Spirituality: the Holy Grail of contemporary nursing practice

This issue of Journal of Nursing Management is dedicated to understandings and applications of spirituality in nursing and implications for nursing management. It presents a wide and varied range of international papers written by authors working in diverse fields of nursing, health care practice and professional education. Collectively, the papers provide a rich, valuable and deep insight into the concepts of spirituality and spiritual care. The broad range of subjects addressed raise a number of conceptual, practical and educational challenges but more importantly they provide useful recommendations/solutions to assist nursing managers to understand, support and engage with the spiritual dimension of care. Over the last two decades interest in spirituality within the context of nursing and health care has ‘mushroomed’ both within the United Kingdom (UK) and internationally. It is probably right to assert that spirituality is now established and recognised as a fundamental, integral part of nursing practice. However, in recent years the role and usefulness of the concept for nurses and nursing have been contested and debated both within the profession (Bradshaw 1994, McSherry & Cash 2004, Swinton 2006, Ross 2008, Clarke 2009, Pesut et al. 2009, Swinton & Pattison 2010) and outside (Walter 1997, 2002, Gilliat-Ray 2003, Paley 2008a,b, 2009, 2010 Hussey 2009). These debates have at times felt personal and deeply critical but they are welcome as they are undoubtedly leading to a refinement and illumination of the concept as it becomes more embedded within the fabric, culture, practice and history of nursing. Right from its inception nursing has and always will be a blend of the artistic and the scientific. The challenge for nursing is balancing and obtaining equilibrium (Ross & McSherry 2010). The art and practice of nursing must be underpinned with sound scientific principles and evidence. Yet the art and science of nursing are constantly unfolding as societies, people, technology and new understandings emerge. Nightingale (1969 p. 8) recognised that transition is important and that nursing knowledge and practice are not static, or monolithic when she states that ‘the very elements of nursing are all but unknown’. Nursing has changed considerably over recent years and the ‘very elements of nursing’ to which Nightingale (1969) refers are indeed more explicit. Yet, the very foundations of nursing practice, those core values, beliefs, principles that differentiate nursing from other professions may have been eroded in contemporary practice. When one plots the evolution of spirituality within nursing it is clear that nursing has had a strong ‘spiritual’, religious heritage. Bradshaw (1994 p.169) articulates clearly the intrinsic nature of this relationship ‘The spiritual dimension in nursing's tradition cannot be separated from the history of nursing itself.’ Nightingale (1969 p. 11) herself recognises clearly the work of God in creation, acknowledging the mystery of the laws of life indicating how ignorance and indifference and the fragmentation of knowledge, indeed the over specialisation of knowledge ‘They call it medical or physiological knowledge fit only for doctors’ may be detrimental to nursing. Nightingale (1969) suggests medical and physiological knowledge are not the preserve of doctors. When one reads her words, the subtheme is prophetic in that she is almost cautioning that too rigid a focus on the medical and the physiological at the expense of those ‘other laws’ (however defined) means we may not see the ‘whole’ person or understand the full situation. As we write this editorial one cannot fail to think about some of the negative images surrounding nursing appearing in a number of damming reports (The Patients Association 2009, 2010, 2011) accusing nurses of lacking care, compassion, dignity and respect. Perhaps, we are naive in thinking this may be in part due to nursing becoming disconnected from the spiritual dimension focusing too much on the medical, physiological, technical and scientific at the expense of the those other ‘laws’ to which Nightingale refers the equilibrium between the artistic and scientific has not been achieved. One cannot offer a compendium of papers in a special edition of the Journal of Nursing Management addressing spirituality without providing an overview or clarification of what this may constitute. This necessitates engaging with some of the factors and forces that have shaped the conceptualisation and practice of spirituality over many years. Therefore, this editorial outlines some of these forces setting a context and background for this special edition. There are many definitions and interpretation of spirituality espoused within the nursing and health care literature. Spirituality may be described as an umbrella term