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Nature of spirituality
SPRITUALITY- (Reed, 1992)-an expression of the developmental capacity for self-transcendece
-(Leininger,1997)-a relationship with a supreme being that directs one’s beliefs and practices.
3 CHARACTERISTICS OF SPIRITUALITY (BURKHARDT):

1. UNFOLDING MYSTERY- one’s attempt to understand the meaning and purpose of life
2. HARMONIOUS INTERCONNECTEDNESS – an individual’s relationship to other persons and/or to God
3. INNER STRENGTH – one’s personal spiritual resources

Spiritual need/Psychosocial need:

SPIRITUAL NEED – helps some people accept illness, may look upon illness as a test of faith

“If I have enough faith I will get well”

PSYCHOSOCIAL NEED – associated with a belief that illness is due to immoral behavior and believe their illness
is punishment for past sins.

“What have I done to deserve this?”

3 Dimensions of Spiritual Needs:

1. PHYSICAL OR BIOLOGICAL DIMENSION

- involves caring effectively for the physical body,

- relates to the world around us through our five senses.
2. PSYCHOSOCIAL DIMENSIONS

- relates to self and others, and involves our emotions, moral sense, intellect and will
- centered on the principles of interpersonal relationship
3. SPIRITUAL DIMENSIONS

- capacity to relate to a higher being.

- commitment to our value systems.
(Stallwood, 1975: 1087) These three dimensions are distinct but overlapping. They cannot be sealed in separate
compartments. A crisis or illness affecting our physical body will invariably affect the other dimensions as well.

Spiritual Care Nursing in Todays Perspective

-Religious functions and intervention limited (at least officially) to calling the hospital chaplain
-was directed towards belief systems and religious practices.
-1960-1970 – a growing interest in the spiritual, psychosocial, and emotional aspects of nursing care
-1971 – the nurse ministering to the whole person
Spiritual care

"A nurse does not only seek to alleviate physical pain or render physical care - she ministers to the whole
person. ( Joyce Travelbee, 1971)

Nursing Interventions

- Simply being with clients, -

- listening to their concerns,
- empathizing and responding

The North American Diagnosis Association [NANDA] approved list of Nursing Diagnoses which is widely used in
Australia, includes SPIRITUAL DISTRESS which is described as, "Distress of the human spirit; disruption in the
life principle that pervades a person's entire being and integrates and transcends one's biological and
psychosocial nature." (Alfaro, 1990: 203) This classification, first approved in its present form in 1988,
recognizes that suffering extends beyond the physical, mental and emotional.
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Like all other areas of care, spiritual care should be a team effort. If spiritual needs are accurately assessed and
documented, all staff will be encouraged to see that care is provided. Members of the team who for any reason,
don't feel comfortable about providing that care themselves, will be able to use referral. The result will be a
united approach to spiritual care which is seen as a natural part of nursing practice.

Spiritual care can be a natural part of total care which fits easily into the nursing process of assessment, nursing
diagnosis, planning, implementation and evaluation. Placing spiritual need and spiritual care within this
framework, has proved to be very helpful, for both philosophical and practical reasons. Firstly spiritual care can
become more tangible as well as more assessable. And secondly, the types of knowledge utilised by the Nursing
Process - practice wisdom, ethics of practice, and scientific knowledge (Ziegler et al, 1986:14-18) - are all
relevant to assessing spiritual needs and planning spiritual care. It can also then be documented in nursing care
plans, to ensure a continuity of care.

Unity and Diversity in Spiritual Care

We are told that the very essence of good nursing is to help a person attain or maintain wholeness in
every dimension of their being. 'Holism' has become the buzz word of the nineties, and nurses are
frequently exhorted to care for the whole person. A new wave of terminology has evolved around
this concept, and now in nursing theory you'll sometimes find a person described as a
biopsychosocial unit! Is this a new direction or focus for nursing, or are we simply revisiting
something we have always known to be important?

