The University of Tennessee, Knoxville College of Nursing began offering a new elective course taught at undergraduate and graduate levels in 1991, The development of the course, Spirituality and the Health Care Professional, grew out of increasing faculty awareness that spirituality was a neglected dimension in the curriculum. This appears to be a pervasive neglect in most nursing curricula, although nearly all programs address the spiritual needs of clients as being a major nursing concern. Nursing as a profession has developed a nursing diagnosis, "spiritual distress," to guide nurses in dealing with patients' spiritual suffering. Yet there is little to support nursing students, educators, researchers, and practitioners in the development of deeper understanding and articulation of spirituality, which seems a necessary prerequisite to any attempts to assess and diagnose another individual's spiritual distress. These understandings seem necessary in order for students to understand and adopt the philosophical base of holism. The physical and psychological dimensions are critical to an understanding and acceptance of holism, but these dimensions are usually covered in support courses, and in foundational as well as specialty nursing courses. Rarely is significant curricular support allotted to spirituality.
Appropriateness of Spirituality in Curriculum
Nursing curricula are organized usually by specialty area courses, taught after the foundational nursing courses in the sophomore or junior year. Many programs have early courses on wellness or health promotion that introduce students to holistic principles. "Holistic" assessment is also incorporated in many programs, such that students learn to assess the psychological, developmental, sexual, social, environmental, and spiritual human dimension. Nursing education must provide nurses with the philosophical base and knowledge that allow such holistic assessment.
There is an obvious inadequacy in addressing spirituality in most nursing curricula. Why is there this tendency to be hesitant about teaching spirituality as a valid academic venture? There are those who regard spirituality as so private or esoteric that it cannot be articulated conventionally or so deeply embedded at a person's core that addressing the subject is invasive, But spirituality is not synonymous with religion. Regardless of whether one is theist (believing in a personalized deity), non-theist (espousing the concept of a cosmic force) or atheist (whose higher power consists of expectations for humanity and the environmental milieu), spirituality is both intrapersonal (within) and interpersonal (among).
Another objection states that spirituality is either a subdiscipline of religion or is a species of popular metaphysics. Therefore, it is deemed unsuitable for a legitimate nursing curriculum, particularly in a state-supported university. We proposed a view of spirituality in its broad association with other disciplines: ethics, philosophy, psychology, theology, etc. Each discipline contemplates the matter of ultimate concerns and each maintains its unique particularity. Spirituality merits comparable regard.
Some argue that spirituality is inherently biased, especially favoring religious congregations who sponsor various health care institutions. Our course has attracted a diverse student population, indistinguishable in their ecclesia! attachments. What is evident is a reverence for human dignity, augmented by a belief that dignity may be healed and fulfilled within a nursing framework.
There is an opinion that spirituality is inappropriate for nursing curricula because its classic expressions are said to be doctrinal and uncritical. The essence of spirituality is exactly the opposite of this objection. Science and spirituality share a mandate- to strive toward a coherent system for the investigation of what is proposed to it as being truth. In that enterprise, spirituality's heritage of axioms and postulations is no less arbitrary or formidable than the purported precision of anatomy or the paradoxes of Newtonianism versus Quantum Physics, While Ignatius of Loyola's Spiritual Exercises, authored in the 16th century, may seem initially contrary to the latest contentions of the Surgeon General, their variance is an illusion. For both speak the language of human betterment; both aspire to heighten social awareness; both seek to converse about what ia ennobling from our intellectual legacy; and both vigorously defend the obligation to probe and discern the mechanisms of our context.
How spirituality is defined poses an initial obstacle for the inquirer. It is not difficult to accept that holism involves the totality of body, mind, and spirit. And we are most probably comfortable in assuming that the range of organic sciences adequately portrays the dimension of body just as the behavioral sciences are capable of depicting the domain of the mind. But what serves to delineate the category of spirit? In a review of holistic health care literature, 75% of 260 articles equate spirituality with a personal philosophy of meaning. This is partially tenable in that spirituality does arise out of each person's unique life experience and his or her effort to find purpose and meaning in their life. Spirituality, however, consists of a totality of one's belief system, at the heart of which is what a person values and their analysis of "why." It may or may not have an identity with a higher force, deity, etc.
Description of the Course
The spirituality course was designed with a phenomenological approach so as to allow students to understand spirituality within the philosophical framework of holism. This approach emphasizes an understanding of the human experience as it is lived or is actually experienced. Identification of spirituality's subjective features and an examination of spirituality's objective content is included. The phenomenological framework provides a method to analyze, interpret, and systematize what is humanly received.
