Rehabilitation NURSING

Linda S. Rieg, PhD RN Carolyn H. Mason, MS APRN BC Kelly Preston, MSN RN

KEY WORDS Spiritual care has long been recognized as an essential component in providing holistic care to patients. However, many nurses have acknowledged that their education lacked practical guidelines on how to provide culturally competent spiritual care. Although all nurses are required to provide spiritual care, rehabilitation nurses are particularly challenged to be competent in this area, due to the lengthy recovery time and special needs often presented by rehabilitation patients. This article provides practical guidelines for rehabilitation nurses, to assist patients in meeting their spiritual needs. guidelines rehabilitation spiritual care

From earliest documents to recent literature, there has been an acceptance that all persons are spiritual beings and that care of the spirit is an essential and integral part of healing and wholeness. Although most would agree with this premise, it is of interest that the volume and quality of nursing research and writings related to spirituality and spiritual care is significantly smaller than that related to the physical, mental, and social aspects of nursing. However, within the last 20 years there has been increased interest in holistic nursing, including a focus on spiritual care. Although a need for spiritual care is recognized in all healthcare settings, rehabilitation patients often have significant spiritual care needs related to their conditions. Due to the longer term relationship between rehabilitation patients and nurses, more situations occur that are conducive to addressing spiritual care needs, and that may warrant spiritual care. Most nurses recognize that spiritual care is an essential component of holistic care. However, many will acknowledge that it is rarely given the same priority as other dimensions of care. Not seeing spiritual care as a top priority is cited as a reason for omitting it (Johnson, 2005). However, another significant barrier that nurses identify is discomfort due to a perceived lack of competence to provide spiritual care (Page, 2005). This article provides an overview of the basic knowledge needed to ensure patients receive culturally competent spiritual care for rehabilitation nurses. This article puts theory into practical guidelines which can be used when providing spiritual care to a diverse population of rehabilitation patients and their families. Relationship of Worldview to Spirituality If nurses are expected to provide spiritual care, they must first understand how a persons worldview relates to his or her personal concept of spirituality. Worldview is defined as a basic set of beliefs and concepts that work together to provide a more-or-

less coherent frame of reference for all thought and action. Out of ones worldview, a person evaluates, makes decisions, and makes meaning and sense of his or her life. Although worldviews may be categorized in various ways, there are basically two major divisions: theism and naturalism. In theism, God is the infinite personal Creator and sustainer of the cosmos; in naturalism, it is the nature of the cosmos itself which is primary, and God does not exist (Sire, 1997). Depending on which worldview a person embraces as the foundation for meaning and purpose in life, it will determine many of the persons views and beliefs about spirituality, as well as his or her spiritual care needs. Nurses must understand that in a multifaith society, definitions of spirituality differ, based on a variety of worldviews and opinions (Carson, 1989, 1993; Cusveller, Sutton, & OMathuna, 2004; Doornbos, Groenhout, & Hotz, 2005; MacLaren, 2004). According to Burkhart and Nagai-Jacobson (2002), spirituality is a broad concept, transcending religious boundaries. Other authors have written about spirituality, spiritual care related to diagnosis or cultural backgrounds, and the differences between spirituality and religious belief (Burkhart & Solari-Twadell, 2001; Conner & Eller, 2004; MacLaren; McSherry, & Draper, 1998; Reed, 1991; Stoll, 1979; Taylor & Mamier, 2005). Nurses need to recognize that a persons religious affiliation is not necessarily the same as a persons spirituality. By virtue of being human, all people are spiritual, regardless of whether or how they participate in religious observance. Spirituality is regarded as an essential part of peoples ultimate concern and quest for meaning and purpose (Emmons, 1999; Frankl, 1984; Wong, 2000). Rehabilitation Patients: The Need for Spiritual Care Because of the issues rehabilitation patients frequently face, spiritual care is often a significant need. Assisting patients to draw on their faith as a resource

