Ebook Oxford textbook of spirituality in healthcare: Part 2

CHAPTER30
Nursing
WilfredMcSherryandDrLindaRoss

Introduction
This chapter presents an overview of the historical and contemporary
development of spirituality and spiritual care within nursing. The chapter
commenceswithahistoricalperspectiveofnursingcaredrawingattentiontothe
medicalandholisticmodelsthathaveexisted.Thisisfollowedbyananalysisof
the key arguments that provide a basis for spiritual care within nursing. This
sectionreviewssomeoftheprimarydrivers;political,professionalandsocietal,
resulting in nursing engaging with spiritual aspects of the person. It is
acknowledged that the concepts and debates outlined in this chapter have a
relevance to nursing globally. There is an increasing recognition of the
importance that the spiritual part of an individual's life may make to health,
wellbeing,andrecovery.Asignificantevidencebasetosupportthisisemerging,
for example thepioneering workofKoenigetal.[1] The importance of nurses
addressing the spiritual dimension is also reflected in some of the healthcare
guidanceatworld,European,andnationallevels.Theseissuesarediscussedin
moredetailinRoss.[2]

Historicalperspective
Historically,intheWestthesickwerelookedafterinreligiousorders.Thebody
andspiritwerecaredfortogether,signifyingthepracticeoftrulyholisticcareat
thattime,i.e.careofthebody,mind,andspirit,wherethewholeismorethanthe
sumoftheparts.Therethenfollowedthe‘periodofenlightenment’,withallthat
broughtwithit,includinganescalationinmedicalresearch,andknowledgeand
prevalenceofamedicalmodeloftreatmentwhichfocusedondiseaseprocesses
andcures, rather thanthespirit.Thismedicalmodelstillprevailstodaywithin
manyhealthcareservicesacrosstheworld.However,itcouldbesaidthat,until
recently,nursinghasneverlostsightoftheholisticconceptofcare,whichhas

remained at the heart of the profession right through to the current day. This
unswervingfocusonthewholepersonisaconstantcoreandfoundingprinciple


shapingandinfluencinghownursingisdefined,practisedandtaughtasshown
inthenextsection.Nursingisalsointheprocessofdevelopingitsownevidence
baseforspiritualcare.
Above we implied that nursing has maintained its focus on the holistic
concept of care. However, in the United Kingdom (UK) at present, there is
concernthatnursingmaybeindangeroflosingsightofthisfocusmovingaway
fromthefoundingprinciplesonwhichitisbased.Theneedtorefocusonthese
corevaluesofnursing,suchascare,compassion,dignity,respectisevidentina
numberofreportswherethequalityandstandardofnursingcarearecriticized.
[3–8]Inthesereportsnursesareaccusedoftreatingindividualswithoutdignity
andrespect.ClaireRayner(thelatePresidentofThePatientsAssociationinthe
UK)wrote:
Forfartoolongnow,thePatientsAssociationhasbeenreceivingcallson ourHelplinefrom people
wanting to talk about the dreadful, neglectful, demeaning, painful and sometimes downright cruel
treatmenttheirelderlyrelativeshadexperiencedatthehandsofNHSnurses.[4,p.3]

Fornursestobedescribedinsuchderogatorytermsisofgreatconcern,sinceit
implies that the core principles, beliefs, and values that underpin nursing have
been eroded, lost and misplaced within contemporary nursing practice. While
thesereportshavebeenpublishedwithintheUKtheramificationsandlessonsto
be learnt are of international relevance, since they bring into question the
public'simageofthenursingprofession,andtheneedfornursestore-establish
thefundamentalprinciplesofcareandcaring.

Basisforspiritualcarewithinnursing
Definitionsofnursing

TheInternationalCouncilofNursing[9]definesnursingas:
Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups
andcommunities,sickorwellandinallsettings.Nursingincludesthepromotionofhealth,prevention
ofillness,andthecareofill,disabledanddyingpeople.Advocacy,promotionofasafeenvironment,
research, participation in shaping health policy and in patient and health systems management, and
educationarealsokeynursingroles.

Thisdefinitionemphasizestheimportanceofnursesworkingcollaboratively
with the individual to establish their needs. The definition underlines and
reinforces the importance of nursing adopting a holistic and patient centred
approach to care which is at the heart of the American Holistic Nurses
Associationmissionstatement.[10]
Florence Nightingale considered that ‘the sick body … is something more
thanareservoirforstoringmedicines’.[11,p.36]Thissentimentisstillevident


in the Royal College of Nursing's (RCN) most recent definition of nursing,
wherenursingisdefinedintermsofitskeyfunctions.Theseareconcernedwith
promoting, improving and maintaining health and healing, helping people to
copewithhealthproblems,andtoachievethebestpossiblequalityoflife.The
nurse's focus is on the whole person and their response to health, illness,
disability which includes their spiritual response. Spiritual support is identified
bytheRCNasakeypartofthenurse'srole.[12]Inadditionthefirstofthe8new
principlesofnursingpracticeisconcernedwithdignity,respect,individualneed
andcompassion.[13]
Modelsofnursing
In an early model of nursing, Virginia Henderson said it was the duty of the
nurse to assist the patient to ‘worship according to his faith’ (p. 13) and to
‘practice his religion or conform to his concept of right and wrong.’14, p. 19]
More recent nursing models also incorporate the spiritual. For example, Jean

Watson talks about the caring presence of the nurse and focuses on
transcendence and the quest for meaning in life in her model.[15] One of the
most commonly used models of nursing, the Activities of Daily Living (ADL)
model[16] considers spirituality as a factor influencing ADL's and spirituality
featuresspecificallyunderthe‘deathanddying’ADL.Yetothermodelsaddress
thespiritualthroughtheirfocusonmeaning,wholenessand/ortranscendence.
Oldnall[17,18] suggested that the assertion that most nursing models have a
holistic approachtocareis inaccurate.Thisisbecause,up untilrecently,some
nursing models and theories, while espousing and embracing the mantra of
holisticcare,donotexplicitlyaddressthespiritualdimension.McSherry[19,p.
79]offersapossibleexplanationforthis:
Modelsshouldnotbesolelydevelopedinthe‘ivorytowersofacademia’andthenbeexpectedtowork
inpractice.Thistop-downapproachtotheorydevelopmentmayoverlookandfailtoincorporatemany
issuesthatarebeingfacedbynursesworkingonthefrontline.Thisapproachmayhavepreventedthe
spiritualdimensionfrombeingincorporatedwithincontemporarynursingtheoriesandmodels.’

