ENTRAR            

ORIGINALS

Nurses attitudes to the Spiritual and Religious Care in a General Hospital

María Socorro Morillo Martín,¹ José María Galán González-Serna,¹ Francisco de Llanos Peña^2
1Centro Universitario de Enfermería San Juan de Dios, adscrito a la Universidad de Sevilla. Bormujos (Sevilla), España. ²Facultad de Enfermería, Fisioterapia y Podología, Departamento de Enfermería, Universidad de Sevilla. Sevilla, España

Manuscript received by 6.8.2016
Manuscript accepted by 26.10.2016

Index de Enfermería [Index Enferm] 2017; 26(3): 152-156

How to cite this document

Abstract

Objective: To describe in our environment the level of knowledge about the construct internationally accepted by the nursing profession on spirituality and religiosity and attitudes towards the practice of spiritual and religious care. Methods: Quantitative, descriptive and transversal study. We have explored the knowledge and attitudes of nurses regarding the concept of spirituality and religiosity using a self-designed questionnaire. Results: We obtained 78.23% in correct knowledge and 69.84% in positive attitude towards spiritual and religious care. Conclusions: In our environment, nurses demonstrate an understanding of spiritual and religious care in tune with the construct that advocates internationally. Attitudes before this care are favorable although the need for awareness of direct accountability to them beyond the correct referral to other competent professionals is detected. It is necessary to complete the training in some aspects of the intervention.
Key-words: Holistic Nursing/ Nursing Process/ Spiritual Therapies/ Religion and Medicine.

Introduction

    The service of spiritual assistance by nurses is receiving wide spread acceptance at the international level.^1,2 Spirituality is included in nursing theories and is integrated into the nursing documentation system.^3,4 In Spain, spiritual attention in the context of holistic assistance is beginning to be taken into account.^5,6
    We understand spirituality as "the aspect of the human condition that refers to the way individuals seek and express meaning and purpose, as well as the way they express a state of connection with the moment, with oneself, with others, with nature and with the meaningful or sacred".⁷ Religion is a personal experience that gives rise to an organized system of beliefs, practices, rituals and symbols that characterize a community in the collective sphere.^8,9 Religion is believed to be composed of three dimensions:⁷ a cognitive one, in relation to religious beliefs; another behavioral that includes religious and ritual, institutionalized or conventional behaviors; and the affective, which corresponds to the links between man and transcendency.¹⁰
    Spirituality conceptually possesses an area shared with religion as it includes a search for and discovery of the transcendent, as with religiosity, although in the case of spirituality it may imply religious beliefs or not.¹¹ Besides, the words spirituality and religiosity when referring to the transcendent experience are usually interchanged in our environment.^10,12
    Although spiritual care is an integral part of nursing care, its provision is very diverse and may be influenced by the personal, cultural and educational needs of each nurse.¹³ However, all professionals should be alert, sensitive and prepared to recognize spiritual anxiety, evaluate it and attend or refer to it.^7,14 Therefore, it is necessary to promote training and nurse performance in this care setting. In Western Andalusia, it has been argued that this dimension is weakly integrated into the nurses' imaginary about care in the dying process.¹⁵
    The aim of this study is to describe the degree of knowledge about the internationally accepted construct in our medium by the nursing profession on spirituality and religiosity as well as the attitudes towards the nursing practice of spiritual and religious care.

Methodology

    It is a descriptive and cross-sectional study. The study sample was for convenience and has been collected through a survey among the nurses of the Hospital San Juan de Dios del Aljarafe, which serves a region of 250,000 people in the province of Seville (Spain). The total population, constituted by the nurses on the staff of the afore mentioned Hospital was 184. Of these, 128 agreed to participate in the study. The surveys were answered voluntarily and anonymously. The study period was from December 2015 to May 2016.
    Nurses' knowledge and attitudes regarding the concept of spirituality and religiosity were examined using a self-designed questionnaire consisting of 30 items scored on a Likert scale. The items were selected from among those which an internationally accepted construct of spirituality and religiosity gathered and consists of three groups, a first group of 15 items (of which 6 are proposed in the opposite direction), based on the Spirituality and Spiritual Care Rating Scale modified by us and examines knowledge, another group of five items (of which 2 are proposed on the opposite way) based on the work of Puchalski et al., examines attitudes about the role of the nurse, and the third group of 10 items selected among the Nursing Interventions Classification (NIC), that explores the attitudes of nurses to the practice of spiritual and religious care.^7,16 Their theoretical construct has been validated through a board of experts in order to verify their adequacy to our Spanish context. Cronbach's alpha was 0.764 for the 30 items.