Spirituality deals with the phenomenon of what might be termed "beyond-withinness." As a response, as a perception, spirituality may be explored from the subjective angle. But as a record, spirituality is objective, known because it is bequeathed, not because it is conjectured. And there is objectivity because whatever the "beyond" with which spirituality is concerned, that beyond describes itself, presents itself, offers itself, and embodies itself within the human framework, Fourteen themes provide focus for the seminars. These can generally be grouped as descriptive, reflective, universal, and generative (Table). Each theme comprises several subtopics, some of which are indicated in italics.
A seminar format is used in this course. Required reading assignments assist students in developing an interdisciplinary perspective of spirituality. Students analyze the concept of holism as operative in health care and they examine the contributions of contemporary authors who have addressed spirituality and health care. Students are encouraged to reflect on and define their personal spiritual view and to evaluate what constitutes an interpersonal spirituality (e.g., the nurse as a "team member" and as significant to a patient's spirituality). Students also evaluate what constitutes an institutional spirituality (e.g., the nurse as vital influence on the corporate and communal spirituality of a health care facility). Students are asked to describe and analyze nursing strategies to assess clients who may be spiritually distressed and to propose nursing interventions to promote wellness in these clients. Further, students explore the direction in which health care spirituality is evolving and deduce ways that health care providers might assist in shaping its future. Finally, research questions in relation to spiritual issues are identified.
Student recruitment for the course is through flyers, personal contact, and mailers to various community agencies, including hospitals and churches. This has allowed both regularly enrolled nursing students to use the course for elective credit, and also has attracted nonenrolled, practicing nurses to take the course through the Evening School.
One seminar is devoted to nursing assessment of the client's spirituality. Nurses can assess a client's spirituality in several ways. We can ask them what the sources of their strength may be. For example:
1. When you are struggling in life, where do you find your strength?
2. Are people available to you when you are in need?
In the same way we can elicit their concept of a higher power and what, if any, religious practices they observe.
1. Are there any religious practices meaningful to you?
2. Has your illness affected your religious practice?
Nurses facilitate communication by listening, being empathie, even touching clients if it seems appropriate. The client will frame the interaction with the nurse. The nurse can refer a troubled client to the parish nurse if the hospital has a parish nurse program or to the hospital chaplain for further spiritual assistance.
Students' written and verbal evaluative responses in regard to relevancy of course content, method of instruction, and quality of instruction were highly positive. Upon reading these critiques, we were struck by students' needs to explore the deeper meanings of their lives. They seem to want a forum to openly examine their spiritual dimensions and in a few instances, their crises of faith.
I found the group to be very helpful and in fact inspiring. Thie couree and my interactions with the instructor were a big help to me in mending some of the spiritual alienation I felt throughout my nursing education program. I especially enjoyed the selfexploration and interprétation that we did... I am glad that we covered areas that were important to our nursing practice.
We believe a principal strength of this course was the primary instructor, who has a profound spiritual life of hie own and a world view free of bias and inclusive rather than exclusive. One student wrote:
I appreciated [the instructor*a) insights, vast knowledge base and experiences which you shared with us. Your experiences were some of the most valuable teaching lessons. You were very tactful and careful not to bring in denominational barriers or attempt to discuss heated religious issues.
Another wrote, "...the instructor was able, again and again, to strike chords that resonated for each of us regardless of our backgrounds or beliefs. I now feel more confident about expressing my spirituality with colleagues and patients who I know are very different from me."
As one student said, "...if we are to be taught nursing within a holistic framework, spirituality must be included because it is integral to every human." A student who stated that the course was excellent said. This course has made me rethink and re-evaluate how spirituality fits into my life, my work, my interactions with patients and peers. I believe that all nurses would benefit from a course such as this."
During class, students were enthusiastic and involved in discussion. Their comments were reflective, thoughtful, and pertinent. The informality of the class provided an atmosphere conducive to open sharing. Many students commented on the relevance of the personal spiritual exercises and the increased understanding they now possessed in relation to differing religious orientations.
Many students expressed how fortunate they were to have had the opportunity to take a class on spirituality. Most indicated that they benefited from listening to their peers as they shared their faith, spiritual dilemmas, or in some instances, the spiritual distress or lack of it that they encountered in their patients. It is obvious to us that this course is meeting a need. There is no location in North America where a person can receive specialized training in the spirituality of health care. The time is opportune for a college or university to propose a Masters of Science in Nursing degree with a concentration in spirituality.