Martsolf & Mickley[20] undertook a detailed review of some modern nurse
theorists’ ideas concerning spirituality. Their review sheds light on two key
areas:
1. The contribution to nursing knowledge made by some of the contemporary
nursetheorists
2. The position that spirituality has within those ideas; whether implicit or
explicit.
It is beyond the scope of this chapter to provide a full critique of the place


spirituality holds within each model. It is sufficient to say that, within nursing
models and theories, the importance of the spiritual dimension for individual
healthandwellbeingisnowrecognized.
Codesofethicsandeducationguidelines

Spiritual care is central to nursing Codes of Ethics, both internationally and
within the United Kingdom (UK). The International Council of Nurses (ICN)
CodeofEthicsforNursesstates:[21,p.2]
Inprovidingcare,thenursepromotesanenvironmentinwhichthehumanrights,values,customsand
spiritualbeliefsoftheindividual,familyandcommunityarerespected.

The Australian Nursing & Midwifery Council[22] accepts and builds upon the
ICNCode.
In the UK, the Nursing and Midwifery Code of Professional Conduct states
that:‘Youmusttreatpeopleasindividualsandrespecttheirdignity.’[23]
Unlike the ICN code[21] the spiritual dimension is not explicit, but implicit
withintheNMC(2008)code(anditsassociatedpublications)throughtheuseof
the words ‘individual’ and ‘respect for dignity.’ Therefore, failure to include a
spiritual dimension within nursing and recognizing the importance of this for
someindividuals,mayleadtoaviolationofanindividual'sfundamentalhuman
rights. The NMC further expects that at point of registration newly qualified
graduatenursesshouldbeableto:
‘Carry out comprehensive, systematic nursing assessments that take account of relevant physical,
social,cultural,psychological,spiritual,geneticandenvironmentalfactors…’.[24,p.18.]

The Essential Skills Clusters for pre-registration nursing programmes
identifies ‘skills that are essential’ in order to be ‘a proficient nurse.’ Included
underthe‘Care,compassionandcommunication’clusteristheexpectationthat
thenursewill‘demonstrateanunderstandingofhowculture,religion,spiritual
beliefs…canimpactuponillnessanddisability.’[24,p.108]
This is a similar expectation of the Quality Assurance Agency for Higher
Educationwhichexpectsnursestobeeducatedto:
Undertakeacomprehensivesystematicassessmentusingthetools/frameworks
appropriatetothepatient/clienttakingintoaccountrelevant…spiritualneeds
Plancaredeliverytomeetidentifiedneeds

Demonstrate an understanding of issues related to spirituality.[25,pp.p. 10,
12]
Despitetheaboveguidance,thereisgreatvariationintheamountandnatureof
the spirituality component within nurse education programmes. Despite these


inconsistencies, there is evidence that spiritual care teaching is gaining more
attention as evidenced by the increasing numbers of papers debating the many
issues and dilemmas raised. Currently, a great deal of work has[26–28] and is
being done (a current doctoral level study is in progress) to establish
competenciesinspiritual carefor nursesandmidwivesatpointofregistration.
Thisisamuchneededdevelopment.

Spiritualcare:whatisitandwhatdoesitlooklike?
If one looks at the evolution of spirituality and spiritual care in nursing then
there is a noticeable shift in emphasis and direction. Much of the early
pioneering work sought to elucidate and define the concept at a macro level.
Macrointhisinstance,meansapplyinggenerallyanduniversallytothenursing
profession.Thisearlyworkwasconcernedwithunderstandingthemeaningand
perception of spirituality, and the practice of spiritual care and much of it was
American.[29–31] The emphasis now is not so much on elucidation of the
concept,butaboutpracticalrelevanceandapplication.Nursesarenowengaging
with the concept at a micro-level. Micro- meaning they are trying to apply the
general principles of spirituality and spiritual care and developing knowledge
andunderstandingspecifictotheirownsphereofpracticebethismentalhealth,
orthopaedicorcriticalcarenursing.Thismicroapproachhasseennursingfocus
onspiritualassessmentwithinthedifferentbranchesofnursing.
Spirituality
The spiritual dimension is deeply subjective and there is no authoritative
definition of spirituality.[32] Swinton and Pattison[33, p. 236] affirm that it is

probably more beneficial for nursing not to have a definitive definition when
theywrite:
‘As a matter of fact, it is probably important that spirituality remains a contested and functional
conceptratherthanbecomingconsolidatedifitisusefullytodenotethekindsofcontextualabsences
thatneedtocontinuetoberecognizedandworkedwith.’

However, when one looks at the range of definitions of spirituality across
disciplinesinvolvingdiversegroupsofpeoplewithdifferingworldviews,there
seem to be common attributes, namely: hope and strength; trust; meaning and
purpose; forgiveness; belief and faith in self, others, and for some a belief in
God/deity/higherpower;values;loveandrelationships;morality;creativityand
self-expression.
Given this broad concept of spirituality, what then does spiritual care look
like?Andhowcanitbegiven?