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can be an important way to help them strengthen their spiritual beliefs and find hope during rehabilitation. Patients in rehabilitation are often ready to learn, and the rehabilitation environment seeks to maximize potential in every facet of a persons life (Derstine & Drayton-Hargove, 2001; Easton, 1999; Mauk & Schmidt, 2004). Schmidt (2004) identified that when faced with the loss of physical and/or mental abilities, patients and their families commonly had feelings of anger, bargaining, and other forms of emotional response to grief. Depression was not uncommon among those with long-term health problems; anxiety, frustration, and hopelessness often loomed with progressive and degenerative health concerns. In addition, patients expressed feelings of chronic sorrow with each exacerbation or setback. Feelings of loss may cause patients and families to confront their spiritual nature, ask questions about their spiritual beliefs, and turn toward their faith to find comfort and hope. Hope is often what patients say keeps them going through difficult times. Rehabilitation promotes hope because its goal is to maximize function to allow a patient to reach the highest level of holistic independence possible. A necessary part of successful rehabilitation is the development of a different set of coping skillsskills that many patients or families may not yet have developed, but which are essential for satisfactory recovery. During the process of healing from injury or disease, each patient must work toward integrating his or her old self into a new self and toward rediscovering meaning and purpose in life with newfound hope. In Frankls book Mans Search for Meaning (1984), he describes tragic optimism as a state where hope and despair can coexist and in which we can remain optimistic, no matter how helpless and hopeless we feel. Nurses often work closely with patients and families during the rehabilitation process and as a result establish close, long-term relationships. Due to the rapport established in these relationships, nurses are often instrumental in helping patients develop this tragic optimism. Wong (2004) identified five key ingredients necessary for the development of tragic optimism: acceptance of the reality of the situation, affirmation of the value and meaning of life, courage to move forward, faith in God or a higher power, and selftranscendence (serving others or a cause larger than oneself). A first step for rehabilitation patients is a realistic understanding of their conditions and a recognition of their losses. Patients in the contexts of suffering, disability, terminal illnesses, and dying are often struggling with the meaning of life and death (Puchalski, 2002; Wong,
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2000; Wong & Stiller, 1999). This is especially true for the rehabilitation patient who is struggling to integrate old self into a new self. Understanding patients beliefs about spirituality and their identified needs in this area of life is essential to providing spiritual care. Nurses Therapeutic Use of Self Before providing appropriate spiritual care to patients, a nurse needs to clearly identify his or her own worldview, understand how that worldview is foundational to their spiritual beliefs, and recognize how those beliefs are integrated into their life. In order to do this, several authors have suggested that nurses need to appreciate the attributes that foster ones spiritual sense, such as love, understanding, wisdom, and faith (Cavendish et al., 2000; Fowler, 1981; Haase, Britt, Coward, Leidy, & Penn, 1992). When a nurse does not understand his or her own worldview and personal spiritual beliefs, it makes it more difficult, although not impossible, to address patients spiritual concerns. By discovering their own spiritual foundations, nurses are better prepared to distinguish the actual needs of their patients from their own spiritual perspectives. Guidelines for Providing Spiritual Care Many authors have analyzed the complex issues inherent in spirituality and how to provide spiritual care (Barnum, 2003; Brillhart, 2005; Burkhart & Solari-Twadell, 2001; Cavendish et al., 2000; Cusveller, 1998; Goldberg, 1998; Grant, 2004; Gucwa, 2002; Kelly, 2004; Krebs, 2001; MacLaren, 2004). How authors have identified spiritual needs varies. In one study, seven major constructsbelonging, meaning, hope, the sacred, morality, beauty and acceptance of dyingwere revealed in an analysis of the literature pertaining to patient spiritual needs (Galek, Flannelly, Vane, & Galek, 2005, p. 62). Others have discussed best practices for approaching spiritual care, spiritual well-being, spiritual assessment, and spiritual care interventions (Cavendish et al.; Conner & Eller, 2004; Draper & McSherry, 2002; McGrath & Clarke, 2003; Van Dover & Bacon, 2001; Walton, Craig, DerwinskiRobinson, & Weinert, 2004). The essence of providing spiritual care is the therapeutic use of self. Nurses must be willing to engage self in this activity while recognizing that spiritual care must be patient led, not nurse directed. Nurses need to clearly understand where their own spiritual needs start and stop and where their patients needs begin. Skills of listening, observing, and presence are inherent in nursing and support spiritual care.

Process for Spiritual Care Spiritual care should be purposeful in the same way as other nursing care. However, it does not always require formal planning; in fact, if a nurse is present and sensitive to a patients cues, then spiritual care often occurs spontaneously and purposefully during that unique patient situation. As with all nursing care, a therapeutic use of the nursing process is necessary to address spiritual care needs. Assessment Todays healthcare environment makes it challenging for the nurse, with a heavy patient load and little time, to identify spiritual care needs. Therefore, nurses need the ability to do a succinct spiritual assessment by asking just a few questions. Not every patient encounter will necessitate nor warrant a complex, formal spiritual assessment with a detailed plan of care. However, every patient deserves the nurses willingness to be present and respond to spiritual needs, whether expressed verbally or nonverbally.