The nursing profession has traditionally viewed persons holistically, even though the term itself was
not introduced into the nursing literature until the1980s by Rogers, Parse, Newman and others. In
fact it would have been hard to find a nurse in any era who saw only the physical aspect of care as
that which defines nursing. FLORENCE NIGHTINGALE, who brought to nursing not only her
traditional Christian values but also some very 'modern' nursing values such as autonomy and
professionalism, was a firm believer in holistic care. She claimed, "The needs of the spirit are as
critical to health as those individual organs which make up the body". We've all observed that a
physical condition can affect the mind and spirit. We're also aware that when a person is hurting
emotionally or spiritually, all sorts of physical ailments may be manifested. What has changed is that
we're now giving more attention and time to those other less tangible dimensions of a person's need.

RESTORING WHOLENESS

If we accept that restoring wholeness is a legitimate goal of nursing, the term 'holistic' from the
Greek 'Holos' meaning whole or complete, is a very appropriate way to describe what we aim to do.
Even so, we may not always stop to consider the full implications of that concept. Holism has been
defined as "concerned with the inter-relationship of body, mind and spirit in an everchanging
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environment"1 (Dossey 1995), while the American Holistic Nurses Association define wellness
(health) as "a state of harmony between body, mind and spirit". So if we're aiming to help a person
attain or maintain wholeness in all dimensions of their being, we need to be prepared to provide care
in each of those areas.

In this paper I'll consider one of those dimensions - the needs of the human spirit and ways we might
provide spiritual care for our clients. I'll also suggest that in spite of the diversity we encounter in a
multicultural, multi religious setting, it is possible to do this appropriately and unitedly.

THE NATURE OF SPIRITUALITY

Spiritual needs, and psychosocial needs are much less tangible than physical needs, because they are
often abstract, complex and more difficult to measure. These more intangible needs have frequently
been given a much lower priority than needs which are more obvious and more easily measurable.
Spiritual needs, if expressed outside of a religious framework, are very likely to go unnoticed. So if
we are to identify spiritual needs and provide spiritual care, it's first necessary to have some
understanding of the nature of spirituality and how it may be expressed by different individuals.

In Australian society, and therefore in our health care setting, we encounter a diversity of cultures,
philosophies and religious traditions, as well as individuals who have no clearly defined philosophy
or belief system. Therefore it's important that we develop some general definitions which can help us
to recognise spiritual needs when we encounter them in our clients. In recent years, a number of
definitions have emerged which are helpful both for defining spirituality, and differentiating between
spiritual needs and religious or psychosocial needs.

Simsen defines spirituality by saying... "THE SPIRIT is that part of man which is concerned with the
ultimate meaning of things and with a person's relationship to that which transcends the material."
(Simsen, 1985:10) Moberg says it is... "The totality of man's inner resources, the ultimate concerns
around which all other values are focussed, the central philosophy of life which influences all
individual and social behaviour." (Moberg, 1979) SPIRITUAL NEED has been variously defined as,
"Any factor that is necessary (requisite, indispensable) to support the spiritual strengths of a person
or to diminish the spiritual deficits." (Simsen, 1985:10). "The lack of any factor or factors necessary
to maintain a person's dynamic relationship with God/Deity (as defined by that person)." (Stallwood,
1975: 1088), and "That requirement which touches the core of one's being where the search for
personal meaning takes place." (Colliton, 1981: 492). I find all these definitions helpful because
together they give a comprehensive (though not exhaustive) picture of what we are aiming to do in
giving spiritual care.

We need to realise however that spirituality may not always be expressed within a religious
framework. Therefore we need to make a distinction between spirituality and religion. One definition
of RELIGION is, "a framework of spiritual beliefs, a code of ethics and a philosophy that governs a
person's activity in pursuit of that which he holds as supreme, his God." In the book, Nursing and
Spiritual Care, McGilloway says, "Religion helps people answer basic questions about life and death
and the unexplained happenings in the world around them". (McGilloway, 1985: 23) As these
definitions demonstrate, spirituality is not limited to religious affiliation and practices, but is a much
broader concept. Another difficulty in identifying spiritual need is that we can fail to make the
distinction between spiritual needs and psychosocial needs, since they are not always opposites, and
may in fact overlap.