Recentcriticisms
Theconceptofspiritualityanditsplacewithinnursinghasbeenthesubjectof
recentdebateandcriticism.Thespirituality-in-nursingdebatehasbeenaccused
of insularity; that is it has not drawn sufficiently on the established body
knowledge of other academic disciplines, meaning it has lacked the external
scrutinyorpeerreviewfromgroupsofpeoplefromoutsideofnursingsuchas
theology, psychology, philosophy, sociology and religious studies. This is an
importantpointsincemanyofthesedisciplineshaveengagedwiththeconcept
of spirituality over many centuries and they have a wealth of knowledge and
skills that shed valuable light enabling a deeper understanding of the concept.
However, while nursing must and should draw upon the wealth of knowledge
generatedbysuchdisciplinesitmustnotbeheldransombythem,inthatthey
arenotthesoleavenuesofknowledgeandunderstanding.Nursingmustcontinue
to plough its own furrows with regards to spirituality and its application to

nursing, however being mindful of the important contribution other disciplines
canmaketohelpingnursingunderstandandexpeditethisfieldofenquiry.
A further criticism of the spirituality-in-nursing debate has been the
perpetuation of concepts theory and definitions that have not been developed
withinthecontextofempiricalstudy.Oneexampleofthisistheuncriticaland
almostuniversaladoptionofadefinitionofspiritualityfirstpresentedbyMurray
and Zentner.[34] This definition was used uncritically and unchallenged by
nursing scholars and academics, especially within the UK. A further concern
raisedhasbeentherelationshipofspiritualitywithotherhumanisticaspectsof
theindividual,suchaspsychosocialcare.Clarke[35]proposesthatnurseshave
always addressed the spiritual concerns of individuals which were
accommodatedwithinthepsychosocialdomain.Clarke35,p.1672]suggeststhat
thereasonfortheinabilitytodistinguishbetweenthespiritualandpsychological
domainsisthatthemodelofspiritualcaredevelopedbynursingis‘…toolarge,
too existential and too inclusive to be manageable in practice without being
indistinguishablefrompsychosocialcare.’
For nursing research into spirituality to be more representative then it must
seektobemoreheterogeneous.[36]Thispointismadebecause,ifonereviews
the many studies undertaken in this area, the samples are often homogenous,
lacking religious, ethnic, and cultural diversity, primarily reflect a JudeoChristian perspective and often only focus on key groups, such as nurses,
chaplains, and patients. There is a need for the nursing profession to be more
inclusive, ensuring that study samples reflect the diversity of people, cultures,
andgroupswithincontemporarysocieties.


Oneofthepositiveoutcomesoftherecentdebatesassociatedwithspirituality
is that nursing scholars, researchers, and practitioners are more cautious and
awareoftheneedtobeanalyticalandcritical,ifconceptsaretobedevelopedin
ameaningfulandrigorousmanner.Therefore,asSwinton[37]pointsout,nurses
doneedenemies,nottobeconfrontational,buttoassistinthedevelopmentand

refinementofconceptssothatthesewillbebetterconstructedandunderstood.
Someofthecontemporarycriticismraisedwithinthenursingliteraturerelated
tospiritualityandspiritualcarehavebeensummarizedinarecentarticlewritten
by Swinton and Pattison.[33] This article offers a positive way forward for
nursingin understandingandapplyingtheconceptsofspiritualityandspiritual
care within nursing practice. The following quotation presents succinctly the
outcomeofrecentcontroversyandwhereasolutionmaybefoundoutliningthe
directionforfutureactivity:
‘Wesuggestthatinsteadofarguingaboutwhetherornotspiritualitycanexistinanyrealist,essential
sense—alineofargumentthathasproventobesomewhatcircular,controversial,andunhelpful—itis
moreusefultodevelopathin,vague,andfunctionalunderstandingofwhatthiswordanditscognates
mightconnoteanddointheworldofhealthcare.’(p.227)

Spiritualcare
Forsomepeople,theexperienceofillness,theuncertaintiesaboutdiagnosisand
the possibility of disability or even death may trigger spiritual distress. It has
beensaidbyGranstromthat:
‘Manyindividualsdonotseriouslysearchformeaningandpurposeoflife,butliveasiflifewillgoon
forever. Often it is not until crisis, illness … or suffering occurs that the illusion (of security) is
shattered…Thereforeillness,suffering…andultimatelydeathbytheirverynaturebecomespiritual
encountersaswellasphysicalandemotionalexperiences.’[38,p.26]

KarlJaspers[39] calls such encounters ‘limit situations,’ i.e. situations that we
cannot change and cause us to think about what is really important in life.
Questionslike‘Whyisthishappeningtome?’,‘AmIgoingtodie?’,‘Whatlies
after death?’ may be triggered, and cause existential, spiritual distress. Nurses
are often the first point of contact for people facing such challenges. It is
important,therefore,thattheyareequippedtobeabletorespondappropriately
insuchcircumstances.
Spiritualcarehasbeendefinedas:

‘Thatcarewhichrecognizesandrespondstotheneedsofthehumanspiritwhenfacedwithtrauma,ill
health or sadness and can include the need for meaning, for self-worth, to express oneself, for faith
support,perhapsforritesorprayerorsacrament,orsimplyforasensitivelistener.Spiritualcarebegins
withencouraginghumancontactincompassionaterelationship,andmovesinwhateverdirectionneed
requires.’[40,p.6]

Givingspiritualcare


The practice of spiritual care is about meeting people at the point of deepest
need.SomepointersaregiveninBox30.1andhavebeenadaptedfromtheRCN
PocketGuidewhichtheauthorshelpedtoproduce.[41]
Ofcourseourownvaluesandbeliefsareverydearandpersonaltoeachone
of us. This can cause conflict for nurses in their dealings with patients, clients
and families, particularly if the latter's life view differs from that of the nurse.
Whenthishappensweoftenhearaboutitinthemedia.Someexamplesofrecent
UKheadlinesandtheirknock-oneffectaregiveninBox30.2.
Box30.1Somepointersforgivingspiritualcare
Spiritualcareisabout:
Notjust‘doingto’,but‘beingwith’theperson
Thenurse'sattitudes,behavioursandpersonalqualitiesi.e.howhe/sherelatestotheperson
Treatingspiritualneedswiththesamelevelofattentionasphysicalneeds.
Skillsthatareusefulinclude(fromtheresearchonnursesandpatients):
Adopting a caring attitude and disposition. Showing empathy. Watson (15) referred to this as the
‘caringpresenceofthenurse’.
Beingrespectful
Recognizingandrespondingappropriatelytopeople'sneeds
Beingsensitive
Givingtimetolistenandattendtoindividualneed.Goodcommunicationskills
Beingawareofwhenitisappropriatetorefertoanothersourceofsupporte.g.chaplain,counsellor,