Spiritual assessment, similar to physical assessment, requires both baseline data and ongoing assessments based on the changing status of the patient. There are many ways to approach spiritual care assessment. However, we suggest these approaches may be grouped into two basic categoriesintentional and situational. Intentional spiritual assessments are completed using a deliberate, systematic method. These are generally completed at times of admission or transfer, or during a crisis event that might trigger spiritual distress. Several excellent approaches, using mnemonics, for spiritual assessment are available (see Figure 1). The most important ability for the nurse to master is to become comfortable with the types of questions that elicit spiritual assessment data. The following key questions can be asked and answered in a short period of time during the assessment: Do you have spiritual beliefs that are important to you and help you with lifes issues and problems?

Figure 1. Mnemonic Devices for Intentional Spiritual Assessment Maugans S.P .I.R.I.T.
S P I R I T Spiritual belief system Personal spirituality Integration into a spiritual community Rituals and restrictions Implications for medical care Terminal care (as required): How their beliefs impact the care they offer when patients reach the end of their lives

Maugans, T. A. (1996). The SPIRITual history. Archives of Family Medicine, 5, 1116.

Anandarajah and Hights H.O.P .E.

H O P E Sources of hope, meaning, comfort, strength, peace, love and connection Organized religion Personal spirituality/practices Effects on medical care, disability, end-of-life decisions

Anandarajah, G., & Hight, E. (2001). Spirituality and medical practice: Using the HOPE questions as a practical tool for spiritual assessment. American Family Physician, 63(1), 8189.

Puchalski and Romer F.I.C.A.

F I C A Faith or belief: Do you consider yourself spiritual or religious? Importance / Influence: What importance does your faith or belief have in your life? Community: Religious or spiritual: Are you part of a spiritual or religious community? Address: How would you like me, your healthcare provider, to address these issues in your healthcare?

Puchalski, C. M., & Romer, A.L. (2000). Taking a spiritual history allows clinicians to understand patients more fully. Journal of Palliative Medicine, 3, 129137 .

Combination of Cultural and Spiritual: E.T.H.N.I.C.S.

E T H N I C S Explanation: Why do you think you have this? Treatment: What have you tried for this? Healers: Who have you sought help from for this? Negotiate: How best do you think I can help you? Intervention: This is what could be done Collaborate: How can we work together on this? Spirituality: What role does faith/religion/spirituality play in helping you?

Kobylarz, F . A., Heath, J. M., & Like R. C. (2002). The ETHNIC(S) mnemonic: A clinical tool for ethnogeriatric education. Journal of the American Geriatric Society, 50, 15821589.

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If so, what can we do to assist you in practicing your faith or receiving spiritual support? If you are having a particularly difficult time, is there someone, such as a spiritual leader, clergy person, or friend whom you would like us to contact? If notwhat provides you with the most support in dealing with lifes issues or problems and how would you like us to help you? Situational spiritual assessments are not planned but depend on the patients or familys behavior or expressed needs. In almost every rehabilitation setting, nurses will see patients struggling with physical or emotional setbacks and perhaps expressing strong emotions. Many times during a crisis, patients or families will not express their needs directly. Patients may not be aware that what they are experiencing is a spiritual need until they are helped to recognize the nature of their need. The nurses role is as a detective who discovers what a patient believes his or her needs are, as well as what interventions might be helpful. Nurses are ideally situated to pick up on verbal and nonverbal cues. Verbal cues may include expressions of anger or frustration, requests for help, prayer, and requests for support from family, friends, clergy, or nurses. Nonverbal cues may include silence, withdrawing from others, crying, or a sad appearance. Nurses should see these as signs that a situational spiritual assessment should be done. Nurses who are sensitive and willing to listen to these cues and ask key questions (Figure 2) can often help patients identify spiritual needs and offer spiritual support. Sensitivity, insight, and knowing when to ask strategic questions can be enough to identify a spiritual need. Diagnosis and Plan As a nurse analyzes a spiritual assessment, it leads to nursing diagnoses, which in turn should determine the appropriate spiritual care interventions. The nursing diagnoses of spiritual well-being and spiritual distress are well established and have recognized defining characteristics, related factors, suggested interventions, and evaluative client outcomes (Burkhart & Solari-Twadell, 2006a, 2006b; Solari-Twadell & Burkhart, 2006). Familiarity with these diagnoses can increase a nurses comfort and confidence in providing spiritual care. Culturally Competent Spiritual Care Interventions The patient or family should set the direction for spiritual care and should freely give permission for any interventions. Patients need to feel safe in
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Figure 2. Situational Spiritual Care Assessment Questions

