the nurses' own feelings about death than had originally been anticipated.
Spiritual Care in Nursing
The concepts of religious awareness and spiritual care were first addressed at the end of the second week of Nursing Fundamentals as the students were introduced to the methodologies of the Nursing Process and the use of Care Plans. A two-hour presentation attempted to build upon the general approach being used.
Two questions posed by the nurse educator, Ruth Piepgras, were used to show how appropriately spiritual care fits into the nursing process: 1. Isn't spirituality such a personal matter than we should avoid it? 2. By what authority can a nurse address spiritual concerns? Isn't it better to avoid taking a stand? (Piepgras, 1968).
The presentation pointed out that the nursing process is so person-centered that many concerns not dealt with in ordinary, casual contact will arise naturally in the course of assessment, planning and implementation of patient treatment. The nurse naturally functions in areas which the patient would ordinarily perform personally and privately if he or she were able. The nurse should therefore be willing to be open to all concerns tht may arise, including matters of religion or spirituality (Wolff, Weitzel & Zsohar, 1983). Because of the "bonding" that occurs, and because the nurse has no previous knowledge of either the patient's past relationship with God or activity in the church, he or she may serve as a sounding board for the patient's spiritual concerns (Fish & Shelly, 1983).
A study at the State University of New York at UticaRome revealed that while clergy clearly topped the list of those with whom patients discussed their spiritual needs, nurses were turned to more frequently than doctors, friends, or "God only." In the same study, 97% of the patients surveyed expressed the belief that the nurse could help patients meet spiritual needs, but 58% of that same sample indicated that nurses were actually too busy to do it. (Fish & Shelley, 1983). Case studies were used to illustrate ways in which the nurse may facilitate or stifle discussion of spiritual concern.
Following this general introduction, specific ways in which spiritual assessment may occur were suggested using the Guidelines for Spiritual Assessment developed by Ruth Stoll (1979). Stoll's guidelines relate to four areas: 1. the patient's concept of God or Diety; 2. the patient's sources of hope and strength and the relationship of those sources to the reality of the patient's condition; 3. the patient's religious practices, recognizing that not all religious practices are helpful. 4. and the patient's perception of the relationship between spiritual beliefs both in general and in the specific situation at hand.
After introducing these spiritual assessment techniques, the areas of spirituality in nursing care were touched upon under two rubrics: religious care and direct spiritual care. A distinction was made between the general area of spirituality, longing for God, searching for wholeness and meaning in life, and the specific religious path that an individual takes on that pilgrimage.
Under the rubric of "The Religious Manifestation of Spirituality," a very broad overview of the major contemporary religious denominations and sects was given. This material is addressed fairly comprehensively in the student text (Wolff, Weitzel, Zornow & Zsohar, 1983), and represents the kind of information often covered in nursing curricula. The class presentation focused on ways in which the nurse may be supportive of 1. the official functioning of clergy, and 2. the institutional needs of patients: making sure Jewish patients have kosher food; not offering Mormons coffee; clearing the bed table before the priest arrives to offer Mass. The presentation did not focus on those superficial manifestations of religion, as important as they are, but on the person whose needs may or may not be met by them. The relationship between nurses and clergy was highlighted from two different perspectives, that of Fish and Shelley (1983) and that of DiMeo (1980).
The second rubric in this section was "Direct Spiritual Care: appropriate for nurses. Two general methodologies were introduced: Carson's Incarnational Approach (Carson, 1980) and Dickinson's Relational Approach (Dickinson, 1975). It was stressed that whichever approach is used the first goal is to assist the patient in exploring and expanding his or her own faith and that converting the patient is not the appropriate role for the nurse. This unit ended with a brief word about the limitations of the nurses' role.