since it comprised of many attributes, variables or components. For example the Royal College of Nursing (RCN) (2011) suggest that spirituality is about: hope and strength; trust; meaning and purpose; forgiveness; belief and faith in self, others, and for some this includes a belief in a deity/higher power; peoples’ values; love and relationships; morality; creativity and self expression. This means that there is no single authoritative definition and indeed producing an all embracing definition may be less beneficial and helpful to nursing. This is articulated by Swinton and Pattison (2010 p. 236) ‘As a matter of fact, it is probably important that spirituality remains a contested and functional concept rather than becoming consolidated…’ While different interpretations exist, spirituality is essentially about people's desire to find meaning in life (Narayanasamy 2004). Contemporarily it is useful to separate this from the term religion, which means rituals and outward manifestations of sacred beliefs (Wilson 2009), because (1) they exist as separate (but interconnecting entities); (2) a broader interpretation of spirituality is capable of understanding and responding to humanities inclinations across a diverse and pluralistic society (3) overt reference to religion in the UK at least, is often met with resistance. The main reason for this is that the UK (and much of the Western world) is deemed to be secularised. This means that religion no longer plays a central role in the administration and management of the state and people are free to choose whether to have a religion or not (Wilson 2009). From a sociological perspective religion served to enhance social cohesion, legitimise social order and maintain social control (Wilson 2009); functions which, to a large extent have been taken over by the state in many modern societies. However, secularisation doesn't necessarily mean a decline in religion or the practice of religion (Wilson 2009). Nonetheless, dispensing with religion as a part component of humanity; spirituality is difficult to define and Sessanna et al. (2007) in their concept analysis draw our attention to four approaches to understanding spirituality suggesting that it be defined according to: (1) a religious system of beliefs and values; (2) that which gives life meaning, purpose, and connection with others; (3) a nonreligious system of beliefs and values; or (4) as metaphysical or transcendental phenomena. Essentially, spirituality is an individual belief system that can vary according to individuals, their particular cultural or religious background and according to the society in which they find themselves. Both Vance (2001) and Miner-Williams (2006) consider religion, religiosity and practice of religion as fundamental to individual patient's spiritual needs, and although one must be cautious not to exclude those without religious beliefs (McSherry 2006), there is merit in not shying away from finding out how people personally express their spirituality. In this special issue addressing the topic, Cockell and McSherry (pp. 958-969) allude to the cautious approach of UK nurses in regard to this and we would advise against this caution. Viewing spirituality through a lens that omits the patient's own perspective (including religious beliefs) on the topic results in a limited approach may result in fragmented care (Ross 2008). Most people at some level aim to find meaning in life; indeed it is this very quest that now drives people towards religion. Increased diversity of populations, together with disparate complex societies often means that there is a void as people struggle to find meaning in life (Wilson 2009). Additionally, whether people have a professed religion or not there is continued evidence that people have a desire to believe in metaphysical or transcendental phenomena. Kevern (pp. 981-989) raises this very point in his paper, that regardless of rational empirical phenomena, people continue to hold spiritual beliefs. Kevern also introduces the notion of societal influence on manifestations of spirituality and indeed the importance (or not as he explains) with which it is regarded. ‘secret codes…with future hopes’, thus permitting ‘aspects of the past which are disturbing [to be] overcome by reinstating a past Utopia’ Moreover, there is interest since the 1960's in the notion of a civil religion, particularly in the USA and UK. Although a contested notion (Cristi 2001), civil religion refers to certain collective societal behaviours including collective ‘beliefs, symbols, and rituals’ with respect to things held sacred by society (Bellah 2002 p. 101). These are ‘independent of religious and political institutions’ (Cristi 2001 p. 1). Civil religions are said to utilise and make sacred non-traditional representations [such as the Declaration of Independence and the Gettysburg Address] (Bellah 2002) and