Mrs. M. was admitted to a medical unit with a new, potentially life-threatening, diagnosis of cancer. She felt anxious and feared the implications of this diagnosis, given how it would affect her life’s goals. She wondered why this would happen to her and where God is in all of this. If she shares these thoughts with her nurse, she will receive a diagnosis of altered spiritual function; she exhibits maladaptive expressions of spiritual needs, a dysfunction that requires nursing intervention. On the basis of this diagnosis, her nurses will intervene through spiritual support, evaluating her progress until she reaches a state of spiritual well-being. How will she and the nurses know when she has reached this state? She will feel peaceful, connected, forgiving, loving, balanced, integrated, and hopeful. The nurse will wait for her to express understanding and acceptance of her situation.
The scenario described above is a typical description of spiritual care in nursing textbooks. The scenario provokes a number of questions, particularly if the reader is the patient. A patient may ask, “Would I want this diagnostic language used to describe my struggles in the face of illness? Would I want the nurse to intervene in this aspect of my life? Are these experiential descriptors of spiritual well-being realistic amid my suffering?”
Spirituality and spiritual care in nursing are increasingly characterized by three common assumptions. First, all individuals have a spiritual nature, whether or not they agree with that claim. Second, spiritual care is an ethical responsibility of holistic nursing care. Although most ethical codes would phrase this responsibility as being respectful and supportive of patients’ spiritual practices, the nursing literature has gone beyond the notions of respect and support to intervention. Third, many nurses are unprepared for spiritual care, which is a neglected area of practice. The call is often made for more education so nurses can become competent in this form of care.
The literature on spiritual care frequently cites three primary nursing competencies related to spirituality: self-awareness, knowledge about religion and spirituality, and how to implement spiritual care in a nursing context (Greenstreet, 1999; Narayanasamy, 1999). van Leeuwen and Cusveller (2004) conducted a literature review with the purpose of describing a set of nursing competencies for spiritual care. Their results were described in terms of three core domains and six competencies. The three core domains were “awareness and use of self, spiritual dimensions of the nursing process, and assurance and quality of expertise” (p. 234). This final core domain addressed the institutional processes and characteristics that contributed to quality spiritual care. The six spiritual care competencies were “handling one’s own beliefs, addressing the subject, collecting information, discussing and planning, providing and evaluating, and integrating into policy” (p. 234).
In light of this call to prepare nurses for competence in spiritual care, the purpose of this study was to investigate and analyze what was being taught to first-year nursing students about spirituality and spiritual care through nursing fundamentals textbooks. McEwen’s (2004) analysis of spirituality content in nursing textbooks provided a helpful overview and summary of the core content found in various categories of nursing textbooks, including six nursing fundamentals textbooks. She calculated the percentage of pages devoted to the topic, commented on the various chapter headings and the content contained in the chapters, and characterized the content in nursing fundamental textbooks as comprehensive. This study builds on McEwen’s work by focusing on the content related to spirituality and spiritual care specifically in first-year nursing fundamentals textbooks. Ten textbooks (Table 1) were reviewed and analyzed using a philosophic inquiry. Eligible textbooks were identified through the web sites of major publishing houses. To be included in the study, the title of the textbook needed to contain the language of fundamentals (or foundations), to be aimed toward a student audience preparing to become an RN, and to have at least some content related to spirituality.
Table 1: Nursing Fundamentals Textbooks Used for Analysis in This Study
Philosophic inquiry is useful for addressing what Edwards (2001) referred to as second-order questions. These questions seek to clarify the underlying concepts and assumptions within a particular discourse that cannot be answered through scientific means. Philosophic inquiry can also play a deconstructive role in seeking to reveal potential distortions. The method uses the conceptualizing, judging, and reasoning processes of the researcher to ask an ever-deepening cycle of questions around a particular problem. In this study, the method was used to identify those concepts and assumptions about spirituality and spiritual care that are potentially problematic and need to be considered further when educating practitioners on this aspect of nursing care. Problematic issues were identified using a pragmatic approach. Content related to spirituality and spiritual care were continually tested by the question of what implications this approach may have for the practicing nurse.
The research began with a series of questions about the textbook content related to spirituality and spiritual nursing care (Table 2). These questions were derived from the understanding that the nature of philosophic inquiry concerns “common” as opposed to “special” experience as described by Adler (Simmons, 1992, p. 15). Questions were selected that would typify common questions nurses may have related to spiritual care such as, “What is it?”, “What is my role as a nurse?”, “What interventions are entailed?”, and “How do I know that I have been effective?” These questions had been tested in an analysis of a different body of literature. The answers to these questions led to other questions such as, “What are the underlying assumptions?”, “What concepts are missing?”, and “What is incongruent or otherwise potentially problematic?” This article describes a general overview of what is presented as spirituality and spiritual care in first-year fundamental nursing textbooks and then examines some of the more problematic conceptual issues.