Spiritual Care: Death, Dying and Grief
During the eleventh week of the first semester of the Associate Degree Nursing Curriculum the care of the dying patient is introduced. It is at this point in the curriculum that the second unit on spiritual care was offered, a threehour unit on "Spiritual Care: Death, Dying and Grief." The approach was similar to that used in the first unit, focusing on ongoing assessment and ways in which the nurse can provide direct spiritual care rather than solely on the ministries provided by religious institutions. An audiovisual presentation of excerpts from the book, Gramp: A Man Ages and Dies, was viewed and discussed (Jury & Jury, 1976). Special emphasis was placed on the helper's awareness of the patient's need to communicate his or her feelings. The Judeo-Christian holistic perspective on persons was viewed with two special implications for dealing with death: 1. on the one hand, life is regarded as sacred in the Scriptures so that appropriate medical intervention for preserving life has always been understood by the Christian community as the medical norm, but 2. on the other hand, Christians recognize that all finally die and that death is not perceived as the end of existence, so that extraordinary medical intervention or hopeless grief are inappropriate from the perspective of religious faith and spiritual care.
Kübler-Ross' (1965) stages of dying and Engel's similar stages of grieving (Wolff, Weitzel, Zornow, & Zsohar, 1983) were discussed, using case studies for illustration. The case of King David's blocked grieving and subsequent inability to rule (II Samuel 19ff) was used to illustrate the fallacy of the notion that persons in positions of responsibility should not openly grieve. Both Kübler-Ross' and Engel's schematas were presented as tools that are useful in ongoing assessment and evaluation, stressing the fluid movement that occurs from one stage to another. The will to live or die and the need for hope were discussed, with particular emphasis on important psychosomatic implications of guilt (Lynch, 1977) and grief (Russell, 1984).
The role of religious faith per se was introduced as one of three important factors influencing how a patient faces death. Shelton's (1981) outline of the role of faith was employed. Shelton's final role, that of faith providing a point of entry for help and empathy, leads naturally to ways in which the nurse can incorporate spiritual help into the care-giving process.
As in the first unit, care-giving was presented under two rubrics: meeting the patient's religious needs, and meeting the patient's spiritual and emotional needs. With regard to meeting religious needs, the nurse's role as facilitator for the clergy was reviewed very briefly. It was in the second area, that of meeting spiritual needs directly that more attention was focused. Simundson's two-level approach to dealing with suffering was used to highlight the way in which most nurses will most frequently function, namely at the Survival Level rather than the Intellectual Level (Simundson, 1981). Two special cases were explored briefly: Sudden Infant Death Syndrome (Nikolaisen, 1981) and Near-Death Experiences (Oakes, 1981).
Spiritual Care of Mental Health Patients
In the presentation of the first two components of spiritual care in the Associate Degree Nursing Program, a very positive approach was utilized. Although the potential for problems related to belief systems or religiosity were mentioned, the emphasis was on the benefit of spiritual health and the ways in which the nurse may aid the patient in maintaining a positive, hopeful, and helpful spiritual outlook. It is in the mental health setting that many of the misuses of spirituality and the unhealthy uses of religious language and ideation may be observed. It is at this point in the curriculum, the third week of the third semester, that some of the problematic aspects of religiosity were introduced.
As with the two earlier components, the approach focused on the ongoing process of assessment and evaluation, and on ways in which the nurse can directly aid in the spiritual care of patients. Here, however, a much greater emphasis was placed on the judgment of whether or not the religious expression is being used in a way that is helpful or detrimental to the patient. The criterion for evaluation is not whether the religious language or behavior pleases or displeases the nurse, but whether or not it is helpful to the patient in his or her own context.
The two-hour unit began where the nursing curriculum began for the students a year earlier, with self-examination. It was once again stressed that the nurse's personal religious value system and attitude toward religion is the single most important factor in whether or not the nurse is able to assist the patient in the area of spirituality. The danger of extremes was discussed: while some nurses may have had bad experiences that have turned them against organized religion, or led them to regard all religious language or concern as irrational or neurotic, others will have had such positive and good experiences with religious faith that they will regard all religious language and behavior positively, overlooking the possiblity of distortion or misapplication. The need to discover what the patient means and understands was highlighted.
