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Thomas Cox

Spirituality and Nursing

Virginia Commonwealth University

School of Nursing

INTRODUCTION

Nursing as a profession makes a strong case for engaging clients holistically and spiritually to offset the impact of illness, promote health and prevent disease. As a profession, nursing believes that its contribution is 'unique' because of its focus on the wholeness of the person. Dr. Martha E. Rogers developed a nursing framework (Rogers, 1970) that is clearly holistic in that it incorporates the major scientific ideas of her age with eastern metaphysics (Lao Tzu, 1944; Radhakrishnan, 1957)) in a way that few scholars came to recognize as valid until far later (Zukav, 1979). Her theory of nursing is difficult for most nurses to incorporate into practice and many nurses simply do not understand how to apply Rogers' work and/or its implicit spirituality in their practices, nor do they understand the underlying science and metaphysics that makes it so appealing to its adherents. Cox (1998) offered an example of being present and intentionally honoring the mutual process of nursing clients while delivering medication to a client from a Rogerian based spiritual approach.

However, despite its complexity, Rogers' theory of nursing provides an excellent backdrop for a discussion of spirituality in advanced practice nursing, and particularly, Native-American spirituality. This topic has been selected because J (a pseudonym), a Native-American client I cared for, was deeply committed to Native-American spirituality. He was experiencing spiritual distress, in part, because he was involuntarily committed to a brick, glass and steel facility where he found it hard to maintain contact with nature. However, it is also possible to incorporate Roger's work with spiritual intervention with clients of other belief systems and an exemplar case with a Christian client will be presented as well.

Rogers’ Science of Unitary Human Beings and Spirituality

Rogers' theory of nursing is deeply indebted to the revolutions that occurred in physics and philosophy during the late 19th and early 20th centuries. That she grasped the implications of these changes and melded them with non-western metaphysical ideas is testimony to her remarkable foresight.

Rogers' Science of Unitary Human Beings (SUHB) describes humans as energy fields that are both integral and in continuous mutual process with their environmental energy field. Humans are recognized by pattern manifestations that emerge from this continuous mutual process in the form of experiences, perceptions, and expressions. While Rogers did not address spirituality directly, she postulated that energy fields are pandimensional; that is, they exist in a nonlinear domain without spatial or temporal attributes (Rogers, in Barrett, 1990). This view suggests a quality of timelessness and the principle of integrality weaves energies together and fosters a sense of oneness with the universe. This same notion of oneness is present in non-western cultures (Suzuki, 1964) as well, as is the notion of respect for life and stewardship of the resources provided to us. Rogers (1992) herself, developed a theory of paranormal experiences and proposed that what formerly was considered paranormal is becoming normal. These paranormal experiences are becoming usual rather than unusual and ordinary rather than extraordinary. Malinski (1991) suggests that integrality is what is experienced when people refer to spiritual experiences.

From the standpoint of general system's theory (von Bertalanffy, 1968), Rogers' work and Native-American spirituality are holistic systems of mutuality, openness and equifinality. Rogers work and Native-American spirituality are entirely consistent with systems theory, presenting an organized whole to the relationships between (wo)man and (wo)man, (wo)man and environment, (wo)man and earth and (wo)man and universe/God. Similarly, other major religions offer conceptual systems that are systemic and incorporative, assisting clients to position themselves in a grand whole

Spirituality and Nursing

Spirituality has been discussed by many nurses. Nightingale believed that spirituality involved a higher intelligence that creates, maintains and serves to organize the universe and that we, as spiritual beings, can become aware of our connection to this higher power (Macrae, 1995). Watson (1988) suggests that caring nurses can help clients find meaning in the disharmony, suffering and strife of their lives and promote their feelings of self-control, power and self-determination in regard to health care issues. Morris (1996) states, "The spiritual component includes transcendent and existential features pertaining to an individual's relationship with the self, others, and a higher being (however that may be conceived)." Morris continues that "Coupled with interaction with one's environment, spiritual relationships can foster hope, a sense of life's meaning, and the acquisition and refinement of virtues."

Frankl (1965), a psychiatrist, is frequently cited in the nursing literature for his ability to wrest spiritual enrichment from the worst possible environmental challenges. Frankl was interned in four concentration camps during World War II. Logotherapy is a monument to his achievement of meaning and spirituality amidst monumental suffering and seeming hopelessness. Relf (1997) stated, "Spirituality encompasses hope; faith; self-transcendence; a will or desire to live; the identification of meaning, purpose and fulfillment in life; the recognition of mortality; a relationship with a 'higher power,' 'higher being,' or 'ultimate;' and the maintenance of interpersonal and intrapersonal relationships." Laukhuf and Werner (1998) presented a broad overview of spirituality in nursing practice, guidelines for assessing spiritual health and distress and methods to use to intervene with clients experiencing distress. Jung (1973) is also frequently cited by nurses in discussions of spirituality.