Table 2: Beginning Questions for Analysis
Basic Competencies of Spiritual Care
Seven of the 10 textbooks reviewed had a chapter devoted to spirituality. Spirituality and religion were addressed in various places throughout the remaining textbooks. All 10 textbooks addressed the competence of understanding spirituality and contrasting it with religion. Related concepts frequently addressed included faith; hope; and healing therapies, such as complementary therapies, faith healing, and healing prayer. The implications of religious beliefs on health care were a major emphasis in the texts, with several of them having devoted a significant amount of the chapter to explaining the perspectives of the various world religions and the implications for nursing care. Religious worldviews were categorized in different ways. Often, the authors would delineate a number of categories along eastern and western, denominational, or ethnic lines. Many of the texts included a developmental approach to spirituality using Fowler’s (1981) stages of faith development. The textbooks that contained a chapter dedicated to spirituality used a nursing process approach to discussing the delivery of spiritual care. In summary, the competencies of knowledge about religion and spirituality, as well as how to implement spiritual care using a nursing process approach, were fairly well developed in this literature.
Less well developed was the competence of nurses’ self-awareness related to spirituality and religion. Self-awareness entails having thought through one’s perspective related to religion and spirituality and understanding how that perspective may influence interactions with patients. Although the literature frequently acknowledged the need for this self-awareness, little or no guidance was given about what this means or how it should occur. Craven and Hirnle (2003) and Taylor, Lillis, and LeMone (2005) articulated some of the questions that nurses should consider in developing this self-awareness, and Taylor et al. integrated the concept of critical thinking with the nurses’ spiritual self-awareness. Another competency that was relatively undeveloped is van Leeuwen and Cusveller’s (2004) competency of assurance and quality of expertise, helping to develop spiritual care at the institutional level. This is probably appropriate considering the primary audience for this literature is first-year students learning the fundamentals of nursing; however, the lack of guidance regarding spiritual self-awareness is a little more concerning.
Conceptual Problems with Spirituality
On review of the content of this group of textbooks, some of the more problematic issues in this literature will be addressed. These problematic issues are related to how spirituality and religion are being conceptualized in this body of literature and can be summarized as follows: First, clearly separating spirituality from religion, as most of the textbooks do, creates some interesting dichotomies that fail to acknowledge the holistic nature of individuals. Second, the tendency to define spirituality primarily by positive emotional descriptors potentially creates an idealized immaterial state that pathologizes the basic human experience of suffering. Third, most definitions of spirituality depend on cognitive experiences and capacity, and that dependency may result in marginalizing those that are most vulnerable in society.
In keeping with the current trend in nursing literature, the authors of these texts have defined spirituality inclusively. All individuals are considered spiritual. Although there is no common definition, there are a number of common descriptors. These include connectedness, harmony, meaning, purpose, transcendence, and integration. These descriptors are similar to those found in integrative reviews of spirituality in the literature (Chiu, Emblen, Van Hofwegen, Sawatzky, & Meyerhoff, 2004; McCarroll, O’Connor, & Meakes, 2005). Each of these terms describes something that humans feel; spirituality is characterized by an experience of the individual. In contrast, religion is characterized as formal, organized, associated with rituals and beliefs, and sometimes conflated with culture (Berger & Williams, 1999). Harkreader and Hogan (2004) suggested that spirituality is the experiential individual descriptor, whereas religion is the conceptual group descriptor. Other authors (e.g., Berger & Williams, 1999; Daniels, 2004) suggested that spirituality can also be conceptual in that it is a set of beliefs, but is an individual conceptualization rather than a group conceptualization.
This understanding of spirituality and religion sets up some interesting dichotomies, such as a separation between individual and cultural selves (Pargament, 1999) and conceptual and experiential selves. Individuals are always shaped to some extent by culture, and culture is ultimately a culmination of individual expression. Likewise, experiences shape conceptual structures, and concepts help to dictate how individuals interpret experience. One gets a sense from this literature that the intent of these distinctions is not to create false dichotomies but to help nurses recognize spirituality outside those who are religious. However, the effect is somewhat paradoxical. Religious beliefs and their implications for health are often discussed in a table format, with little acknowledgement of the spectrum of variability of beliefs, even among those who might identify with a particular religious affiliation. Spirituality, on the other hand, is treated as if it is relatively free of beliefs, or contentless. This approach fails to do justice to the way that most individuals navigate their spirituality by selecting some beliefs from institutions and other beliefs as a result of their own experiences (Fuller, 2001). It also fails to recognize the fundamental importance of beliefs to the experience of spirituality. A devotional or spiritual experience must have some content, or nothing can be said about it (Taylor, 2002).