Because religious expression is so personal, so reflective of personality types, it was stressed that special care must be taken to avoid stereotyping and labeling as "abnormal" a style of relating to God that is different from one's own. A "Circle of Sensibility," illustrating the variety of religious expressions used by large numbers of persons of all faith traditions, was discussed (McBrearity, 1983). Given the realities that judgment need to be made about the value of religious expression and that this task is very difficult, three approaches were surveyed: those of Galanter (1982), Oates (1973), and John (1983). The importance of the level of religious concern and the possible correlation of religious concern with mental illness was also surveyed (Oates, 1978).
In all of these areas of assessment and observation, both sides of the issue were examined: on the one hand, religious manifestations of mental health problems are often very similar both in description and treatment to non-religious problems; but, on the other hand, the religious issue is different because it is not primarily concerned with human relationships but with transcendent ones. Because spiritual needs may not be met by ordinary psychosocial intervention, an awareness of specific techniques of spiritual care is necessary, particularly in the areas of values and guilt.
Once again, after dealing with assessment and evaluation tools, specific techniques of spiritual care were suggested. In the mental health context, appropriate goals are often difficult to determine, so John's list of general goals for spiritual care was shared (John, 1983). In most of these goals the best approach is that of the therapeutic use of self, the technique in which the nurses incarnates the qualities the client needs (Carson, 1980). Once again the use of prayer and Scripture were suggested as possible appropriate ways to assist patients spiritually, but with more reservations in the mental health context than in the general hospital setting.
Whatever else it possesses, prayer has elements of autosuggestion and positive or negative reinforcement. It was, therefore, suggested that while one can greatly aid a patient by being open to prayer requests, one should not pray for things that reinforce delusional or paranoid patterns of behavior (Carson, 1980). Similarly, while religious literature in general and Scripture in particular are often very helpful to persons in times of spiritual crisis or stress, they will not be useful for persons who read them selectively to highlight negative or antisocial themes, or for persons whose delusions are fed by reference to God or the saints.
Throughout the presentation the theme was the need for the nurse (1) to remain open to what the patient understands by the use of religious language, and (2) to attempt to use that understanding for the patient's good.
Bioethics in Maternity Nursing
The fourth presentation was given as part of the introduction to Maternity Nursing during the first week of the fourth semester. While courses in bioethics are frequently offered as électives, Maternity Nursing seemed to offer a good opportunity to give an overview of ethical methodology and to examine some common bioethical principles in a particular context.
The issue of the Sanctity of Human Life was used to illustrate the complexity of arriving at ethical conclusions. Beginning from two different bases, Judeo-Christian and non-theistic humanism, a list of common elements of the Sanctity of Life was developed. Three divergent schools of thought were then explored with respect to the question of personhood: the genetic, the developmental and the social consequences schools. Case studies concerning contraception and abortion were used to illustrate how and why all three of these schools are both embraced and rejected by a wide spectrum of persons (Brody, 1976).
Case studies were discussed to clarify some basic bioethical principles: primum non nocere; Double Effect; and Ordinary and Extraordinary Treatment. The broad and expanding area of genetic counseling was used to illustrate three areas of general professional ethics: confidentiality, truthfulness, and the appropriateness of referrals and interventions in terms of both emotional and financial costs.
Professional ethics is an important aspect of any professional curriculum. A 90-minute session was devoted to this topic in the tenth week of the fourth week semester Survey of Nursing Course. The goal of the session was to underscore the ethical dimension of everyday health-care situations rather than perceiving only dramatic or life-anddeath situations as having ethical content. It was pointed out that ethics becomes most crucial when there are alternate courses of action which may entail no more than the manner in which a procedure is carried out or interpreted to a patient or his or her family.