Ask open ended questions that focus on what the patient is feeling, such as questions about their concerns, needs, or hurts. Examples of these types of questions include What is the hardest part of this or the situation? What hurts the most? What angers you the most right now? Then direct the conversation to what the patient believes would help them, such as What has helped you the most in the past when you have felt this bad? Does your family, friends, or faith help you? The patient at that time may express the desire for spiritual support.
Mason, C. H. (1995). Prayer as a nursing intervention. Journal of Christian Nursing, 12(1), 48.

expressing their spiritual concerns. Patients will generally reflect their worldviews and the corresponding role of spirituality in their lives through information gathered during assessments or requests for specific spiritual care interventions. It is important to determine who is best suited to meet the patients spiritual needs. Ideally, the best care can be provided when the nurse and the patient have the same worldview, with like values and spiritual beliefs. Examples include a Christian nurse praying with a Christian patient, a Buddhist nurse sharing sources of hope with a Buddhist patient, or a Jewish nurse supporting the worship needs of a Jewish patient. However, in the real world that usually does not happen. Nurses and patients come from all cultures and have varied spiritual beliefs. Nurses must decide upon the most ethical and culturally sensitive manner to provide spiritual care when the patient and nurse have differing worldviews or spiritual perspectives. Most important is that both the patient and the nurse are treated respectfully and recognize that each one has a right to embrace his or her own individual spiritual beliefs. All nurses have a responsibility to assess spiritual needs and to help patients identify appropriate spiritual care resources. However, every nurse should not be expected to participate in every type of spiritual intervention. This is especially important when the spiritual beliefs and worldviews of the nurse and patient are different. For example, many complementary and alternative therapies are compatible with all worldviews, such as literature, music, and meditation or quiet times of devotion, but other spiritual care interventions that a patient may desire may not be compatible with the nurses worldview, or vice versa. Without understanding the

Table 1. Spiritual Care Engagement Based on Worldviews Culturalistic/Instrumental

Appropriate culturally defined spiritual practices are incorporated, based on spiritual assessment and history. This approach can be nonreligious. The nurse uses listening, empathy, and reflective techniques to help the patient explore personal feelings about the situation.

Procedural/Instrumental

Therapeutic Interaction

Transformational
This approach is based on more spiritual knowledge and compassionate care; it demands a personal spiritual experience. Spiritual care becomes not just a tool, but the sharing of ones own spiritual life with the patient. It involves a healing connection and presence (Wong, 2004). Intense engagement is required.

Description

A logical and technical approach to addressing spiritual needs is used; this is based on routines such as standardized assessments for religious preferences and practices.

Type of nurse-patient engagement A patient may be uncomfortable receiving spiritual care from a nurse with a different worldview. Nurses may not be able to participate in certain practices based on worldview. Comfort and rapport between nurse and patient are needed for the sharing of beliefs and practices. Emotional and spiritual needs often overlap.

Minimal engagement is required.

Moderate engagement is required.

Complete engagement is required. The nurse practices therapeutic use of self; nurse presence is required.

Considerations

Strength: Anyone can do it and little time is required.

Mutual understanding and sharing is required. Nurses need to be aware that his level of engagement can lead to professional boundary confusion.

Concern: Nurses who use this approach may tend to stereotype patients based on religious labeling; potential exists for making inaccurate assumptions; patients real needs may not be identified or met. Most interventions are non-worldviewdependent. This is not dependent on having similar worldviews. This is dependent on sharing similar worldviews.

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Worldview

Differences in worldviews are not problematic.

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A Buddhist nurse understands the need for a calm, peaceful mind at death and the need to avoid analgesics and sedatives as the patient approaches the end of life. This nurse would likewise be able to aid a Buddhist patient by using appropriate Buddhist rituals and writings.

Evangelical Christian patients and nurses feel a sense of relationship because of their shared beliefs. Prayer, presence, scriptures, and music may be shared for comfort.