However, there is something more troubling about the descriptors that are being used to define spirituality. A close read of these texts suggests that what has been constructed as spirituality is a highly postmodern idea of the perfect immaterial individual. This individual seeks to exist in a state of peace, joy, meaning, balance, trust, connectedness, and forgiveness. Indeed, to be outside of this idealized state is to be considered spiritually distressed, and those experiencing fear, boredom, rejection, or frustration are said to be maladaptive in their spiritual needs. Beyond the distastefulness of being labeled in such a way is the paradox of juxtaposing a postmodern view of individualized experiences of spirituality with normative religious concepts such as faith, hope, love, and forgiveness. The idealized immaterial individual has been created in terms of an emotional state without any corresponding content of how one achieves that state. This is one of the risks of drawing the boundaries too clearly between spirituality and religion. Taylor (2002) suggested that the inner experience that seeks to connect us, and the outward practices we engage in to respond to what we believe is expected of us, are meant to be complementary. Religious worldviews support the ability of individuals to exercise the virtues of faith, hope, love, and forgiveness even if they may not feel particularly peaceful or joyful. That is, they provide meaningful cognitive frameworks to bridge the idealistic state of well-being that one can envision and the daily life where the emotional state is often less than ideal.
In addition, religious worldviews usually recognize the limitations on realizing an idealized spiritual state while embodied. A concept notably absent within these first-year textbook discussions of spirituality is that of suffering. This is an interesting absence, given that suffering is a common human experience and one that is particularly relevant during times of altered health states. Suffering has been replaced in this literature by the diagnosis of spiritual distress. However, spiritual distress implies a state to be solved rather than an acknowledgment that one might experience suffering, attended by all the undesirable emotions, and still remain spiritually well. Indeed, it is often a comfort to individuals to know that their negative emotional states have no bearing on their fundamental relationship to a higher power. By labeling negative emotional states as spiritual distress, we run the risk of threatening that source of comfort and hope. In failing to embrace the common human struggle of suffering, we may be pathologizing people, working against the therapeutic healing environment we hope to create.
A third challenge with the conceptualizations of spirituality in this literature is the assumption that spirituality is linked to cognitive capacity, the capacity to make meaning and to find purpose within life. As McSherry and Cash (2004) pointed out, definitions of spirituality that assume the ability to reason inevitably exclude those who have diminished cognitive capacity. The theological literature provides a solution to this challenge by acknowledging a dimension of the individual that transcends the dimensions of body and spirit—the dimension of the soul. Whereas the spirit is the heart or will of the individual, the soul is the timeless, unique dimension of the individual that does not depend on cognitive capacity (Willard, 2002). To hold to the assumption that all individuals are spiritual, there must be a way to include those with diminished cognitive capacity, otherwise we are marginalizing a group of individuals as nonpersons. Perhaps the time has come to rethink the concepts of religion, spirituality, and culture to ensure that they are constructed in a more meaningful, realistic, and inclusive way.
Conceptual Problems with Spiritual Care
The second area of focus for this study was the concept of spiritual care. What is being taught to nursing students in these fundamental textbooks about spiritual care? The nursing process approach is used almost exclusively in this literature. Students are taught to assess, diagnose, set goals, intervene, and evaluate the spirituality of patients. The assumptions underlying a nursing process approach to spiritual care, as well as the challenges of these assumptions, have been discussed in another article. A prescriptive nursing process approach to spiritual care rests on the assumptions that spirituality has a normative frame of reference, that it can be expressed meaningfully through language, that it should be influenced by nurses, and that nurses are competent to intervene (Pesut & Sawatzky, 2006). An analysis of this body of literature suggests three other potentially problematic areas: the challenge of identifying what constitutes a uniquely spiritual intervention, the nature of the outcomes being set for care, and the assumption that nurses should develop their spiritual worldviews but then lay those aside as potential biases in the context of care.