Self-awareness was again stressed since ours is an age of moral pluralism when what seem clear moral imperatives to us as individuals or a profession may not be shared by patients. Values commonly held by the public with regard to health care (Steele & Harmon, 1983) were compared with values influencing the selection of nursing as a profession and tensions and potential conflicts were discussed.
A simple process for ethical decision making was presented:
1. Clarify the problem in its own context;
2. Gather facts and other relevant data;
3. State pertinent belief and value systems; (Pertinent to all involved, which may clarify conflicts);
4. Assess available alternatives. (Desirable alternatives may not be available;. available alternatives may not be desirable);
5. Consider risks and costs to all involved;
6. Confer with appropriate others for validation;
7. Set a target time;
It was in the context of this process that the various philosophical value systems upon which morality is built were examined. Our interest in normative and non-normative bases for values was not abstract, but to see how drastically they affect step three in the process, and how they may account for drastic differences in outcome. Special attention was given to some of the non-normative bases for values such as Emotivism and Skepticism since these positions, while of little interest to many ethicists, show up frequently in real-life conflicts. Strengths and weaknesses of various normative systems were examined. Particular note was made of the "Appeals to Higher Authority" commonly associated with institutional religion, whether the higher authority is Natural Law, Holy Writ or Holy Church. The often overlooked weakness of such appeals is that pluralism has made inroads into the various religious traditions so that there exists less commonality than may be implied (Shelly, 1980).
Case studies were again used to concretize these concepts. Examples were concerned with everyday matters such as dealing with patients smoking or drinking against medical advice, the handling of an apparently minor meal mix-up and conflicts between institutional and personal values.
Our experience has shown us that with careful planning it is possible to devote eight hours of class time to issues of the religious needs and spiritual care of patients, a greater amount of time than was reported by any institution responding to the Wesley College Survey. Another three hours were devoted to the ethical basis for nursing action. While some of the topics were new, particularly those dealing with direct spiritual care, others utilized a different approach to topics already in the curriculum such as abortion or professional ethics. While we have used Maternity Nursing as the point to examine some of the ethical underpinnings of health care, a similar approach could be used to examine any area of specialization. We are also exploring the possibility of devoting group conferences to spiritual care where verbatims or other experimental tools might be utilized.
Wesley College is a United Methodist institution. Two logical questions might be raised about the possiblity of transferring our model to non-sectarian or public institutions: is the material appropriate; and who does the teaching? With regard to the first issue, our focus was the religious needs and spiritual care of patients in their context according to their articulation. As Banks' study suggests, religious diversity and the separation of church and state would be key issues at such schools but need not be impediments to addressing these vital issues.
In our situation, the classroom instruction was carried out by the seemingly obvious choice, the college chaplain, a United Methodist clergyman and member of the Department of Philosophy and Religion. It should be pointed out, however, that neither ordination nor academic rank would be necessary for this task, nor would they guarantee the interest or expertise to carry it out. As several of our references indicate, many nurses and nursing educators have training in religious and spiritual care. Most large hospitals now have specially trained chaplains who regularly conduct inservice training that could be integrated into an ADN program with sufficient planning.
The Wesley College experience with the ADN curriculum has shown that it is not necessary, as some had supposed, to devote specialized courses or seminars or to usurp large blocks of teaching time in order to address religious, spiritual, and ethical concerns. Careful planning and strategic placement in the curriculum can capitalize on rather modest time allotments. These important topics can be a part of the two-year nursing curriculum if there are members of the academic community who are willing to invest the time and energy it requires to truly integrate them into the program.
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- Wolff, L., Weitzel, M. Zoraow, R., & Zsohar, H. (1983). Fundamentals of Nursing, Seventh Edition, Philadelphia: JB. Lippincott, p. 215.
TIME DEVOTED TO RELIGIOUS AWARENESS AND SPIRITUAL CARE IN NLN SCHOOLS RESPONDING TO THE WESLEY COLLEGE SURVEY