Native-American spirituality involves reverence for the earth, feelings of connectedness and abundance, respect for all forms of life and mineral resources, belief in spirit guides and affinity with a higher consciousness (Castaneda, 1968; Castaneda, 1981; Rogers, 1982). In particular, shamans are the cultural repository for orally transmitted healing and spiritual practices. Such notions are entirely consistent with J's stated spiritual beliefs.

Nursing Research on Spirituality

Smith (1995) reported in her Rogerian study of power and spirituality among polio survivors, that the experience of living through polio is related to spiritual notions of "unity with nature" and "evolutionary becoming". Peri, (1995) reviewing her research on people with AIDS (PWA's), cited obstacles to spiritual care including lack of religious rituals and practices that facilitate closure, inadequate sensitivity among pastoral caregivers, lack of privacy and access to loved ones, and lack of comfort on the part of caregivers with spiritual issues and their own spirituality. Sherman (1996), whose study was also framed within Rogerian science, concluded that the greater the level of a nurse's spirituality the higher his/her willingness to work with PWA's. Engebretson (1996) found that nurses differed from alternative healers in seeing spiritual healing activities as separated from other health activities. This suggests that nurses require more support and encouragement to view spiritual caring as significant, appropriate and necessary. Wright (1998) suggested that the nursing diagnosis of spiritual distress include both an ethical and legal obligation to render spiritual care as needed by the client. As with many other nursing interventions, spiritual care is to be rendered in a manner that is not intrusive, meets clients where they are, respects their personal privacy and integrity and allows them to discover or work with their own spirituality.

CASE STUDY 1

J is a 37 year old, divorced male. His Axis I diagnoses and major depressive disorder and acute psychotic reaction. At the time of the first interview he was involuntarily committed to a psychiatric facility having just attempted suicide by taking an overdose of anxiolytics. Culturally, he identifies himself as a Native-American from his maternal grandmother though he does not know her tribal affiliation. He prefers to live close to nature, spends a great deal of time foraging in the woods near his house where he lived with his girlfriend, her pregnant sister and two children, his 16 year old son and a 17 year old unrelated woman. He reported feeling overwhelmed by his inability to meet the needs of this group of people and felt that he needed to 'exit' the situation.

J receives disability pay due to a work-related accident affecting both feet. He supplements this income by selling artwork created from animal bones, tree limbs, brush, rocks and other artifacts that he finds on the 100 acre parcel of land he shares with other members of his patriarchal extended family. He also hunts, harvesting squirrels, rabbits and occasionally larger game he uses to supplement food stamps and provide food for himself and his household. He reported that he recently stopped taking his anti-depressant and anti-psychotic medications. J's plan of care included the diagnoses of spiritual distress and energy field disturbance. His spiritual needs serve as the focal point for this paper.

When first approached, J was withdrawn, mumbled inaudibly and incoherently and refused to make eye contact. His assessment revealed that he closely followed common Native-American traditions which include: respect for the land, taking the minimal amount that he needs from the environment, preserving the integrity of the environment and respecting all natural forms, i.e. mineral resources, animal and plant life. He stated his belief that he attempts to live in harmony with nature. He reported that he is on a spiritual quest and has spiritually enriching visions. It is unclear whether these visions are self-induced using Native-American traditional herbals and rituals or if they are hallucinations from his psychiatric condition. He shuns contact with the general public preferring to be in the woods, often for several days at a time. These characteristics are aspects of J's spirituality pattern manifestation. Indeed, when he was encouraged to elaborate about his spiritual beliefs, his mood became more elevated and his interaction became more dynamic, coherent and peaceful. J affirmed his belief that he is himself, a shaman, healer and spiritual entity.

Research based nursing interventions with J related to the diagnosis of spiritual distress. These included being present for him, encouraging his expression of his own spirituality, supporting him in the unfolding of his spiritual beliefs, facilitating access to the only location at the facility where he could feel closer to nature and, helping him realize how he could integrate his spiritual beliefs with his treatment plan to attain discharge.

We continued to discuss his life, his longing to leave the treatment setting, to be back at home, his treatment plan and goals. Discharge plans included arranging to have several troublesome members of his household move as well as plans for continued monitoring of medications for depression and psychosis at a local clinic. He reported that he felt more powerful by being able to share so much of himself and it was the first time in weeks that he had felt positive about himself and his life. He denied any current suicidal ideation and was released after two days of hospitalization.