Results

Of the 128 nursing professionals who participated, 30 (23.40%) were men and 98 (76.60%) were women. The mean age was 34.61 years (SD 7.436), with an age range between 22 and 60 years. The mean number of years of professional practice was 11.34 (SD 6,786) with a range between 1 and 34 years. Regarding their experience in palliative care, 54 (42.20%) reported having no experience in this area of care and 74 (57.80%) declared as having experience.
    78.23% was obtained in the correct knowledge score [Table 1] and 69.84% in a positive attitude towards spiritual and religious care [Tables 2 and 3]. Among these, 68.91% of the positive attitude regarding the role of the nurse in regard to spiritual and religious care was obtained [Table 2] and 70.31% regarding the attitude about the nursing interventions for spiritual and religious care [Table 3].
    In regard to knowledge of the spirituality and religiosity construct [Table 1], the traits accepted by most of the nursing professionals surveyed included a personalized understanding of spirituality (98.44%) and intensely lived individually (47.66%). The word religiosity was linked to the beliefs in a God or Supreme Being as well as to the practices and standards of approaching Him (77,35%). It was understood that spirituality and religion are not the same issue (67.19%). In fact, spirituality was not necessarily related to belief in God or a Supreme Being (76.56%), nor mainly to places of worship (88.28%), so that spirituality care was considered applicable to atheists and agnostics and was related with life transcendence(88.28%), with art, creativity, free expression (75.00%) as well as with ethics and morality (85.16%). Spirituality and religiosity are related to the growth of personal friendships and other interpersonal or social relationships (49.22%), and the need to forgive and be forgiven, to feel at peace with ourselves and others (71.09%). It was considered that "in practice, spirituality and religiosity impel individuals to face difficult life situations, seeking answers about the meaning and purpose in life" (96.09%) and that "spirituality is a force that allows each person to be in harmony within, in peace with oneself, with others and with the world, cosmos and eternity" (93.75%). It was also considered that spiritual and religious well-being is important for the emotional well-being of a patient (90.63%).
    Regarding the understanding of the Nurse's Role in Spiritual and Religious Care [Table 2], most of the respondents expressed the conviction that excellent care provides spiritual well-beingto the patient (92.18%), that this care must be provided by a multi-professional team approach (85.94%), and that the nursing professional should explore spiritual and religious needs and plan their care adequately (64, 06%). Disagreement was expressed with the role of nurses in providing religious care that consists solely in facilitating the intervention of the patient's chaplain, pastor or religious adviser if requested (57.03%). Neither is it understood, although not mainly, that it should be nurses who are more aware of their own spirituality or religiosity who should provide spiritual and religious care rather than nurses who do not have that awareness of their own spirituality or religiosity (45.31%).
    In relation to attitudes about the practices of the Nursing Competences for Spiritual and Religious Care [Table 3], the professionals surveyed showed favorable attitudes towards identifying spiritual and religious needs and use this knowledge to evaluate and provide spiritual and religious care (48.44%), to provide adaptation of the environmental setting for self-reflection (85.16%), to be available to actively listen to expressions of spiritual suffering (97.66%), to use communication techniques to help them clarify their values, beliefs and reasons for hope (53.13%), to encourage interpersonal relationships (89.85%), to teach methods of relaxation, meditation and guided imagery (39.84%) to provide the patient with music, literature or radio or TV programs to their liking (74.22%), to refer to the spiritual/ religious adviser according to demand (83.60%), to help the patient pray, if needed (63.28%), to facilitate the practice of religious and/or spiritual traditions and rituals (67.97%).

Table 1. Dimension A. Knowledge of the Spirituality and Religiosity Construct

Elaboration based on the modified Spirituality and Spiritual Care Rating Scale16. Note: Items 2, 3, 4, 9,11 and 12 are written the opposite
direction to what is desired to be measured

 Table 2. Dimension B. The role of the nurse regarding spiritual and religious care

Elaboration based on modified Puchalski C et al.7,. Note: Items 2 and 4 are written in the opposite direction to what is to be measured

Table 3. Dimension C. Nursing interventions for spiritual and religious care

Elaboration based on the modified Nursing Interventions Classification (NIC)

Discussion

Nurses have been criticized for underestimating the spiritual dimension in care and several factors have been proposed that explain this limitation, such as lack of awareness of their importance and lack of preparation; a misinterpretation of the term spirituality; the lack of willingness to offer spiritual attention.¹⁷ These difficulties partly contrast with the results of this study.

