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Nursing care is designed to accommodate the biological, psychological, social, cultural, and spiritual needs of clients.

~ Canadian Nurses Association; Code of Ethics (p.13) ~ Nurses provide holistic care that includes care not only for the physical body and mind, but also for the clients spirit. When meeting clients needs, nurses can decrease suffering and aid in physical as well as mental healing. Physical: Stimulus response Psychosocial: Awareness of sensation & action roles Spiritual: Transcendent awareness To implement spiritual care, nurses must: Be skilled in establishing trusting nurse-client relationships (Should possess a healthy spiritual awareness which can help nurses identify and be empathic towards the spiritual concerns of clients). Be aware of the diverse spiritual beliefs and practices that client may possess. (These can be coping resources for persons, and it is vital how these beliefs/ practices help or hinder a clients health). Nurture clients spiritual strengths to promote spiritual and emotional health, help with coping adjustments, or assist one to face a more peaceful death. RELIGION AND SPIRITUALITY First, it is important to note that religion and spirituality are two different things though they are being used interchangeably. Let us define Spirituality first; its root word spiritual came from the Latin word spiritus meaning to blow or to breathe and has come to signify that which gives life or essence to being human. Thereby, Spirituality refers to a part of being human that seeks meaning through intra-, inter-, and transpersonal connection (Reed, 1992). It generally involves a belief in a relationship with some higher power, creative force, divine being, or infinite source of energy. To be spiritual, you dont have to be linked with a religion or religious group. e.g. A person may believe in God, Allah, the Great Spirit or Higher Power According to Martsolf & Mickley (1998), spirituality includes the following aspects: 1. Meaning (having purpose, making sense of life) 2. Value (having cherished beliefs and standards) 3. Transcendence (appreciating a dimension that is beyond the self) 4. Connecting (relating to others, nature, Ultimate Other) 5. Becoming (involves reflection, allowing life to unfold and knowing who one is) Spirituality can be described by measuring it by means of spirit titer (Jourard, 1971). It is influenced by numerous factors, such as life experiences, coping skills, social supports, and individual health belief systems. A low spirit titer causes clients to be disspirited or depressed. Meanwhile, a high spirit titer makes client to be inspired and may become an inspiration to others despite of hardships. As nurses the goals and planning should be directed to assist the clients in attaining and maintaining a high spirit titer. Furthermore, Spiritual needs are often accentuated by an illness or other health crisis. Nurses need to be sensitive to indications of the clients spiritual needs and respond appropriately.

Spiritual Health or spiritual well-being is manifested by a feeling of generally alive, purposeful, and fulfilled (Ellison, 1983). According to Pilch (1998), spiritual wellness is a way of living, lifestyle that views and lives life as purposeful and pleasurable, that seeks out life sustaining and life-enriching options to be chosen freely at every opportunity, and that sinks its roots deeply into spiritual values and/or specific religious beliefs. According to Nursing Outcomes Classification project, spiritual health is the connectedness with self, others, higher power, all life, nature and the universe that transcends and empowers the self. Indicators of Spiritual Health Uncompromised Faith Hope Meaning and purpose in life Achievement of spiritual world Feelings of peacefulness Ability to love, forgive, pray and worship Spiritual experiences Participation in spiritual rites & passages, meditation, and spiritual reading Interaction with spiritual leaders Expression through song/music, art, and writing Connectedness with inner self and with others Interaction with others to share thoughts, feelings and beliefs Examples of Spiritual Needs Needs related to self: Need for meaning and purpose Need to express creativity Need for hope Need to transcend life challenges Need for personal dignity Need for gratitude Need for vision Need to prepare for and accept death Needs related to others: Need to forgive others Need to cope with loss of loved ones Needs related to the Ultimate Other: Need to be certain there is God or Ultimate Power in the universe Need to believe that God is loving, and personally present Need to worship Needs among and within groups Need to contribute or improve ones community Need to be respected and valued

Need to know what and when to give and take Spiritual Distress refers to a challenge to the spiritual well-being or the belief system that provides strengths, hope, and meaning to life Factors contributing to spiritual distress: Physiologic problems (include having a diagnosis of terminal disease, experiencing pain or loss of body part/function, and/or miscarriage or stillbirth) Treatment-related concerns (recommendation for BT, abortion, surgery, dietary restrictions, amputation of body part, or isolation) Situational factors (include death or illness of significant other, inability to practice ones spiritual rituals, or feelings of embarrassment when practicing them) A client experiences spiritual distress if he/ she: Expresses lack of hope, meaning and purpose in life Expresses being abandoned by or having anger toward God Refuses interaction with family or friends Suddenly changes spiritual practice Requests to see religious leader Have no interest in nature, reading spiritual literature RELATED CONCEPTS RELIGION Organized system of beliefs and practices. It offers a way of spiritual expression that provides guidance for believers in responding to lifes questions and challenges. According to Vardey (1996), it offers: Sense of community bound by common beliefs Collective study of scripture such as the Koran and Bible Performance of ritual Use of disciplines, practices, commandments and sacraments Ways of taking care of persons spirit (such as fasting, prayer and meditation) Religious rules of conduct may influence matters of daily life, such as dietary habits, dress and others. Religious development refers to the acceptance of beliefs, values, rules of conduct, and rituals. (It may or may not be parallel to spiritual development; for instance, a person may abide their religious practice but does not internalize the meaning behind it.) Agonist = doubts existence of a supreme being Atheist = do not believe in God Theist = believe in God Monotheism =believing in one God Polytheism = believing in two or more supreme being FAITH