It is unlikely that a non-spiritually based intervention would have had such a dramatic result. J's refusals to take medications and his efforts to avoid interaction with the professional staff made it likely that he would be in the hospital for several weeks. By attending to his spiritual needs the barriers to his own healing journey were easier for J to overcome. By supporting him in developing a healing vision of his hospitalization, this nurse assisted J to integrate the experience into his life as a useful part of his spiritual quest.

CASE STUDY 2

S was a 58 year old African-American male. He was a long-term patient in a state facility where he had been in residence for over 20 years. His clinical diagnoses were Major Depressive Disorder and Schizophrenia, Paranoid Type. He had one tooth and the lack of dental structure in his oral cavity made his speech difficult to understand. He frequently engaged in emotional outbursts during which his speech was pressured and indecipherable to most of his caregivers. At the time of this intervention S had not slept in a bed in over eight years. At that time he had been suddenly transferred from one unit to another, in the facility, without his agreement or foreknowledge. He slept, if at all, in a chair in the day room but refused to even consider using a bed.

His behavior attracted the attention of the psychosocial rehabilitation team and a behavioral treatment plan was instituted to deal with the issue of sleeping in a bed. The basis for this intervention was that his refusal to sleep in a bed would hamper efforts to secure his release to a community residential facility. A very well appointed room was prepared to meet numerous of his objections. Despite these efforts, S refused to use the room, or the bed. This nurse became involved by virtue of a chance conversation about behavioral planning with a member of the psychosocial rehabilitation team.

Based on prior interactions with this client, this nurse had noticed that S frequently sang a few words, among his very few distinguishable utterances, and seemed to relax when he did. The words were apparently from a song: "Come to Jesus". He sang the first line, over and over, often for 20 to 30 minutes. The behavioral plan developed for him included evening snacks, and required that a nurse accompany him to his room. The intent of the plan was that a nurse would stay with him, in his room, for an hour each night. A deficit of the plan was that there were no efforts to augment staffing to facilitate this plan and it was frequently the case that the nurses on duty were unable or unwilling to comply with the behavioral plan. Beyond that, it was unclear that the behavioral reinforcers in the plan, a can of soda and a bag of snacks to be given at bedtime, would be effective. S would usually take the reinforcers, sit in a chair in the bedroom long enough to eat and drink and then leave the room to return to the day room.

This nurse, having noted the pattern of singing and relaxing, suggested that music might be a better reinforcer than the soda and snacks. There were two problems with this suggestion. First, it was not part of the approved behavioral plan. Second, it required a source of music in an environment where electrical cords were taboo. The first issue was resolved informally by agreeing to abide by the extant plan but with no obligation not to provide a reinforcer not in the plan. The behavioral team even assisted with securing a tape player for use by the patient. There were, however, no batteries for the tape player. State institutions are what they are, and after approximately a week, permission to use an electrical cord was obtained. This nurse first suggested gospel music, anticipating that it would be appropriate to his age and many years ago when he was last outside the hospital setting. Instead, a tape of a modern, Christian Rock band was delivered. S did not like this tape. A second tape was no better. This nurse than found an old Peter Paul and Mary tape with "If I had a Hammer" on it.

S responded quite well to the tape. On the first night it was played S was asked to sit on the bed while he ate the snack, drank the soda and listened to the tape. After 20 minutes he unexpectedly took off his shoes, socks, and coat, folded down the sheets and blankets and crawled into the bed. He fell asleep in another twenty minutes and remained asleep for 4 hours. That was the first occasion on which he had either sat on a bed or been in a bed in eight years.

An appropriate tape, with his favorite song - "Come to Jesus" was eventually secured. The 'spiritual' intervention was very successful and over the course of the next few weeks this nurse often sat with S while he listened to Gospel music, ate his snacks and went to bed. Providing access to spiritually meaningful resources can be done without conflict if the nurse simply attends to the needs of the client rather than addressing their own religious or spiritual concerns.

CONCLUSION

Spirituality is related to the work of Martha E. Rogers on the Science of Unitary Human Beings. Spiritual intervention is clearly within the framework of SUHB and can be an effective tool for assisting clients making transitions, dealing with crises or, as suggested above, with simple aspects of treatment. By employing spiritual as well as conventional interventions in a holistic fashion, the nurse can become a more effective caregiver and better respond to the complex needs of clients. Clients do not leave their spiritual, physical or intellectual needs at home when they interact with health care professionals. The more completely a client is responded to by health care personnel, the more likely they are to accept and benefit from the care that is offered. Spiritual interventions are often as simple as listening carefully to the expressions of clients and can be performed with little or no material resources. Spiritual intervention need not sacrifice the beliefs of the client nor the provider if they are offered in a non-challenging, supportive and comfortable manner, which neither endorses nor refutes the clients or nurses personal belief system.