Spiritual interventions in this literature fall into two general categories: support for religious and spiritual practices and therapeutic use of self. Providing support for religious and spiritual practices includes ensuring patients have privacy for rituals, referring to spiritual counselors, prayer, facilitating access to sacred texts and objects, and ensuring that health-related religious rituals and prohibitions are met (e.g., dietary restrictions, end-of-life care). Therapeutic use of self includes interventions such as presence, listening, touch, respect, time, and directed conversation around themes such as meaning, purpose, hope, values, connection, and forgiveness. Other interventions less commonly recommended include the use of nature and art therapy, reminiscence, alternative therapies, and creative writing.
The first problem with this approach is that it is difficult to identify uniquely spiritual interventions apart from what has traditionally been considered simply good religious and psychosocial care. This is important because spiritual care is being positioned as an integral and neglected aspect of care in the broader nursing literature. Respecting and facilitating patients’ religious rituals and prohibitions has always been an accepted part of practice. Likewise, the therapeutic use of self has been central to nursing practice. One might argue that engaging the patient in conversations around meaning, purpose, and connection constitutes spiritual care, but this has long been a focus of good psychosocial care. Some have argued that the word spirituality has been reconstructed in the nursing discourse (Bash, 2004; Beech, 2005). Perhaps the adoption of the term spiritual to describe this care has simply created an artificial perception that this aspect of care is neglected.
The second problem with this approach is the proposed goals for spiritual care. Goals include expressing acceptance of current life situation, satisfaction with spiritual beliefs, reestablishing a purpose in life, and having warm relationships with significant others. As educators, we tell students that their nursing care planning goals should be achievable. And although these spiritual goals are often met at various times in patients’ lives, one has to wonder whether these are realistic outcomes for a time-limited encounter between nurses and patients, and how students feel about being confronted with such lofty goals. Given the deep and mysterious nature of how individuals come to accept their circumstances and find purpose and meaningful relationships amidst adversity, these goals seem somewhat presumptuous. Nurses’ caring presence is important to patients and has the potential to make a significant difference in how patients experience their circumstances. However, the struggle of finding meaning and satisfaction in life seems to characterize human existence in general and perhaps is not something that nurses should necessarily set out to solve.
The third problematic approach in this literature is that nurses should develop their own values and beliefs related to spirituality but then lay those biases aside in the context of spiritual care. This assumption is typified in the following statement about assessment: “The nurse must remove from the assessment any personal biases or misconceptions and be willing to share and discover a client’s meaning and purpose in life, sickness, and health” (Potter et al., 2006, p. 493). Other claims are that the nurse should accept inclusive definitions of spirituality (Craven & Hirnle, 2003), realize that their own beliefs could obscure spiritual needs (Harkreader & Hogan, 2004), and acknowledge the value of all religions, not letting their own needs guide the discussion (Du Gas, Esson, & Ronaldson, 1999). Certainly, nurses should care from a fundamental ethic that acknowledges that patients’ spiritual concerns take precedence, and that it is inappropriate for nurses to apply any sort of spiritual coercion during times of patient vulnerability (Pesut, 2006). But should this entail thinking of our spiritual worldview as bias in the context of care? Spiritual development is often described as a journey whereby one discovers more of the fundamental values and meanings in life and seeks to live in accordance with those understandings. Values and beliefs, although they often take on a more inclusive and mature character, become more consolidated (Fowler, 1981). Is it reasonable to expect that those in a spiritually mature state should treat that lifetime of development as a bias in nursing care?
This assumption is characteristic of Western society’s approach to religion and spirituality in general. Religion and spirituality have increasingly become individualized, socially constructed worldviews that are not open to challenge or constructive debate (Taylor, 2002). This unbiased approach was meant to foster a spirit of tolerance of religious differences. However, by removing religious and spiritual ideas from the realm of constructive debate, there is limited capacity to compare positions and to address religious ideologies that are destructive or unhealthy (Bibby, 1993; Zacharias, 1996). Likewise, in health care, it is neither realistic nor healthy to suggest that nurses hold all beliefs and values related to religion and spirituality as personal biases. In practice, nurses regularly encounter and address spiritual and religious beliefs that may be considered delusional or unhealthy. We need to move from the naïve view that personal beliefs have little or no place in spiritual care to a more sophisticated understanding of how those beliefs should be negotiated within a profession that has a public trust with patients in positions of vulnerability. Even a purely relativistic position of accepting all religious and spiritual perspectives unquestioningly is in itself a bias, and one that potentially marginalizes those from certain traditions (Fawcett & Noble, 2004).
