Even though the Joint Commission on Accreditation of Healthcare Organizations1 (JCAHO) requires nurses to conduct a spiritual assessment and provide spiritual care to all patients, less experienced nurses may wonder how to approach patients' spiritual needs. Depending on their educational program, they may have received little guidance in identifying and addressing spiritual needs. With concerns about issues of separation of church and state, new nurses may wonder what content can be discussed during patient interactions. Furthermore, new nurses may be uncertain of how to deal with different cultural practices and religious customs, or they may feel addressing spirituality invades a patient's privacy.
How can we better mentor students and new graduates in spiritual caregiving? A study examining the effects of student characteristics and nursing education on perceived ability to provide spiritual care provides helpful answers to this question. Students (N=280) at twelve private and public nursing schools in the Midwest completed two survey instruments that assessed their spirituality, religious commitment and queried the emphasis placed on spiritual care during their education. The students also wrote a definition of spirituality and described how their view of spirituality changed since beginning their nursing education. All of the students were anticipating graduation at the end of the current semester.
As expected, the students' personal spirituality and religious commitment were the strongest predictors of their perceived ability to provide spiritual care. One student expressed this relationship, saying, "The choice of my profession has been reinforced by my spiritual beliefs and values of equality and altruism grounded in Christian faith. I have gained a deeper sense of vocation and calling in my life."
Emphasis on spirituality in nursing education also made a significant contribution to perceived ability to provide spiritual care. In public programs, spirituality received less emphasis than private religious programs where spirituality was integrated throughout the curriculum.2
To coordinate with the students' responses, faculty members were asked to indicate the percent of time devoted to spirituality in the classroom, during clinical experiences and in informal interactions with students. In both public and private programs-even those with a religious affiliation-they indicated that less than 10 percent of their time in the classroom and clinical settings included attention to spirituality. However, more students in public programs expressed dismay at the lack of content related to spirituality. The nursing faculty in public programs also expressed concern about what can be presented without promoting religion.
HOW STUDENTS DEFINED SPIRITUALITY
Student definitions of spirituality provided by 75 percent of the students in this study ranged from a simple belief in a higher power to full declarations of Christian faith. Even though 98 percent of those participating in the study identified a religious affiliation with a Protestant or Catholic church, only 31 percent included a reference to Jesus, God or the Holy Spirit as part of their definition. Twenty-six percent of the students incorporated the words higher power as some part of their definitions. One student gave examples of God or Buddha as the higher power. Another wrote: "It is much more than a religious denomination or regular attendance at a church. It's a feeling of comfort and inner peace and a strong relationship with God or a higher power; having a feeling of being a part of a greater purpose."
Inner peace without reference to a higher power was mentioned by 22 percent of the students. A student in a public program wrote, "Spirituality is being in touch with my inner self and a broader ideation of life and the world." Another student, incorporating both concepts of inner peace and God as higher power, stated: "Spirituality, if not speaking religiously, involves a sense of inner peace and belonging, that life and events have a purpose and a plan, and often a sense of relief or letting go of our burdens. For me, this means recognizing that I belong to God and recognizing where my purpose and peace comes from."
The variety of responses suggests that spirituality may have a different meaning for nurses entering the workplace than for preceptors with a Christian belief system. Certainly the role of mentor takes on greater importance in providing guidance for those less certain of their personal spirituality and religious commitment.
SUGGESTIONS FOR SPIRITUAL CARE
Since JCAHO mandates attention to spirituality, most institutions have added spiritual questions as part of the admission assessment. While obtaining a spiritual history is important, caring and listening-the gift of presence-serves as the most effective component of spiritual care. Providing attentive physical care, offering a reassuring squeeze while holding the patient's hand, meeting small requests in a positive manner all display the >love and compassion consistent with Christianity. Offering to call a chaplain or other religious leader are appropriate interventions; however the nurse may be the only one available when the patient is lonely during the middle of the night.
Even though prayer forms a component of many religious belief systems, the nurse should be aware of patients' religious practices before offering to pray for patients. Offering to pray with a patient should be approached with caution, lest this be misunderstood as forcing your beliefs on them. New nurses also need to be reassured that their role is not to give advice or try to fix a spiritual problem.
One issue of concern for new graduates is how to provide spiritual care without violating the principle of separation of church and state. The First Amendment of the U. S. Constitution mandates that the government maintain a neutral stance regarding religious beliefs and activities. This means that public institutions may not favor or support one religion over another, nor support religion over non-religion.3 However, patients are guaranteed the freedom of religious expression based on their beliefs. Therefore, what is important for nurses is respecting the beliefs of our patients-not avoiding spirituality or religion.
Since many patients choose to express their spirituality through religious practices, nurses should assess patients' spirituality and provide appropriate care.
Since each individual's spirituality is personal, the nurse can consider learning about her patients as a journey of spiritual discovery. Obvious indications of a religious belief system, such as a Bible, a rosary, crystals or other indications of religious practices, serve as prompts in asking the patient to share their personal beliefs.
The role of mentor provides an >opportunity to reflect on the spiritual care you have provided and to renew your commitment to nursing. Additionally, while serving as a spiritual care mentor, you may become aware of personal problems experienced by others. In the process of collecting information for this study, one student shared a personal spiritual struggle: "I have a lot of hate and sadness inside that needs to heal so I can move on. I love God, but my conflict is that he keeps taking those closest to me away year after year[horizontal ellipsis] Dad then Grandpa[horizontal ellipsis] I don't understand."
Christian nurses' beliefs greatly impact their understanding of spirituality. While non-Christians strive to personalize their perceptions of spirit, for Christians the Holy Spirit infuses their spirit as a precious gift of God. One way we can share that gift is effectively mentoring students and new graduates in spiritual care.