Hospice nurses must provide spiritual care
Address with organized nursing approach
A hospice nurse goes about her business of providing care when her patient suddenly ponders out loud: "Is this all there is? Or is there something beyond this life?"
In the few seconds it takes the nurse to digest the depth of the patient’s query, she is unable to come up with a response. Instead, she turns the conversation to more mundane matters.
Perhaps she quashed her patient’s spiritual yearnings because she felt she wasn’t qualified to discuss such lofty matters. Or maybe she didn’t want to impose her own religious beliefs on her patient. Or perhaps she didn’t want to tread on the domain of the chaplain.
Whatever the reason, the nurse missed a golden opportunity to help her patient sort through spiritual questions that may be standing in the way of a peaceful death. Whether they want to believe it or not, hospice nurses have the responsibility of helping patients fulfill their spiritual needs, says Joanne Sheldon, MEd, RN, CRNH, educational coordinator at the Hospice of the Western Reserve in Cleveland.
A lack of training
But nurses often neglect or ignore this responsibility because they feel ill-qualified, that matters of the spirit are the responsibility of chaplains, or they don’t have a spiritual identity of their own. Probably most important is their lack of spiritual training.
"I think many nurses come out of nursing school unable to address spirituality because they have no training," Sheldon says. "It’s an intimate topic so you can understand how they don’t know how to respond."
But Sheldon stresses that nurses must learn to overcome their lack of training and their self-professed inadequacies so that they can address the spiritual needs of their patient. But clinical habits are hard to shake, and many nurses may still find it hard to break out of the mold of providing care from a clinical approach. So rather than remove nurses from their comfort zone, Sheldon said nurses can address spiritual needs using a nursing approach.
"Nurses are very used to using a process," she says. "These are people who are very organized."
Five phases of care
Sheldon breaks this process spiritual care into five steps:
1. Assessment. Like clinical matters, nurses should assess the spirituality of their patients. Nurses need to learn how to observe the spiritual and religious habits of their patients. For example, look for religious symbols around the house, or the lack of them, to help to determine the level of spirituality the patient has.
To assess a patient’s spirituality, nurses should conduct interviews with both the patient and caregivers. Assessing a patient’s spirituality should also include listening for clues that the patient is yearning for some spiritual understanding. "They need to listen to what the patient is saying so that they can prompt the patient to go to deeper reflection of spirituality. Other important items to note assessing spirituality are family relationships that might affect the patient’s perception of lofty matters.
Ingleside Skilled Nursing and Rehabilitation Center in Mount Horeb, WI, uses a spiritual assessment tool that congruent with the minimum data set (MDS 2.0) to help determine spiritual needs. (See Hospice Management Advisor, February 1999, pp. 17-19.) The assessment tool includes a list of questions regarding faith and religion and section for recommended care plan.
2. Analysis. Once the nurse has collected the needed information about the patient’s spiritual status, such as religious beliefs, church attendance, and caregivers’ religious leanings, it is time to gauge the patient’s spiritual needs. While it is not the nurse’s job to solely interpret the data, her observations and input are key in helping the interdisciplinary team, including the hospice chaplain, to determine the direction spiritual care should take.
3.Planning. Once the interdisciplinary team has identified specific needs, it will develop a plan that members of the team, including the nurse, will help implement. Just as the team would develop a plan based on a clinical diagnosis, a spiritual care plan should include specific goals, objectives, the nurse’s involvement in the plan, and specific interventions that will be used to achieve each goal.
Sheldon uses the example of an elderly woman who told her nurse that she felt abandoned by the Catholic Church because 50 years ago she married a Protestant and the church did not recognize their marriage. Although the nurse did not completely understand the nature of the woman’s spiritual conflict, she addressed the woman’s concerns at the next team meeting, where the chaplain explained the dilemma the woman was in. Before she died, she wanted to be reconnected to her faith and wanted her marriage to be blessed by the Catholic Church.
The chaplain also explained that church rules had relaxed in the five decades since the elderly couple had been married. The nurse and chaplain devised a plan that called for the woman and her husband to be married again, this time with a priest officiating the ceremony. "Once the nurse recognized a need for spiritual care, a plan was devised and the patient felt at peace with God when she died," Sheldon recalls.
Spirituality vs. religion
4. Implementation. Carrying out a spiritual care plan calls for the nurse to be involved in getting the patient to open up and begin reflecting on spiritual matters. Sheldon advises that nurses approach this aspect with great flexibility. The approach will be unique to each person. In addition, she warns nurses not let their own beliefs effect their approach. For instance, they should be aware of the difference between spirituality and religion. Instead, nurses should focus on listening, empathy, along with prayer and religious rituals.
5. Evaluation. Just as any health care provider would assess the performance of its clinical actions, hospices should evaluate outcomes of the spiritual care that was given. Staff need to look back at the plan and its implementation and gauge the success or ineffectiveness of each plan, including whether the goals of the plan were met. The hospice and its nurses should also be prepared to make adjustments in their approach to spiritual care when poor outcomes warrant it.
Because nurses are often the professional in contact with the patient the most, it is important that they understand why their role as spiritual caregiver is important. To begin, terminally ill patients have a number of needs that are intertwined with matters of the spirit.
Filling needs
Specifically, terminally ill patients’ spiritual needs are as follows:
• Freedom to discuss their spiritual needs. Because nurses are in direct contact with the patient and a relationship develops, the patient may feel the nurse is the best person to express their spiritual concerns.
• Knowledge about the dying process. It is routine for nurses to explain the dying process with their patients. Patients, however, may ask how spiritual matters relate to the process.
• Preparation for dying process. Again, nurses help prepare the patient physically and emotionally for death. It is likely, the patient will want to include spirituality into his or her preparation.
• Family and caregiver relationships. Because of the unique relationship the nurse has with the patient and family, the nurse will often have to help resolve spiritual issues between them, including explaining to family members that their religious beliefs cannot be imposed on the patient.
• Forgiveness and reconciliation. Nurses need to help delve into spiritual matters to help solve unresolved guilt or broken relationships.
• Need for hope. The dying patient is not only looking for care in his or her final days, but hope in whatever lies ahead of them after death.
• Spiritual pain. Nurses should be the first to notice whether a person is suffering spiritually and make the first attempts to start a dialogue so that the team can come up with a plan of care.
So, how does a nurse address those needs? It is through their presence, answers Sheldon. Listening at first, showing empathy, understanding the patient’s vulnerability and the nurse’s approach of humility that begins to break down the barriers that surround spiritual contentment.
Sheldon says hospices nurses are not strangers to those concepts. They understand the need for spiritual care, but often take the easy route by simply asking if they would like to speak with the chaplain.
"It really helps to be reminded or to review their responsibility to provide spiritual care," she says. "We always need to keep learning."
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