Concept of spirituality and religiosity. 90.63% of the participants considered that spiritual and religious well-being is important for the emotional well-being of a patient and 88.28% of them stated that spirituality care is applicable to atheists or agnostics, in addition to believers in a religion. This data supports the inclusion of 27.5% of the Spanish population who are considered agnostic or atheist.¹⁸ In addition, it supports the integration of spirituality and religiosity into the concept of holistic health care advocated by the World Health Organization¹⁹ and the International Council of Nursing.²⁰
    Given the absence of comparable Spanish studies to ours, we do so with a European study.¹⁶ Thus, some conceptual differences between Spanish and British nurses have been identified. Of these, 76.56% of the professionals surveyed state that "spirituality does not necessarily have to do with belief and faith in a God or Supreme Being," while McSherry only found it in 31.60%. 96.09% state that "in practice spirituality and religiosity drive individuals to face difficult life situations by seeking answers about the meaning and purpose in life" while McSherry found 69.30%.

71.09% stated that "spirituality and religiosity have to do with the need to forgive and the need to be forgiven, to feel at peace with ourselves and with others while McSherry found this to be 41.80%. These conceptual differences can be explained by cultural differences between groups and individuals²¹ from different countries, as well as by the different nuances that have been theoretically described in the understanding of the spirituality and religiosity construct.⁷ To better understand the influence of culture in the understanding of this construct, it should be explored more thoroughly in different territories and professional groups in our country.
    On the other hand, beyond the above-mentioned differences, the results show that some aspects conceptually related to spirituality are similarly understood in this Spanish study and the one carried out by McSherry in Great Britain.¹⁶ Thus, only 3.13% points out that "Spirituality does not include areas such as art, creativity and free expression" while McSherry found 9.90%; only 3.13% affirm that "The care of spirituality is not applicable to atheists or agnostics", while McSherry found that 9.20% did not believe that either; only 8.59% stated that "Spirituality and religiosity do not include the ethics and morals of people," while McSherry found this to be 15.70%.

Role of the Nurse in Spiritual and Religious Care. Participants in the study accept that excellence in nursing care provides spiritual well-being to the patient (92.18%) and that this care must be provided by a multi-professional team (85.94%). However, despite this fact together with that spiritual suffering can be detrimental to patients' health,^22,23 and consequently, the nursing professional must play an active role in satisfying their spiritual needs,^24-26 in this study, the commitment to assume this active role reaches a moderate support, of 64.06%, by the participants. In other studies, the involvement of nurses has also proved to be insufficient, even to a greater degree.²⁷
    On the other hand, the results show a high acceptance to refer to the chaplain or religious adviser, which, in itself, may be adequate and related to the fact that the majority of the Spanish population declares themselves to be of the Catholic religion (67,80%),¹⁸ and that the immediate availability of Catholic chaplains in public hospitals is guaranteed by Church-State agreements.²⁸ Such a referral to the Catholic chaplain or another spiritual or religious counselor should be performed with the patient's consent or explicit request but it should not mean the inhibition or withdrawal of the nurse, so coordination is required in the provision of such care as this must be multi-disciplinary.⁷
    Moreover, it is of some relevance for the group surveyed to prioritize the performance of this care by especially vocational nurses, as in other studies, which have shown that the nurse's own spirituality and attitudes in care are predictors of spiritual attention.²⁹ Possibly, when applying spiritual and religious care, it may be especially relevant to distinguish between the degree of personal involvement, by virtue of one's own values or beliefs, and the professional obligation to respond to a universal right of the patient.³⁰
    Both issues, the active involvement in this care and its implementation independently of personal beliefs or values, require a certain adjustment in our environment, which could be achieved by encouraging greater awareness and practical training of all professionals towards this care.