A model I find helpful in clarifying this, is one that describes a person in terms of three dimensions....
(1) The PHYSICAL or biological dimension which relates to the world around us through our five
senses. (2) The PSYCHOSOCIAL dimension which relates to self and others, and involves our
emotions, moral sense, intellect and will. (3) The SPIRITUAL dimension which transcends physical
and psychosocial dimensions and has the capacity to relate to a higher being. (Stallwood, 1975:
1087) These three dimensions are distinct but overlapping. They cannot be sealed in separate
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compartments. A crisis or illness affecting our physical body will invariably affect the other
dimensions as well.

SPIRITUALITY IN NURSING TODAY

How does nursing today view spiritual care? For a long time, nursing literature concerning spiritual
care was directed towards belief systems and religious practices. If considered at all, it was largely
defined in a very narrow way as relating to frankly religious functions and intervention limited (at
least officially) to calling the hospital chaplain. Regardless of that, we were often confronted with
spiritual need and recognised at least the more overt expressions of this. For example, statements
such as "God must be punishing me" or questions like, "Nurse, do you think there is anything after
death?" were recognised as indicating a spiritual concern.

By the late 1960s and 1970s the nursing literature had begun to reveal a growing interest in the
spiritual, as well as the psychosocial and emotional aspects of nursing care. Nursing theorists of this
era saw the human person as an integrated whole with different dimensions or capabilities (as they
put it) for discerning the world around and within. Their writings suggest that when they spoke of
spirituality or spiritual need, they had in mind a much broader concept than just religious or
denominational adherence and practice.

In 1971, Joyce Travelbee declared, "A nurse does not only seek to alleviate physical pain or render
physical care - she ministers to the whole person. The existence of suffering, whether physical,
mental or spiritual is the proper concern of the nurse".4 (Travelbee, 1971: 159). Here we see clear
evidence of a return to the traditional focus of nursing, a concern for the whole person. This focus is
even more evident today.

The North American Diagnosis Association [NANDA] approved list of Nursing Diagnoses which is
widely used in Australia, includes SPIRITUAL DISTRESS which is described as, "Distress of the
human spirit; disruption in the life principle that pervades a person's entire being and integrates and
transcends one's biological and psychosocial nature." (Alfaro, 1990: 203) This classification, first
approved in its present form in 1988, recognises that suffering extends beyond the physical, mental
and emotional.

Spiritual care can be a natural part of total care which fits easily into the nursing process of
assessment, nursing diagnosis, planning, implementation and evaluation. Placing spiritual need and
spiritual care within this framework, has proved to be very helpful, for both philosophical and
practical reasons. Firstly spiritual care can become more tangible as well as more assessable. And s
econdly, the types of knowledge utilised by the Nursing Process - practice wisdom, ethics of practice,
and scientific knowledge (Ziegler et al, 1986:14-18) - are all relevant to assessing spiritual needs and
planning spiritual care. It can also then be documented in nursing care plans, to ensure a continuity of
care.

Like all other areas of care, spiritual care should be a team effort. If spiritual needs are accurately
assessed and documented, all staff will be encouraged to see that care is provided. Members of the
team who for any reason, don't feel comfortable about providing that care themselves, will be able to
use referral. The result will be a united approach to spiritual care which is seen as a natural part of
nursing practice.

SOME IMPORTANT PRINCIPLES

(1) Nursing diagnosis is intended to identify strengths of the client as well as actual and potential
problems. (2) Our primary goal in spiritual care is to mobilise the patient's spiritual resources (3)
Nursing staff should be aware that spiritual care is not an attempt to proselytise or win converts to a
particular point of view. Rather, it is responding to a client's expressed needs. Interventions are by
their request or permission. (4) Spiritual assessment and care should be sensitive and based on a
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relationship of trust between client and nurse. It will involve awareness of the person's culture, social
and spiritual preferences, as well as a respect for their beliefs and religious practices. (5) Recognising
our own limitations and knowing when to make a referral, or utilise other members of the team is as
important for spiritual care as it is for other aspects of care. (6) The importance of documenting
spiritual care in nursing plans must be recognised, since this will ensure that care is systematic, well
thought out, and consistent.