national rituals [such as military remembrance celebrations] to codify, represent and transmit particular religious traditions (Cristi 2001, Parsons 2001). Civil religion, driven by a ‘shared sense of nation's history and destiny’ (Pierard and Linder, cited in Parsons 2001 p. 6/7), is reflected in sometimes spontaneous, unplanned collective gatherings to share ceremony, tradition, ritual and emotional experiences. After Diana's death for example, civil religion was represented by spontaneous public gatherings, the laying down of flowers and notes at UK royal palaces, and by the appearance of shrines in new and strange places, such as shop windows (Bowman et al. 2009). During this people experienced a shared connectedness to the transcendent. These examples demonstrate that man's spirituality remains constant while its manifestation metamorphisizes. If we return to the Holy Grail analogy interpretation of the truth changed and developed alongside man's intellectual development and in many ways mirrored societal developments. In the same way the development of many modern religions and traditions within these changed and developed over time in response to society's development. Most notably the post Enlightenment period of the 17th Century, challenged past reliance on purported legend and myth difficult in the presence of scientific, intellectual and technological advancements (Moyise & Pearson 2001). The ‘quest for the historical Jesus’ was played out in both academic and media circles, with a concurrent skepticism about and interest in Jesus emerging as a result (Moyise & Pearson 2001). Indeed the Monty Python team is reflective of the extent to which a modern society can openly criticize long held religious and spiritual beliefs, while at the same time rebuke and defend public criticism and charges of blasphemy (Friday Night, Saturday Morning 1979). However, this backdrop of irreverence (Hewison 1981) towards religion popularized by the aforementioned in the context of secularisation renders any meaningful discussion of the role of human spirituality difficult and Cockell and McSherry (pp. 958-969) refer to this atmosphere in their paper. ‘ it is tempting to see the promotion of spirituality in nursing as another jurisdictional claim, another effort to secure the profession's status’ This is compounded by the perceived dominance of Christianity which affects how notions of spirituality in nursing are perceived and understood. In the same way as the Holy Grail, while emerging from multiple traditions, ultimately became subsumed into Christian mythology as Christianity became the dominant European religion (Kempe 1905), contemporarily understandings of spirituality in nursing tend to have their origins in Christianity evidenced by a concern with forgiveness and the transcend nature of (presumably one) God (Timmins & Kelly 2008). Kevern (pp.981-989) finds issue with stances that are adopted in this post enlightenment, secularised period, finding a nurse who a pragmatic literalist the most helpful for patients as they can suspend their personal convictions, and begin to really understand the importance of the patients beliefs or non-beliefs. While obviously overt religious convictions of nurses presents ethical dilemmas to practice, in terms of potential unwarranted proselytising to patients, in the same way (and this has received less attention) the non-religious convictions and secular convictions are equally damaging. Interestingly Biro's (pp. 1002-1011) paper in this issue concludes that there are many parallels between good nursing and spiritual care. ‘…its persistence is assured as long as men continue to seek the experience of community, brotherhood [and] fellow-feeling’ While debates about the existence of religion are not the primary purpose of this editorial, it is important to point out firstly that using secularisation theory to support the notion that people no longer have spiritual beliefs is inaccurate, and attempting to devise a understanding of spirituality that does not incorporate respect for religious beliefs (if relevant to the individual) is inadequate. The irreverence for society's or individual's need to nurture their spiritual side has its roots in the Enlightenment and is perpetually fostered by media interpretations. The scepticism towards spirituality that exists in some corners in the UK is unique internationally and not reflective of either the pluralist UK society or the world as a whole. As Kevern (pp. 981-989) points out fundamentalist non-religious views are not helpful in this setting. Indeed Biro (pp.1002-1011) is clear that nurses have a fundamental role in supporting patients’ spiritual needs, and while nursing care delivery is often culturally determined, in pluralistic societies nurses need to become increasingly skilled in supporting diverse spiritual and religious beliefs, depending on