Practices of Nursing Competencies for Spiritual and Religious Care. The attitude towards interventions in spiritual and religious care was favorably considered in the generality of the items, although some actions more clearly assumed and scored with more than 80% of the possible total, such as the predisposition to listen actively to expressions of spiritual suffering, promoting interpersonal relationships, adopting a peaceful environment, and referral to the chaplain or spiritual/religious adviser on demand. These attitudes are essential for spiritual and religious care, and systematically integrated into the general care plans of patients.
    However, other non-punctual interventions are precisely those that are more specific, such as teaching methods of relaxation and meditation, identifying needs and designing care plans in this area, using communication techniques that generate hope, helping the patient to pray, facilitate the practice of religious or spiritual traditions and rituals or provide the patient with music, literature or audiovisual programs to their liking. This lower acceptance may be motivated by lack of time, professional skills to perform them or lack of motivation, and coincides with other studies in which it is considered as a training objective for nurses to increase their competencies in the detection and management of these needs and their incorporation into professional practice.²⁷
    To ensure in the future that each nurse has an adequate competence in spiritual care, nursing educators should be encouraged and helped to teach and choose methods that promote the integration of the necessary knowledge and skills, including the capacity for self-reflection in both theory and practice.³¹ Specific education that includes reflection on one's own life experiences leads the nurse to be able to be more responsive to the patient.³²
    The study has some conditioning factors. The hospital where it has been performed is of a public nature and is managed by the Hospital Order of San Juan de Dios, which expressly promotes a model of holistic care,³³ which probably influences the care system and the mentalization of nursing professionals on the importance of Spiritual and Religious Care. It may be conceivable that in most hospitals in the public network, if they were managed differently, they would yield different results.
    In conclusion, we can point out that in our country, nurses demonstrate an understanding of spiritual and religious care in harmony with the construct that nowadays is mainly advocated both in our Spanish environment and in Europe and the United States. The nurses' attitudes towards this care are favorable, although the need to be aware of the specific responsibility in this respect has been detected. It is necessary to complete the training, in some aspects,of the intervention such as the identification of spiritual and religious needs, the use of techniques to help the individual to clarify their beliefs and values, their areas and reasons for hope in life as well as the value for the patient and family to practice methods of relaxation, meditation and guided imagery.