Recommendations for Teaching Spiritual Care
Where does this leave nurse educators charged with the task of introducing spiritual care to first-year nursing students? First, it is helpful to know that some fundamentals textbooks cover the issue of spirituality more thoroughly than others, and educators may need to augment the text with other resources. The textbooks that have a chapter devoted to spirituality generally address the competencies of knowledge about religion and spirituality and implementing spiritual care in a nursing context. There is less emphasis on self-awareness in the area of spirituality and the role that it plays in spiritual nursing care. Catanzaro & McMullen (2001) provided some valuable educational strategies for increasing nursing students’ spiritual sensitivity.
However, because of some of the problematic issues related to this body of literature, introducing students to spiritual care provides an ideal opportunity to help students think critically about the material presented. Students can be shown some of the problems with the definitions of spirituality and religion. Dichotomous thinking such as individual and cultural thinking and conceptual and experiential thinking can be replaced by a more accurate notion that all individuals carry worldviews, derived from a variety of sources, that explain how they perceive the spiritual world and their place within that world. There are useful typologies available in the literature that categorize spirituality in ways that address fundamental beliefs without being limited by traditional religious descriptors (Fenwick & English, 2004; McSherry & Cash, 2004) In addition, in keeping with a holistic notion of individuals, students can be shown how the conceptual and experiential selves are highly related. What we believe shapes what we experience, and what we experience, in turn, shapes what we believe.
Educators can also help students resist the notion that there is some idealized spiritual state that the absence of necessarily dictates some pathological process. An exploration of suffering and the role it plays in human growth and transformation may help to offset any experiential ideal. Educators can seek alternate ways of teaching spiritual care that do not use the diagnostic language of the nursing process. Case studies and reflective journaling might better facilitate the kinds of self-awareness and humility necessary to care in the realm of the spiritual (Bush, 1999). In addition, students need to grapple with the limitations of spiritual definitions that depend on the cognitive and experiential aspects of the individual. Perhaps it is time to reclaim the concept of the soul, that timeless unique essence that acknowledges personhood beyond the ability to think or have positive feelings.
Finally, when teaching students about spiritual care, educators can draw explicit links to other aspects of the curriculum that teach the therapeutic use of self. Understanding that the interrelational skills that undergird all of nursing practice are the same skills used in spiritual care may help to offset some of the feelings of inadequacy in this domain. However, it is also important to help students overcome the discomfort often associated with speaking about religion and spirituality; many are still shaped by the prevailing societal understandings that religion and spirituality should not be discussed in public. The classroom is a place where students can practice articulating their own values and beliefs and discussing those with others whose perspectives may differ. This kind of facilitated discussion is a perfect opportunity for students to grapple with what constitutes ethical (i.e., respectful and noncoercive) conversation around spiritual and religious ideas as they affect health and nursing care (Pesut, 2003). The content of this kind of discussion could focus around what constitutes spiritual awareness and maturity and the role that it plays in the nurse-patient interaction. Educators can help students to think a little more carefully about the goals of spiritual care. This could entail focusing on the effect of a caring nursing presence in the lives of patients, while avoiding the impression that this effect needs to be observed and documented through a nursing process goal.
Teaching nursing students to care for the spirituality of patients is a potentially daunting endeavor. Fundamentals textbooks in nursing provide a good starting point for addressing this aspect of care. Some of the more problematic issues in this literature can be used as an opportunity to develop students’ critical thinking and to highlight areas for further development of nursings’ knowledge as it relates to this important topic.
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Nursing Fundamentals Textbooks Used for Analysis in This Study
|BergerKJWilliamsMB. (1999). |
|CravenRFHirnleCJ. (2003). |
|DanielsR. (2004). |
|DeLauneSCLadnerPK. (2002). |
|Du GasBWEssonLRonaldsonSE. (1999). |
|HarkreaderHCHoganMA. (2004). |
|KozierB. (2004). |
|LindemanCAMcAthieM. (1999). |
|PotterPAPerryAGKerrJCWoodMJ. (2006). |
|TaylorCLillisCLeMoneP. (2005). |
Beginning Questions for Analysis
|What is the definition of spirituality being used?|
|What related concepts are discussed (e.g., hope, suffering, faith)? How are these concepts defined?|
|How is religion described in relation to the spiritual?|
|Is there any attempt to differentiate worldview approaches? If so, how?|
|How is spiritual nursing care conceptualized?|
|How is the role of the nurse described?|
|How are nurses prepared to engage in this role?|
|How is spiritual assessment performed? What tools are provided?|
|What are the goals of spiritual care?|
|What interventions are included?|
|What evaluation criteria are used to determine if the goals are met?|
|Are there any ethical issues discussed related to spiritual nursing care? If so, what are they? How are the dilemmas characterized?|