anotherstaffmember,familyorfriend
Abilitytoremainfullypresentinthefaceofsuffering
Being personally hope-filled, believing that what one does and what one is always of some value.
Knowingthatitisnevertoolatetodogood.
Assessingspiritualneeds
Just as a nurse would assess patients’ physical needs, so an initial assessment of patients’
spiritual/religiousconcernsisalsoimportant.Assessmentmaytakedifferentforms.Itmayinvolve,for
example:
Usingobservationtoidentifycluesthatmaybeindicativeofunderlyingspiritualneed,e.g.peoples’
disposition (sad/withdrawn), personal artefacts (photographs, religious/ meditational books and
symbols)
Usingquestionstoopentheareaupfordiscussion.Thefollowingareexamples:
Doyouhaveawayofmakingsenseofthethingsthathappentoyou?
Would you like to see someone who can help you talk or think through the impact of this
illness/lifeevent?(Youdon'thavetobereligioustotalktothem)
Whatsourcesofsupport/helpdoyoulooktowhenlifeisdifficult?(Wouldyouliketoseesomeone
whocanhelpyou?)


Itwillusuallyinvolvesomeformofdocumentationwithinthenursingnotesandcareplanaspartof
thewidernursingprocess.
Knowingwhentoseekfurtherhelp:
Itisimportanttoknowyourstrengths,limitationsandwhentoseekhelp(42).Thereisnothingwrong
withreferringtosomeoneelse,e.g.colleague,mentor/preceptor,chaplaincyteam(whoarethereforstaff
andpatientsofallfaithsandnone),counsellor,psychologist.

Thismediainterestresultedintwoofthebiggesteversurveysofnursesbythe
NursingTimes[42] (which attracted more comments and views than any other
storytodate)andtheRoyalCollegeofNursing[43]whosesurveyhadthe2nd
largestresponsetoasurveybyitsmembers.Theseresponseratesunderlinethe

importancenursesplaceonspiritualaspectsofcareandonthegeneralinterest
nurseshaveintheseconcepts.
Theoverwhelmingmessagefrombothsurveyswasthatnursesrecognizethe
importanceofspiritualcare,butwantmoreguidanceonspiritualcarepractice,
particularlyinrelationtotheconflictbetweentheirownpersonalbeliefs/values
and their professional practice. Here, are some key findings from the RCN
survey.[44]Ofthe4054memberswhoresponded:
83.4% agreed that spirituality and spiritual care are fundamental aspects of
nursingcare
90% believed that providing spiritual care enhances the overall quality of
nursingcare
Only 4.3% felt that it was not the nurses role to identify patients spiritual
needs
79.3% agreed nurses do not receive sufficient education and training in
spirituality
79.8% felt that spirituality and spiritual care should be addressed within
programmesofeducation
78.8%felttheprovisionofguidanceandsupportshouldcomefromtheNMC.
While78.1%feltthattheRCNalsohavearesponsibilityinthisarea.
TheRCNcommissionedaTaskandFinishgroup(whichtheauthorswerepart
of) to produce guidance for nurses tackling some of the key concerns raised
above by participants in the survey about this important part of care. This
guidanceisintheformofa‘PocketGuide’andon-lineresource.[45]Achecklist
ofthingstothinkaboutbeforerespondingtopatient/clientspiritualneedisgiven
intheseresources.


Evidencebase
Nursing practice today should be based upon research evidence. The evidence
base for spiritual care within nursing is fairly new, but has escalated in recent

years.ForinstancealiteraturereviewconductedbyLRinthelate1980s/early
1990s showed that there was very little published research on spirituality by
nurses at that time, with only one American published study.[46,47] Most
unpublishedMastersworkwasalsoAmericaninorigin.Whenthisreviewwas
repeated in 2006, 45 original research papers were identified for the period
1983–2005. Whilst much of this research was still American, the number of
countries had expanded to include the UK, other European countries,
Scandinavia,AustraliaandJapan.Thefullreviewispublished,[45]butinbrief
showedthatonthewholenursesconsiderspiritualcaretobeanimportantpart
oftheirrole,buttheyfeelunpreparedforit,feelinginneedoffurthereducation
andtraining.Theyalsotendtofocusonthemoreobviousreligiouspartofcare
whichinmanywaysiseasiertodealwiththanthebroaderaspectsofspiritual
care.
Box30.2Somerecentmediaheadlines
‘Nursesuspendedforprayeroffer’[48]
‘Nursesacked‘foradvisingpatienttogotochurch’(News,26May2009)[49]
‘MuslimnursesCANcoverup,butChristiancolleaguescan'twearcrucifixes’(MailOnline,19Oct
2010)[50]
‘BritishMedicalAssociationtodebatereligionandprayerintheNHS’(News29June2009)[51].

Integratingpersonalbeliefandprofessionalresponsibility
Thenurse'sownpersonalspiritualityseemstohaveabearingonhowspiritual
care is delivered. This can be illustrated by referring to two cases that gained
considerablemediaattentionintheUK:oneinvolvedthesuspensionofanurse
whoofferedtoprayforapatient.Thenursehadbeencaringforawomaninthe
communityandassheleftaskediftheladywouldlikehertoprayforher.The
womensaid‘no’.Subsequently,theladycomplainedtotheTrustandthenurse
wassuspendedpendinganinvestigation.Hersuspensionwasonthegroundsthat
she had not followed her code of professional practice specifically around the
use of professional status; promoting causes that are not related to health. The

nursewaslaterreinstated,afterpublicoutcrythatpoliticalcorrectnesshasbeen
takentoextremeswithhersuspension.[formoredetailssee48]
Theothercaseconcernedanursewhorefusedtoremoveacrucifixwhichshe