References

1. Rothman J. Spirituality: what we can teach and how we can teach it. J. Relig. Spiritual. Soc. Work. 2009; 28 (1-2): 161-84.
2. International Council of Nursing. The ICN Code of Ethics for Nurses. 2012. Disponible en https://www.icn.ch/images/stories/documents/about/icncode_english.pdf [acceso: 17/11/2014].
3. Harding RH, Bishop SM. Logical reasoning. In Nursing Theorists and Their Work. 7th ed. En Alligood MR, Tomey AM (eds). Maryland Heights MO: Mosby Elsevier. 2010; p. 26-49.
4. Herdman TH, editora. NANDA International. Diagnósticos enfermeros: definiciones y clasificación 2012-2014. Madrid: Elsevier, 2013.
5. Grupo de Trabajo de la Guía de Práctica Clínica sobre Cuidados Paliativos. Guía de Práctica Clínica sobre Cuidados Paliativos. Madrid: Plan Nacional para el SNS del MSC. Agencia de Evaluación de Tecnologías Sanitarias del País Vasco; 2008. Guías de Práctica Clínica en el SNS: OSTEBA Nº 2006/08.
6. Payás Puigarnau A, Barbero Gutiérrez J, Bayés R. ¿Cómo perciben los profesionales de paliativos las necesidades espirituales del paciente al final de la vida? Med Paliat. 2008; 15 (4): 225-37.
7. Puchalski C, Ferrellb B, Viranib R, OtisGreenb S, Bairdb P, Bull J et al. La mejora de la calidad de los cuidados espirituales como una dimensión de los cuidados paliativos: el informe de la Conferencia de Consenso. Med Paliat. 2011; 18 (1): 55-78.
8. Quinceno MJ, Vinaccia S. La salud en el marco de la psicología de la religión y la espiritualidad. Divers Perspect Psicol. 2009; 5:321-36.
9. Rivera-Ledesma A, Montero-López Lena M, Ejercicio clínico y espiritualidad; An Psicol. 2007; 23: 125-36.
10. Sandoval Guzmán PE, Rangel Domínguez NE, Allende Pérez SR, Ascencio Huertas L. Concepto de Espiritualidad del Equipo Multidisciplinario de una Unidad de Cuidados Paliativos: un Estudio Descriptivo. Psicooncología 2014; 11 (2-3): 333-44.
11. Koenig HG, D. E. King DE, Carson VB. Handbook of Religion and Health 2nd edition. New York, NY, USA: Oxford University Press, 2012.
12. McSherry W, Cash K, Ross L. Meaning of spirituality: implications for nursing practice. J Clin Nurs. 2004 Nov; 13(8): 934-41.
13. Van Leeuwen R, Tiesinga LJ, Post D, Jochemsen H. Spiritual care: implications for nurses' professional responsibility. J. Clin. Nurs. 2006; 15: 875-84.
14. Muñoz Devesa A, Morales Moreno I, Bermejo Higuera JC, Galán González-Serna JM. La Enfermería y los cuidados del sufrimiento espiritual. Index de Enfermería 2014; 23(3):153-6.
15. Ortega Galán AM, González de Haro MD. El valor de la dimensión espiritual en el final de la vida desde la perspectiva de los profesionales de enfermería. Med Paliat. 2016; 23(2):93-8.
16. McSherry W, Draper P, Kendrick D. Construct validity of a rating scale designed to assess spirituality and spiritual care. Int J Nurs Stud. 2002; 39: 723-34.
17. Cadge W, Ecklund EH, Short N. Religion and Spirituality: A barrier and a bridge in everyday professional work of Paediatric Physicians. Social Problems 2009; 56: 702-21.
18. Centro Investigaciones Sociológicas de España. Estudio 3146 Barómetro de julio de 2016. Disponible en https://www.cis.es/cis/opencms/ES/NoticiasNovedades/InfoCIS/2016/Documentacion_3146.html [acceso: 04/09/2016].
19. WHOQOL SRPB group's. A cross-cultural study of spirituality, religion, and personal beliefs as components of quality of life. Social Science & Medicine 2005, 62(6):1486-1497.
20. Consejo Internacional de Enfermeras. Código Deontológico del CIE para la profesión de Enfermería [Monografía en Internet]. Ginebra. CIE; 2012. Disponible en https://www.icn.ch/images/stories/documents/publications/free_publications/C%C3%B3digo%20del%20CIE%202012%20web.pdf [acceso: 30/12/2012].
21. Albarran J, Rosser E, Bach S, Uhrenfeldt L, Lundberg P, Law K. Exploring the development of a cultural care framework for European caring science. Int J Qual Stud Health Well-being 2011; 6(4). doi: 10.3402/qhw.v6i4.11457.
22. Koeing HG, Larson DB, Larson SS. Religion and coping with Serious Medical Illness. Ann Pharmacother. 2001; 35: 352-59.
23. Baldacchino D. Spirituality in Illness and Care. Veritas Press: Malta, 2003.
24. Taylor B. Nursing as healing work. Contemp Nurse. 1995; 4: 100-6.
25. Wright KB Professional, ethical, and legal implications for spiritual care in nursing. Image. J Nurs Scholarship, First Quarter. 1998; 30: 81-3.
26. Speck P. The evidence base for spiritual care. Nursing Management. 2005; 12: 28-31.
27. Mesquita AC, Costa Valcanti Avelino C, Neves Barreto M, Alves Nogueira D, Souza Terra F, Cássia Lopes Chaves E. El bienestar espiritual y la prestación del cuidado espiritual en un equipo de enfermería. Index de Enfermería 2014; 23(4), 219-23.
28. Convenio entre la Consejería de Salud de la Junta de Andalucía y la representación de los Obispos de Andalucía para la asistencia religiosa católica en los Centros Hospitalarios de la Red pública integrada de Andalucía. Boletín Oficial de la Junta de Andalucía, 17.03.1987;22: 845-846.
29. Rafii F, Oskouie F, Nikravesh M. Factors involved in nurses' responses to burnout: a grounded theory study. BMC Nurs. 2004; 3: 6.
30. Royal College of Nursing. RCN spirituality survey 2010. London: RCN; 2011.
31. Giske T. How undergraduate nursing students learn to care for patients spiritually in clinical studies: A review of literature. J Nurs Manag. 2012; 20(8): 1049-57.
32. Cockell N, McSherry W. Spiritual care in nursing: an overview of published international research. J Nurs Manag. 2012; 20: 958-69.
33. Fernandes de Freitas G, Siles González J. Antropología y cuidados en el enfoque de San Juan de Dios. Index de Enfermería 2008; 17(2): 144-148.