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The concept of spirituality in nursing is deeply rooted in the history of our profession, yet it's often overlooked in nursing practice.1 Nursing education describes spiritual care as a necessary component in the holistic care of clients.2-4 This component of holistic care is also required by The Joint Commission, and the North American Nursing Diagnosis Association addresses the importance of spirituality.5-9
Nursing research demonstrates the positive effects of spirituality on health, well-being, and life satisfaction.8,10-15 Through spiritual care interventions, patients find a sense of peace and well-being in times of stress, sorrow, pain, and illness. Patients with a sense of meaning and purpose survive more readily during difficult circumstances, including illness and suffering. Providing holistic care that includes spiritual care can create better health outcomes and improve coping mechanisms.
Despite its positive effects, spirituality remains a neglected area of nursing care. Nurses today are uncomfortable in providing spiritual care for their patients for several reasons: nursing is too biologic; professionalism is synonymous with distancing; more emphasis is placed on technology than holistic care; and nurses may be uneasy about their own spirituality.16-18 Additional barriers include time constraints, lack of education, lack of clarity between religion and spirituality, the presence of multifaith patients and nurses, and the lack of guidance from nurse leaders.
Because nurse leaders influence policy development and patient care practices, it's important for us to accept some responsibility for integrating opportunities for spiritual care into nursing practice.19 Nurses enter the healthcare profession to lead a life of significance; we, as nurse leaders, can support that mission.20 We can make a difference by creating caring communities. By fully understanding the benefits of spiritual care as a necessary component of holistic care, we can advocate for spiritual care in nursing through policy development and education.
Spirituality is complex. Many definitions contain the concepts of personal meaning, values and beliefs, transcendence, or connectedness.18 Spirituality can mean different things to different people, but often, spirituality is considered synonymous with religion. Nurses can provide spiritual care for their patients without addressing religious needs, but religious tolerance and awareness is an important factor in the spirituality equation.18
Spirituality is derived from a Latin term meaning breath of life.10 The word spirit is often used in colloquial language to define an individual's behavior: being in good spirits or highly spirited, having an indomitable spirit or lost spirit, or losing the will to live.21 These common colloquialisms serve as simple spiritual identifiers and reflect the spiritual well-being or distress of people. Spirituality often includes religious experiences, but spirituality has a much broader perspective. Spirituality is highly individual: how one defines comfort, peace, and hope; the things that bring joy and pleasure; or the important things in life.21
The nurse leader's role in the provision of spiritual care for hospitalized patients depends on several factors, but the ultimate goal can only be achieved when we embrace the need for spiritual care and infuse that attitude and value into those we lead. Roles are associated with social positions.22 A social position is an identity that generates a set of commonly recognized behaviors. A role is an expected pattern or set of behaviors associated with a particular position or status.23 Roles carry certain behavioral expectations from the larger social system in which the role is embedded. Nurse leaders, nurses, and unlicensed assistive personnel each have their own unique roles that are different from each other based upon their educational preparation and job descriptions.
Three factors are needed to define a specific role: expectations, conception, and performance.24Role expectations are the attributes that members of an organization (role set) believe an individual (role occupant) will display. Role conception is how the role occupant defines the role. Role performance is the observable, day-to-day social behaviors and specific tasks executed by the role occupant in order to accomplish the department goals. Job descriptions, rules and regulations, professional trends, and personal needs, traits, values, and skills influence the nurse leader's role.25Figure 1 demonstrates the process of role theory in nursing leadership.
Several factors affect role performance. Role conflict exists when incompatible roles are projected onto the role occupant. In meeting one set of expectations, the role occupant is unable to meet the expectations of another group.26 The benefits of providing spiritual care for patients are well documented in the literature, but often remain a neglected component of nursing care. Through the development of spiritual care policies, nurse leaders can create communities where daily work takes on deeper meaning and satisfaction, for both nurses and patients, by creating common values and a shared sense of purpose.
Role overload exists when the demands of a particular role exceed the role occupant's capacity to perform the role. The role occupant may comprehend the nature of the requirement, but lack the time, skill level, or education to perform the requirements.26 The barriers to providing spiritual care for patients are also described in the literature. In order to acquire a comfort level for providing spiritual care interventions, nurses need more education and training. As nurse leaders, we can arrange that training.
The cultural climate of an organization frames and shapes the behaviors of its employees.25 Culture refers to the underlying assumptions and values that explain why things happen the way they do in organizations. This includes a commitment to the organizational mission and goals, shared values and a sense of purpose.
Role engagement occurs when the role occupant fully understands his or her role and the activities required for fulfilling that role.27 By embracing the importance of spiritual care, we can create organizational climates that foster holistic patient care. Figure 2 demonstrates the factors that affect role performance.
The intent of our study was to provide an understanding of the nurse leader's role in the provision of spiritual care for hospitalized, medical-surgical patients, and the factors that affect that role (Table 1). Role theory was used to guide research questions. Ten nurse leaders from four northern California nonfaith-based community hospitals were purposely selected to participate. A grounded theory design was used to explain the process of events, activities, and actions that surround nurse leaders in their role of providing spiritual care for hospitalized patients. This approach allowed for the interpretation of data through ID and coding of themes, concepts, processes, and contexts in order to build explanations or theories.28
One purpose of grounded theory research is to generate a theory that explains a process.29 Three types of nurse leaders participated in the study: managers, directors, and supervisors. The following research question provided the foundation for this study: How do nurse leaders perceive their role in the provision of spiritual care for hospitalized patients? The concepts of role theory guided the interview questions, subquestions, and probing questions in order to explore the role perceptions of the nurse leaders (Table 2).