Transformational

Adapted from Koening & Lewis, 2000; Narayanasamy & Owens, 2001; Schmidt, 2004; and Wong, 2004.

Table 1. Spiritual Care Engagement Based on Worldviews

The nurse asks a patients religion and calls clergy people of faith as indicated by the patient and family.

Procedural/Instrumental

patients worldview, a nurse would be intrusive to apply therapies or interventions without adequate assessment and permission. For example, a nurse would not expect a Jehovahs Witness to accept a blood transfusion due to religious convictions. Likewise, evangelical Christian patients should not be offered energy therapies due to their conviction that these therapies are tied to Eastern mysticism and are in conflict with their belief that Christ is their source of healing (OMathuna & Larimore, 2001). Even if there are differences between a nurses and patients worldviews and beliefs, it does not absolve the nurse from the duty to address spiritual needs. Providing spiritual care may be simple or complex, in addition to requiring different levels of nurse-patient engagement. Four levels of spiritual care are described: procedural/instrumental, culturalistic/ instrumental, therapeutic interaction, and transformational. Table 1 describes these four levels, explains the types of nurse-patient engagement required for each based on worldviews and certain considerations and provides examples of spiritual care interventions. Depending on the circumstances and unique situations, the nurse could use any or all of these interventions. In most circumstances, nurses offer care at the procedural/instrumental level and use only the culturalistic/instrumental level as needed. Because therapeutic interaction requires a more intense use of therapeutic self and presence, it will probably most often be used with patients in times of distress. Some nurses may never interact with a patient at the transformational level, because this requires intense nurse-patient engagement, and similar worldviews, and it involves a healing connection and presence. The nurse should not feel compelled to provide this level of care; however, many nurses and patients find great satisfaction when transformational spiritual care is provided. Evaluation Like all other aspects of nursing, spiritual care should be focused to achieve the best possible outcomes. Professional expectations for spiritual care have been established in the Code of Ethics (American Nurses Association, 2001), dictated by patients rights (American Hospital Association, 1992), and required for accreditation (Joint Commission on Accreditation of Healthcare Organizations, 2003; Commission on Accreditation of Rehabilitation Facilities, 2004). However, the most important evaluation of spiritual care should be determined by each patient, based on that patients personally identified spiritual needs and desired outcomes. When the patient and family indicate that their cultural and spiritual needs have been satisfiedthen spiritual outcomes have been achieved.

A nurse uses therapeutic listening skills to help a patient who is struggling with anger toward another person (emotional) while feeling guilty because his or her faith requires him or her to forgive the person (spiritual). Worldview-related conflict: A Muslim man or woman may not want a Jewish or Christian nurse to provide specific spiritual care. Example of non-worldview-related care: The nurse incorporates cultural sensitivity into care by rearranging the Islamic patients room, as requested, so that the bed faces Mecca.

Therapeutic Interaction

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Intervention example

Worldview-related conflict: A Christian nurse might have a conflict participating with a patient in a voodoo ritual or ceremony.

(Continued)

Culturalistic/Instrumental

Summary Spirituality is an essential dimension of all human beings. Patients in rehabilitation settings are in need of hope and support along with a desire for resources to help them in recovery. Rehabilitation nurses are in strategic positions to use appropriate and culturally competent spiritual care as a resource of hope to help patients construct a new self. This article provides an overview of spiritual care and addresses some of the issues nurses identified as barriers to giving holistic, compassionate care to a diverse set of patients. Practical guidelines were provided to assist nurses as they provide spiritual care for culturally diverse rehabilitation patients. About the Authors
Linda S. Rieg, PhD RN, is an associate professor at Xavier University and can be contacted at 3800 Victory Parkway, Cincinnati, Ohio 45207-7351 or Rieg@Xavier.edu. Carolyn Mason, MS BSN, has worked for three years as a staff member for Nurses Christian Fellowship in Michigan teaching nurses about integrating their faith in nursing. She is certified in community health nursing and has taught nursing for over 23 years. She holds a masters degree from the University of Illinois, Chicago and bachelor of science in nursing from California State University. Kelly Preston, MSN, attended the congregational health/parish nursing program at Samford University. The nursing program at Samford focused on whole person health promotion with the spiritual care of patients as the primary focus. After earning her graduate degree, she coordinated a program within an integrated healthcare delivery system whereby she and her colleagues worked with faith communities to help them establish health ministries.

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