claimedshehadwornfromanecklaceforover30yearswhilstonduty.Shewas
askedtoremovethecrucifixtocomplywiththehospital'sdresscodeandhealth
andsafetypolicy.Thecaseactuallyendedupinanindustrialtribunalandcourt
ofappeal.Thetribunalclaimedthatthewearingofacrucifixisnotamandatory
requirementoftheChristianfaith.[50]
Thesecasesbringintoquestiontherelationshipthatexistsbetweenthenurse's
own personal beliefs and professional practice. It is clear that there is a
professionaldutyforallnursestopracticeinaccordancewiththeirprofessional
codes of ethics which guide conduct. Ultimately, these situations highlight the
importanceofnursesdevelopingself-awarenessoftheirownspiritualityandnot
usingtheirprivilegedpositiontoperusetheirowngoalsorpurposes.Oneofthe
biggest challenges nurses face is the integration of personal belief and
professionalpractice.Spiritualcareisnotaboutimposingyourownbeliefsand
values on another or using your position of trust to convert or proselytize.
Therefore, nurses must always be guided by the person for whom they are
caring; spiritual care like any other nursing intervention requires consent, and
this must always be obtained prior to performing any task or intervention.
Furthermore,thenursemustalwaysactinaccordancewiththeirprofessionaland
employers code of practice. Crucially, the nurse must have the prerequisite
knowledge,skills,andsupporttocarryoutanytaskcompetentlyandsafely[41].
Assumptionsandexpectations
Nursingcannotmakeassumptionsaboutwhatspiritualitymaymeanfordiverse
groupsofpatient.AsignificantfindingfromMcSherry's,[19]investigationwas
that some of the patients interviewed had very little expectation regarding the
provision of spiritual care. Furthermore, the investigation stressed the

importance of nursing not making assumptions that patients and the general
public, share the same understanding of spirituality as that constructed within
nursing.However,thisisnottosaythatjustbecausesomenursesandpatientsdo
notsharethesameunderstandingthatthespiritualdimensionisunimportantor,
indeed,obsolete.Onthecontrary,forsomepatients,thespiritualpartoftheirlife
is important to them, particularly when faced with illness and all the
uncertaintiesthatcomewiththat,providingthemwithstrength,hope,meaning,
andwellbeing.Forthosewithafaith,beingabletocontinuetopracticethatfaith
isimportant.Forthosewithnofaithissuessurroundingmeaning,hope,loveand
belonging, forgiveness, peace, direction, and guidance can become important.
Many patients, however, feel they are given little help with these sorts of
concerns and that hospital staff are too busy dealing with the physical part of
care to be concerned with the metaphysical. However, there is evidence that


whenspiritualcareisoffereditisvalued.[52,53,54]

Practice
McSherry[54, p. 66] provides a useful framework for considering four major
challenges that require deliberation by the nursing profession if the practical
applicationofspiritualityistobefullyrealized.Thefourbroadchallengesare:
Conceptual: consideration must be given to the diverse ways people define,
perceive and understand the nature of spirituality. Assumptions and
generalizations cannot be made by nurses with regards to this personal
dimension of human existence. If concepts and theories of spirituality and
spiritualcarearetobedevelopedthathavemeaningandrelevancetopractice
then flexibility will be required so that the needs of diverse groups and
individualscanbeaccommodated.
Organizational: all institutions and organizations that are involved in the
provision of nursing care, in whatever context, community, hospital,

residentialfacility, mustacknowledgetheimportanceofpeople,places,and
processeswhenseekingtoofferorprovideanyformofspiritualcare.Unless
these organizations acknowledge the importance of this dimension for the
healthandwellbeingofthosereceivingandprovidingcare,thentheprovision
ofspiritualcarewillbeadhoc,uncoordinated,andfragmented.
Practical:thisisabroadtermthatspansanyofthepracticalimplicationsfor
the delivery of spiritual care. This may include attention to areas such as
spiritual assessment, the resources to support nurses in the delivery of
spiritualcareandtheeducationalpreparednessofnursestobeinvolvedinthe
spiritual dimension of people's lives. The nursing profession has made
excellentprogressinsomeoftheseareas.Theemergingliteraturerevealsthat
nursing scholars and practitioners are engaged in a broad range of debates
and activities that will develop nursing practice in this area such as the
development of educational competences and the construction of spiritual
assessmenttoolsforuseinspecificclinicalsettings.Moreimportantlythere
isarealdesiretoensurethatthesedevelopmentsareinformedbythevoiceof
patientsandthosewhorequirenursingcare.
Ethical:thenursingprofessionmuststarttoengageinamoremeaningfulway
andconsidertheethicalissuesandpotentialdilemmasraisedandencountered
when supporting people with the spiritual aspects of human existence. The
spiritual dimension of people's lives is influenced by a number of factors,
personal, social, cultural, political. Therefore, the spiritual dimension by its


verynatureis‘ethicallyladen’.Untilrecentlylittleattentionhasbeenpaidto
theethicalissuesinherentwhensupportingpatientswithspiritualaspectsof
their lives. For example is it correct to routinely assess all patients for
spiritualneedsonlytofindthatthereareinadequateresourcestosupportboth
theindividualandstaffinvolvedinthisactivity.Afurtherconsiderationmay
be educational preparedness that is do nurses have the requisite knowledge

and understanding to support patients with these deeply personal aspects of
humanexistence?
A way forward for nursing is to review and evaluate the evidence base
developedtodatemappingthisactivityagainstthefourchallengesoutlined.This
exercisewouldprovideabenchmarkforwherethenursingprofessionhascome
andmoreimportantlythedirectionitneedstogointhefuture.Itwouldbefairto
saythatthenursingprofessionhaspioneeredunderstandinganddevelopmentsin
spiritualcare.Recentdebateshighlightthatthenursingprofessionisnotclosed
and rigid, but flexible and willing to engage in dialogue and further debate in
ordertoadvancethisimportantdimensionofholisticcare.

Conclusion
Thischapterhasofferedabriefsynopsisofthenursingprofession'sinvolvement
inthespiritualdimensionofcare.Itisbynomeansadefinitiveaccountofallthe
pioneering research and scholarly activity that has been undertaken by nurses
internationally,overseveraldecadesandindeedsinceitshistoricalinceptionand
evolutioninthetwentiethandtwenty-firstcenturies.Thechapterhashighlighted
thatthespiritualdimensionofcareisperceivedbythenursingprofessiontobea
legitimateandfundamentalaspectofnursingpractice.Thespiritualdimensionis
recognizedasoneofthecorefoundingprinciplesofnursingthatisenshrinedin
many codes of ethics and practice. The research evidence demonstrates that
spiritualityandspiritualcareareconsideredbynursestobeintricatelylinkedto
thequalityofnursingcareandinmaintainingthegeneralhealthandwellbeing
ofpatients.
The chapter affirms that the nursing profession's liaison with the spiritual
dimensionisnotsomeattemptatprofessionalization,orsomefleetinginterest,
butasustainedandsincereattempttoensurethatthespiritualaspectsofholistic
care are understood, realized and integrated within nursing practice. This will
ensurethatspiritualcareisavailableforallindividualswhorequiresupportwith
thisdimensionoftheirlives.