the particular context. Unfortunately Battey (pp. 1012-1020) points to gaps in the current system. Though many chaplains, nurses, psychiatrists and indeed medics are sympathetic of supporting patient's spiritual needs, and indeed health care policy internationally requires that these are attended to (World Health Organisation 2002, Joint Commission on Accreditation of Healthcare Organizations, 2005, Pesut et al. 2009, la Cour & Hvidt 2010, Canadian Nurses Association (CNA) 2010). While not legislated for in the same way in the UK, the RCN have recently highlighted the profession's support for this element of care by producing a leaflet (Royal College of Nursing (RCN) 2011) to guide nurses towards spiritual care of their patients and Cockell and McSherry (pp. 958-969) refer to this growing interest in health care. Cockell and McSherry also point out how Nurse Managers need to become proactive in supporting and educating nurses to understand spirituality; to understand the influence of religion on the patient's spirituality and spiritual needs; and the impact of these spiritual beliefs on requirements for nursing care (Timmins 2010, Holloway et al. 2011). In this issue, Fouka et al. (pp. 1058-1068) articulate quite clearly how patients spiritual needs and spiritual care provision is closely related to religiosity in their particular context (Greece), highlighting the need for greater nurse awareness of the importance of spirituality (and possibly religion) to patients. Patients and families may find themselves particularly inclined towards spirituality during health crisis and other ‘tough times’, as they strive to make sense of, and derive meaning from events (Hexem et al. 2011). Research indicates that patients find while that their sense of spirituality improves their mental health (Wilding et al. 2006, Pesut et al. 2011) and quality of life (Sawatzky et al. 2009), distress can occur when spiritual needs are not acknowledged (Radford 2008). While nurses may recognise these needs, and believe them to be important for patients and family; they do not always feel sufficiently confident to address these in an appropriate way (Radford 2008, Timmins 2010, RCN 2010, 2011, McSherry & Jamieson 2011). As a result patients often experience unmet spiritual needs while in hospital (Walton & Sullivan 2004, Tanyi 2006, Radford 2008). While nurses can lack skills and confidence with regard to support, both Daaleman (pp. 1021-1028) and Biro (pp. 1002-1011) demonstrate the simple but fundamental ways that nurses can make a difference, by physical presence and being ‘with’ the patient. While these are incorporate elements of nurses required communication skills, nurses often profess to be better communicators than they actually are, and from a patients perspective gaps exist (McCabe 2004). These potential deficits in nurse-patient or indeed nurse-relative communication together with negative views of religiosity and lack of experience of spiritual care delivery mean that fundamental gaps in the provision of spiritual may exist with detrimental consequences (Radford 2008). Yet, as Kevern (pp. 981-989) points out, patients’ spiritual requirements are often very far down the health priority list, and in the context of secularisation this is understandable. Nursing and healthcare are facing some challenging and turbulent times where the drive is to reduce costs, work more efficiently and effectively while maintaining quality and high standards of patient care. This special edition of the Journal of Nursing Management addressing spirituality demonstrates the potential this concept has to transform organisational cultures, values and attitudes; all of which influence the patient and staff experience. Organisational cultures and values are created and communicated through management structures and systems. Nursing managers and nurses are the custodians of caring – this caring must be person-centred and incorporate the spiritual dimension. Historically, spirituality has been an integral aspect of nursing practice and this legacy and association remains. This means spirituality and the provision of spiritual care are embedded within the fundamental and core values of everyday nursing ritual and practice. It is not something that is added to nursing because it is interwoven within the entire fabric of nursing history, culture and values –one cannot be a nurse without encountering or caring for the human spirit at some point. It is clear from the evidence provided in this special edition of the Journal of Nursing Management that nursing and nurses and indeed a wide range of health care professionals are committed to ensuring the positive impact and potential of spirituality are realised. However, notwithstanding these to it remains the Holy Grail of contemporary nursing practice, with some nurses and health care professionals this quest with and it as of