Prior to data collection, a trustworthiness plan was developed to ensure the credibility, transferability, dependability, and confirmability of the collected data and subsequent findings. The interviews were taped and transcribed, then analyzed using a software program designed for qualitative data analysis. Data saturation occurred after eight participants; two additional interviews were conducted to ensure saturation. No new information was revealed by the additional participant responses. The findings revealed themes and core categories for each research question and subquestion.
Findings revealed in this study offer meaningful insight regarding the perceptions that nurse leaders have about their role in the provision of spiritual care for hospitalized, medical-surgical patients. Both internal and external factors that affect the nurse leader role were identified.
Providing spiritual care. The majority of the participants interviewed perceived spiritual care as religious and pastoral visits as the primary intervention. Participants believed that providing spiritual care as a comfort measure was the primary benefit to patients, but most participants were unaware of any existing holistic or spiritual care policies in their department. These findings indicate that nurse leaders perceive spiritual care as a religious activity that's comforting when performed by a faith leader, and there are no written policies to guide them or their staff in providing holistic or spiritual care for their patients.
Influencing the provision of spiritual care. Most of the participants perceived no influence from their supervisor or job description to guide their role in the provision of spiritual care, and most were unaware of The Joint Commission guidelines related to spiritual care. They did acknowledge holistic care as a professional trend that might influence their role. These responses explain the internal and external factors that affect the nurse leaders' role in providing spiritual care for patients.
Explaining role conflicts. The majority of the participants reported feeling uncomfortable providing spiritual care for patients, but thought their staff was comfortable providing this care. These responses reveal the lack of role clarity; nurse leaders are unable to advocate for spiritual care if they lack understanding and direction themselves.
Describing other factors that affect role engagement. Most of the participants received no previous education on spiritual care for patients, but thought their staff had attended hospital in-services. These responses contribute to the lack of understanding and preparation. Without role engagement, nurse leaders can't adequately ensure the provision of spiritual care for hospitalized patients. Figures 3 and 4 demonstrate the internal and external factors.
These findings suggest that spiritual care for hospitalized patients isn't provided because nurse leaders are inadequately prepared to direct that care. Three different types of nurse leaders participated in this study and none of them could provide a clear definition of spiritual care. Providing spiritual care interventions wasn't an expectation for them or their nursing staff, and most of the participants reported no previous education on spiritual care. These findings support a lack of role engagement.
This study identified the internal and external factors that affect the role of nurse leaders in the provision of spiritual care for hospitalized, medical-surgical patients. The findings revealed the ill-prepared nature of 10 nurse leaders in similar roles. Lack of understanding, guidance, and education were all contributing factors to their lack of role engagement pertaining to spiritual care provided in their departments. This study was limited by a small sample size, homogeneity of population, and geographic location. To validate the findings of this study, data collection could be expanded to include a larger sample size, more hospitals, different patient populations, and other geographical locations.
Our role as nurse leaders is to ensure the provision of quality patient care by a competent nursing staff, and we're in a position to influence nursing staff through policy development. The Joint Commission guidelines and professional nursing trends advocate for holistic patient care that includes spiritual care interventions. One effort to improve the quality of patient care in most hospitals is the use of patient satisfaction surveys. Often these surveys are conducted by outside organizations and the results are publicly reported locally, regionally, or nationally.
Public reporting provides the kind of information that consumers value and creates further incentives for hospitals to focus on patient satisfaction. Providing holistic care that includes spiritual care interventions considers the health needs of individuals as integrated persons rather than as a biological systems; nurses focus on the patient as a whole, not just the individual's disease. Holistic care processes forge better relationships between nurses and their patients and, therefore, improve patient satisfaction.
Findings revealed in this study suggest that the role of the nurse leader in the provision of spiritual care for hospitalized patients is inadequate. Nurse leaders who participated in this study weren't prepared to direct that care. Four recommendations were made to improve the nurse leaders' actualization of their part in providing spiritual care for hospitalized patients:
1. Include spirituality in leadership training. The benefits of spiritual care for hospitalized patients should be stressed, and the state and federal guidelines related to spiritual care should be reviewed. Nurse leaders can achieve role engagement through proper training and education.
2. Encourage staff. Spiritual care should be included in routine patient care. Nurse leaders have the ability to influence policy development and patient-care practices, and can make a difference by creating caring communities. Providing spiritual care can strengthen the nurse-patient relationship and improve patient-care outcomes.30
3. Advocate for a spiritual assessment tool. Numerous spiritual assessment tools can be found in the literature and should be used to assess the unique needs of all patients.31 See Table 3 for examples of spiritual assessment questions suggested by The Joint Commission. Based on the spiritual assessment concepts discussed in the literature, an assessment tool was developed using the mnemonic FAITH. This simple tool can be used to prompt nurses to inquire about the patient's sources of support, important affiliations, consequences related to the current illness, and treatment concerns. By engaging in this dialogue, nurses can discover ways to support patients during the hospitalization period. In forming this connectedness with patients, nurses are meeting the holistic and spiritual needs of patients (Table 4).
4. Include spiritual care education in nursing orientation. Discuss department policies related to holistic and spiritual care, and review the spiritual assessment tool. Provide new nurses with the expectation that spiritual care is a requirement of routine patient care. This will also emphasize the importance of spiritual care as a necessary component of holistic care.
By embracing the benefits of spiritual care as a necessary component of holistic care and being aware of professional regulations related to spiritual care, staff nurses will become better prepared to provide spiritual care to their patients. These efforts will improve patient-care practices and ultimately increase patient satisfaction.
Through proper leadership training and staff development, and by creating the necessary spiritual care policies and competencies, we, as nurse leaders, can effectively engage our role in the provision of spiritual care for hospitalized patients. The findings of this study support the role significance of nurse leaders.
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