References


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CHAPTER31
Faithcommunity(parish)nursing
AntoniaM.vanLoon

Introduction
Faith community nursing (also known as parish nursing, pastoral nursing,
congregational/church nursing) is a specialist nursing practice distinguished by
itsendorsementofafaith-basedperspectiveoftheperson,whichfocusesnursing
care on integration, nurture, and restoration of the whole person in all their
dimensions(physical,mental,spiritualandsocio-cultural).[1]Faithcommunity
nurses (FCNs) help people with existing diseases or complex conditions to
managetheirconditionenablingthepersontomaximizetheirpotentialandtheir
qualityoflife.However,theFCN'sprimaryfocusisonpreventingdiseaseand
illness,andpromotingthepreconditionsforpersonalandcommunityhealth.[2]
Thisislargelyundertakenbynurturinghealthyrelationshipswithintheperson,
between the person and God, between the person and the environment, and

between people by addressing social justice issues, providing education and
supportregardingfaithandhealthissues.[3]Alltheseactivitiesareundertakenin
thecontextof,andwiththesupportof,anauspicingfaithcommunity.TheFCN's
clientsarenotrestrictedtothatfaithcommunity,thusallactivitiesandprograms
conductedbyFCNshavethecapacitytoreachintothewidergeographicand/or
theculturalcommunitywhichthatfaithcommunityseekstoserve.[4]

Faith-basedhealthcare
This chapter focuses on the development and outworking of faith community
nursing within Christian faith communities. This faith has embraced the FCN
role and this group are most frequently represented in the published literature
internationally.Thereislimitedinformationastohowfaith-basedhealthcareand
particularlytheFCNroleisenactedingroupsfromotherfaiths,butinformation
is becoming available as nurses from other faiths (such as Islam and Judaism)
share spiritual and religious aspects that impact healthcare delivery in the
published literature.[5–7] Many religions have a philosophical worldview that
enables them to positively influence values formation and human behaviour


which promotes health and wellbeing.[8] Many Christian denominations are
embracing the FCN health ministry as a vital and contemporary ministry that
enablesatangibleoutworkingoftheirmission.[9–11]Healthministry provides
compassionatecareactivitiesrelatedtohealthneeds,aswellashealthpromotion
anddisease/injurypreventionandhealingactivitiesthatareconductedasapart
ofthechurch'soverallcalling.[12]
The amount of faith-based healthcare varies within and between countries.
Policy and perspectives differ as to the amount and type of services religious
groups can offer. People continue to debate the role that organized religion
should play in thedelivery ofhealthcare;however,there are1.3billionpeople
lacking healthcare worldwide, so the World Health Organization (WHO) states

there will continue to be room for faith- based organizations to make a
contributionalongside,andintandemwith,governmentandprivatesectors.[13]
In the developing world faith-based organizations already provide a significant
percentageofhealthcare.[14]For example,inSub-Saharan Africa,faith-based
groupsprovideupto70%oftheregion'sHIV/AIDShealthservices,andupto
40% of other health care.[13,15]. As the cost of healthcare escalates and the
populationsofthedevelopedworldcontinuetoage,thehealthsystemsofmany
western countries are under strain as the cost burden of current healthcare is
difficult to maintain. The governments of many countries are looking for
innovativeandsustainablewaystocareforpeoplewithinthecommunity.Some
gaps have become apparent which are readily addressed by faith-based health
ministries such as aged care, community mental health, primary healthcare,
communityhealth.[10,14,16–18]Largedenominationalhealthministrynetworks
existinmostwesterncountriesandthesecanbebroughttogethertoeffectively
meet the needs of many people in culturally competent, accessible, affordable,
andsociallyacceptableways.[11,19]

Backgroundtofaithcommunitynursing
Faith community nursing is a renewal of the Deaconess role, which is where
contemporary nursing has its historical roots.[20] Nursing in western countries
todayiscommonlybasedontheNightingalemodelthatdevelopedinChristian
churches in Europe, particularly the Deaconess Institute at Kaiserswerth,
Germany. Lutheran pastor, Theodor Fliedner, commenced a hospital to train
young women to care for the sick and needy using a Deaconess model.[21]
Florence Nightingale chose to obtain her nursing education at Kaiserswerth,
graduating in 1851.[22] The ‘Nightingale model’ she implemented at St
Thomas's hospital in London was characterized by a focus on sanitation,


hygiene, client education, and benevolent support of the client, as well as the

personal,moral,andspiritualdisciplineofthenursewhowastrainedintheology
andnursingskills.[22]Nightingalenursingviewednursingworkasavocational
call,where,inreturnforasimplesalary,nurseswerehoused,fed,trained,cared
for, and provided with spiritual oversight.[23] Graduates trained in this model
travelledtocountriesacrosstheglobe,thereforethismodelbecamethetemplate
formuchwesternhealthcareafterthemid-1800s.[21]
The past century has seen an increased emphasis on biomedical, diseasecentredapproachestohealthcarewithimprovedbodycare,whichisthepractice
domain of medicine, nursing and the allied health professions. The care of the
mind has become the practice domain of psychiatrists, pyschologists, and
counsellors, and the care of the human spirit has been relegated to
pastors/priests/ chaplains/imams/rabbis, etc., and faith community-based
volunteers. However, the 1970s called into question the scientific reductionist
viewofthe‘bodyasmachine,’claimingitwasanarrowperspectivethatdidnot
attend to the needs of the whole person. Arguments for a more holistic
perspective of the person focused more attention on disease prevention, health
promotion,andillnessmanagement.
American churches responded to the holistic health movement in the
1970s/1980s by trialling holistic models of health service delivery by faith
communities.[24] Rev. Granger Westberg, a Lutheran pastor, was involved in
triallingholistichealthcentresthatusedateamapproachtoservicedeliveryby
clergy,doctors,nurses,andsocialworkers,butWestbergnotedthatnurseswere
thevitallinkbetweenallaspectsofthehealthsystemandthefaithcommunity.
[25] Consequently, he launched the first ‘parish nurse’ programme aiming for
more economically viable models to provide holistic programmes within the
faithcommunity.[26]Fromthesetrialscametherevitalizationofnursesworking
with/in churches known as ‘parish nursing’[27] and later as ‘faith community
nursing’ because this name encompassed a broader ecumenical and interfaith
movement.[4] The FCN role has many names that are adapted to fit the local
culture and the language of the faith community and the country in which the
roleisenacted[e.g.parishnursing(Catholicandsomeprotestantdenominations)