MEETING THE CHALLENGE

Spiritual care can still be a daunting prospect for many nurses. The differing beliefs, requirements
and expectations of our clients, face us with a significant challenge. How can we become more
confident and better equipped to meet it? First I think we need to consider the myriad of personal
resources nurses use in their day to day work. Many nursing interventions already provide a degree
of spiritual support. Simply being with clients, listening to their concerns, empathising and
responding, is therapeutic when it comes to meeting the needs of the human spirit - the need for love
and relatedness, meaning and purpose, and hope. Often nurses fail to recognise and document this
excellent and appropriate care.

Then we need to be building up a knowledge base that will equip us for understanding the particular
spiritual and religious needs of our clients. This information will be obtained primarily from our
clients, or where that is not possible, from their families. Interacting with colleagues and liaising with
hospital chaplains will also be helpful. Attending workshops and courses which deal with this aspect
of nursing care will help to increase our knowledge and skills.

Then there are nursing texts that give an overview of the religious/spiritual requirements of a number
of major faiths. eg. Kozier and Erb's chapter on Spiritual Preferences in Fundamentals of Nursing, or
Lippincott's Nursing and Spiritual Care (McGilloway and Myco eds.). This is important because in
many societies culture and religion are closely woven together. A working knowledge of major
religions - especially their beliefs regarding issues such as health and illness, suffering and death -
will be highly relevant to nursing care. Knowledge of customs, ceremonies, cleanliness/hygiene
rules, and food laws will be of practical value.

We should also be aware that most religions accept that there is a presence or dimension in man that
survives the death of the body - Christians believe in bodily resurrection, judgment and eternal life -
in heaven or hell. Eastern religions teach reincarnation. On the other hand we also need to recognise
that some philosophies such as Humanism don't centre around the supernatural at all, and in fact
deny influence of any Deity or supernatural power. This doesn't mean that they don't possess a
spiritual dimension to their nature or do not have spiritual needs, as the models have demonstrated.

It is commonly argued that the need for spiritual nourishment is not only found in individuals who
are severely ill in hospital, but also the whole of humankind (Myco, 1985:40). The anxiety of death
or the helplessness experienced in illness - whether occurring through old age, severe illness or any
other life crisis - produces a heightened need for security, meaning, hope, love & acceptance, which
are all basic human needs. People may seek fulfilment of these needs purely on a horizontal level, eg.
through human relationships, OR on what has been called a transcendent level, through a relationship
with God.

Other factors which will affect our confidence and competence in providing spiritual care include an
understanding of our own beliefs and values, and the degree to which our own spiritual needs are
being met. It's difficult to respond to spiritual needs of others if we ourselves are experiencing
unresolved spiritual concerns or distress. Sometimes we'll need to seek out help and support for
ourselves so that we are more able to help others.

Nursing today acknowledges that the needs of the spirit are as important as physical needs for a
person's well being. Increased awareness and preparation, together with a united approach to this
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dimension of nursing practice, will be shown to enhance the quality of our care and strengthen our
contribution to the ongoing development of our profession. Recognising and meeting the diversity of
spiritual needs in our clients will call for a person centred, flexible approach. It will also require
teamwork and unity in order to provide comprehensive, consistent and ongoing spiritual care. There
is strength in a diverse yet united approach to the challenge of spiritual care in nursing practice.

(c) Margaret G. Hutchison September 1998

RELATED LINKS...More resources for Christians in nursing

Compementary Therapies in Nursing: A Christian Perspective: - Professional Paper
Being Christ's Light in Nursing: - Article
Nursing: Yesterday & Today: - Article
Christian Nurse International Magazine: Published by NCF International
Journal of Christian Nursing: Published by NCF USA
Nurses Christian Fellowship NSW: Home Page of NCFA in NSW

http://members.tripod.com/~Marg_Hutchison/nurse1.html