congregational nursing (Jewish), church nursing and pastoral nursing (some
protestant denominations), crescent nursing (Muslim)]. Today there are
approximately 12,000 FCNs in the United States[28] and networks have
commenced in Australia, the Bahamas, Canada, United Kingdom, Fiji, Korea,
Madagascar, Malaysia, New Zealand, Palestine, Scotland, Singapore, South
Africa,Swaziland,Wales,andZimbabwe.[29]


Describinghealthministry
Health ministry is the deliberate organization and resourcing of appropriately
qualifiedandgiftedpeopletofacilitatethepastoralhealth,healing,andcareof
people within the church, and the community it serves. The contemporary
movementofhealthministryincludesspecificworshipritualsandliturgy,such
ashealingservices,anointingofthesick,prayer,andsacraments.[30]However,
thereismoretohealthministryanditincludeseducationforhealthyliving,good
stewardship of the person, as well as communal health and wellbeing.[12] It
includesactivitiesthatpromotesocialjustice,andreduceandpreventviolence,
oppression and poverty.[8] Activities that provide advocacy, support, direct
assistance,andhealthcareforthosewhoaresickorinneedarecentraltohealth
ministry, as are actions that prevent injury and disease, promote healing and
health, and improve the social determinants impacting an individual's or
community'shealthandwellbeing.[31–33]

Thefaithcommunityandthehealthcarecontinuum
Christian churches have long seen the need to provide care to the sick in
response to the gospel directives of Jesus Christ to follow his example and
become actively concerned about the physical, mental and spiritual health of
people. Consequently, faith communities have provided acute care hospitals,
secondary health services and community health services. In fact, in Australia
the largest district nursing services were all commenced in the 1800s by

Christians compelled to enact their ethos and send out trained women and
religiousnunstoworkamongstthesick,poorandneedywithinthecommunity.
[34] Faith communities recognize the importance of a social perspective of
health and seek to provide food, clothing, medicines and care to those most in
need within the community, aiming to prevent hospitalization and promote
wellbeing.[22]
Christiandenominationstodaycontinuetoplayanimportantpartinhealthcare
provision within most western countries. However, healthcare is becoming
secularized and concurrently faith communities have lost their capacity to
meaningfully connect with people in their time of need, which is an important
part of their mission and mandate. When sickness occurs people often have
questions about life, hope, meaning, purpose, suffering and transcendence, but
asidefromappointedhealthcarechaplains/spiritualcareworkers,mostpersonnel
working in modern healthcare organizations have little time, or perhaps
inclination, (and at times they have no permission) to discuss such important
issueswiththesickperson.[35]


TheChristianfaithcommunityislargelyabsentfromtheprimaryhealthcare
aspect of the healthcare continuum except for the FCN and health ministry
programs (see Figure 31.1). Faith communities are key service providers in
secondary and tertiary healthcare, but have little input into primary healthcare
(PHC). PHC is gaining importance as countries search for sustainable ways to
developtheircommunitiesandimprovethehealthoftheirpopulation.
The PHC movement was endorsed by the World Health Organization[36]in
1978 as a solution to the escalating cost of high tech healthcare, which was
viewedasunsustainableandacontributingfactorinincreasinginequitybetween
thedevelopedanddevelopingworld.[37,38]PHCseekstoreorganizehealthcare
by developing strategies to promote sustainable health services using a
philosophicalframeworkthatincludesanalysis,planning,action,andawareness

that health requires inter-sectoral collaboration, community engagement, and
sound political governance if it is to be available, affordable, acceptable,
accessible, and sustainable to all.[39,40] In recent times, PHC has recognized
that wellbeing depends on a range of social, cultural, political, economic, and
environmental factors that need to be configured effectively if they are to
promotehealth.[37,41]Thishasbecomeknownas‘thenewpublichealth’which
focuses planning on ten social determinants of health,[37,42] which include
one's earliest life experiences, social status, presence of stress, level of social
inclusion,levelofwork,levelandtypeofemployment,levelofsocialsupport,
presence of addiction, presence and availability of food and water, and
availabilityandaccessibilityoftransport.[43]Faithcommunitiescancontribute
positively to these determinants in the activities they conduct in their local
communityandasglobalentities.


Figure31.1Continuumofhealthcarewithexamplesofservices/programmes.

Nursesasleadersofhealthministryteams
The office most often associated with health ministry historically is that of
deacon/deaconess and the religious orders. However, today health ministry
includes lay people with specific gifts in pastoral health and care who work
alongside qualified and educated health professionals as a team. In the FCN
model(Figure31.2)thehealthministryteamisoftenledbyaregisterednurse.
SomereasonsFCNleadershipwasrecommendedbyWestberg[44,p.2]include,
‘The nurse has the sensitivity—the peripheral vision … to see beyond the
patient's problems and verbal statements. She can hear things left unsaid. And
she is the best listener.’ Westberg asserted nurses have scientific expertise,
special gifts in caring, and excellent people skills, which are essential
requirements for effective health ministry. He noted nurses command respect
from the community and are trusted by people enabling them to open up to a

nurse. For example, every year in Australia, an annual ‘Image of Professions’
survey is undertaken by a reputable national polling group, nurses have
consistently topped that poll for 16 consecutive years, as the most ethical and
honestprofessionalgroup,surpassingboththemedicalprofessionandministers
of religion.[45] Westberg[27] notes that nurses use their ‘peripheral vision’ to
identify people who they know need to be visited quickly leading him to
recommendnursesastheprofessionofchoicetoleadafaithcommunity-based
health ministry. Nurses today are well educated in primary healthcare and
communityhealth,andhaveabroadknowledgethatcrossesmultiplediscipline
boundaries, making them ideal ‘navigators’ of an increasingly complex health
system, and an excellent resource people to promote health within the faith
community.

Ahealthministrymodelusingfaithcommunitynurses
In the late 1990s a group of five South Australian Christian faith communities
cametogethertodeveloparesearch-basedmodelofhealthministrywhichcould
be adapted across Christian faith communities, employing faith community
nurses.[1] This model has been successfully adapted by faith communities in
Australiaandoverseas.Thethemesandconceptsarebrieflysummarizedinthis
chapter.(Box31.1)
The overarching goal of all FCN functions is transformation that leads to
healing and restoration in all the dimensions of the person (body, mind, spirit,
socio-cultural).[1] This includes transforming the individual's and the


community'sconceptualizationofhealthandhealing,empoweringpeopletoact
in ways that enable them to respond positively to life and improve their wellbeing.Thistransformativeprocessisadynamic,life-longjourney,whichenables
peopletogrowclosertoJesusChristandtofindtheirhealingandwholenessin
Him.
How this model works to facilitate transformation and promote health and

healingisbestunderstoodbyexaminingthedimensionsoftheperson(keeping
inmindthatinrealitythereisnodistinctionbetweenthesedimensions).Humans
are inseparable wholes, but the prevailing western perspective of the person in
contemporaryhealthcarecontinuestoreducethepersontocomponentparts.The
reductionist worldview of most medical care focuses attention on parts of the
body and still smaller parts that give rise to sub-specialties within medical
specialties.
In the FCN model there are four dimensions to the person. For simplicity
thesearetermedphysical(body),mental(mind),socio-cultural(relational),and
spiritual (spirit). Each of these dimensions is governed by unifying principle/s.
Forhealingtooccurpeopleneedtoundertakecertainactivitiestoreconstituteor
nurture health within each dimension. FCN care is directed toward unifying
activitiesaimingforoutcomesthatchangethoughts,behaviours,andactionsand
leadtohealing,restoration,andhealth.
The physical dimension is governed by the principle of homeostasis.
Reconstitutingactivitiesrevolvearoundadaptation,aimingtorestoreormaintain
equilibrium,wellness,andpromotehealthygrowth.Nursingcareisfocusedon
prevention of diseases, curative regimes, and/or management of the
condition/disease,andthepromotionofhealthygrowthanddevelopment.
The mental dimension is governed by the principle of creative balancing.
Reconstitutingactivitiesinvolveenlightenmentandcreativeactivitiesaimingto
bring contented thinking, inner harmony, stable identity, creativity and mental
growth. Nursing care is focused on emotional and intellectual support,
stimulation,and/orrest.


Figure31.2FaithCommunityNursingModel.[4](NB.revised2010forthisedition.)


Thesocio-culturaldimensionisgovernedbytheprincipleofconnection.The

reconstituting activities pivot around unifying activities that seek to facilitate
identityandvaluesformation,connection,andcommunitygrowth.Nursingcare
is focused on promoting developmental health and strengthening interpersonal
relationships.
The spiritual dimension is governed by the principle of restoration, healing
andsalvation.Reconstitutingactivitiesencompasstransformativeactivitiesthat
seek to provide spiritual growth, healing, wholeness and shalom (Table 31.1).
Nursingcareisfocusedonnurturingrelationshipswithinself,withothers,with
theenvironment,andwithGod.
Box31.1Healthministrymodelusingfaithcommunitynurses
The model represents health ministry as a life giving tree that yields fruit all year that brings forth
healing transformation, health and life for individuals and the community. The tree is grounded and
rootedinloveforGodandfromGod,loveforotherpeopleandfromotherpeople,andloveforone'sself
andfromone'sself.
The tree trunk represents the major model concepts that give the model cohesion. The model's
applicabilityandutilitydependonhowtheseconceptsinterrelate,becausewhentheyworktogetherthey
sustainthelife-givingcapacityofthehealthministry.
ThePersonisunderstoodasawholeunityofbody,mindandspirit;madeintheimageofGodand
sanctified by God to live in relationship. Those relationships include a relationship with God, the
naturalenvironmentandwithotherpeople.
TheFaithCommunityisagatheringofpeoplewhoshareacommonreligiousbelief,andcommune
togetherforthepurposeofworshippingGod,fellowship,witness,teaching,encouragement,service
andhealing.Thefaithcommunityisbuiltinandonlove.
TheFCNiscalledbyGodtofocusher/hisuniquegifts,talentsandprofessionalnursingknowledgeto
thegoalofpromotinghealth,transformation,andhealing,andthecompassionatecareofpeople.The
religiousfaithoftheFCNmotivatesher/himtoalifeofservice,stewardship,andwholepersoncare
thatintentionallyintegratestheFCN'sfaithwiththeirprofessionalnursingpractice.
The Environment is understood as the circumstances and conditions (e.g. natural, physical, sociocultural)inwhichapersonorcommunitylive,relate,growanddevelop.Alloflifeisanendowment
from God and humans have been made stewards of the environment, which brings both
accountabilitiesandresponsibilities.

Howthesefourconceptsrelateandinterrelateimpactshealingcapacityandhealth.Healthisnurturedin
life-affirming relationships within one's self (body, mind, spirit, socio-cultural), between the self and
others,betweentheselfandtheenvironment,andbetweentheselfandGod.Healthenablespeopleto
fulfil many purposes in life, but it is not the be all and end all of living. Relationships that promote
harmonious interconnectedness facilitate transformation, growth, healing and health. Health can be
promoted by responsible stewardship of one's body, one's relationships and one's environment. It is
promotedanddependentuponsocialjusticeandthecapacitytoprovidecompassionatecaretoothersin
theirtimeofneed.
Diseaseandillnessaretheperson'sreactiontointernaland/orexternalstressorswhichcanactin/onany
human dimension, but the impact is experienced by the whole person. The act of living requires
responses to change, stressors, and perceived stressors that may originate within or external to the