To believe in or be committed to something or someone and could be present both in a religious or non-religious person. (It gives life meaning, providing the individual with strength in times of difficulty. It also provides strength and hope) HOPE Concept that incorporates spirituality. According to Stephenson, it is a process of anticipation that involves the interaction of thinking, acting, feeling, relating, and is directed toward a future fulfillment that is personally meaningful. In its absence, client may give up, lose spirit, and illness progresses rapidly. TRANSCENDENCE Coward (1990), the capacity to reach out beyond oneself, to extend beyond personal concerns and to take on broader life perspectives, activities and purposes. It involves understanding that there is something greater than the self. STAGES OF SPIRITUAL DEVELOPMENT DEVELOPMENTAL STAGE CHARACTERISTICS 0-3 years Acquire spiritual qualities of trust, mutuality, courage, hope and love 3-7 years Fantasy-filled, imitative phase wherein child incorporates spirituality and religion through fictional stories. 7-12 years Sorts fantasy from facts by demanding proof/ evidence. Adolescence Generally conforms to the beliefs around them. Mid-adulthood Attempts to reconcile contradictions in mind and experience and to remain open to others truths. Mid-to late adulthood Able to believe in, and participates in a non-exclusive community. GUIDELINES FOR ETHICAL CONDUCT IN SPIRITUAL CAREGIVING: 1) First seek a basic understanding of clients spiritual needs, resources and preferences. 2) Follow clients expressed wishes regarding the spiritual care. 3) Do not force clients to adopt certain spiritual beliefs or practices. 4) Strive to understand personal spirituality and how it influences care giving. 5) Provide spiritual care in a way that is consonant with personal beliefs. SPIRITUAL PRACTICES THAT AFFECTS NURSING CARE: 1.) HOLY DAYS - a day set aside for special religious observance. Examples: Christians Easter & Christmas, however religious affiliation like I.N.C. does not celebrate these occasions

Jews Yom Kippur and Passover Buddhists birthday of Buddha Muslims month long period of Ramadan Hindus Mahashivarathri (celebration of Lord Shiva) - Many religions require fasting, extended prayer, and reflection or ritual observances - Concept of Sabbath is common to both Christians and Jews, in response to biblical commandment Remember the Sabbath day to keep it holy. Some celebrate it during Sundays and some celebrate it during Saturday. - Muslims follow the practice of prayer five times daily and they traditionally gather on Friday at noon to worship and learn about their faith. - Hindus and Buddhists practice meditation, and the nurse may create a quiet time for them to meditate. - Fasting, reflection & prayer are known as high holy days because they are solemn religious practices. e.g. Good Friday & Rosh Hashanah 2.) SACRED WRITINGS - sacred and authoritative scriptures that provide guidance for its adherents beliefs and behaviors. - known as the word of the Supreme being Examples: Christians Bible Jews Torah and Talmud Muslims Koran Hindus holy texts & Vedas Buddhists teachings of Tripitakas - it generally set forth religious law in the form of admonitions and rule for living e.g. Ten Commandments - this may affect a clients willingness to accept treatment suggestions e.g. blood transfusions are in conflict with the religious admonitions of Jehovahs Witnesses - it may give strength and hope such as the story of Jobs suffering from the Bible. 3.) SACRED SYMBOLS - it include jewelry, medals, amulets, icons, totems, or body ornamentation that carry religious or spiritual significance - worn to pronounce ones faith, to remind the practitioner of faith, to provide spiritual protection, or to be a source of comfort or strength. Examples: Roman Catholics rosary Muslims maya (string of prayer beads) 4.) PRAYER & MEDITATION

- Prayer is a spiritual and/ or religious practice and is simply defined as human communication with divine and spiritual entities. - Categories of prayer experiences according to Poloma and Gallup (1991): a.) Ritual (memorized prayers that can be repeated, e.g. Hail Mary) b.) Petitionary (intercessory prayers when is requesting something of the divine, e.g. God, cure me! c.) Colloquial (conversational prayers) d.) Meditational (moments of silence, meaningful phrase, certain aspect of divine) Examples: Muslim 5 prayers or Salat (performed while facing east toward Mecca at dawn, noon, mid-afternoon, sunset & evening) Jews daily Kaddish Roman Catholics 7 canonical prayers - Meditation is the act of focusing ones thoughts or engaging in selfreflection or contemplation. 5.) BELIEFS AFFECTING DIET AND NUTRITION - There may be rules about which foods and beverages are allowed and which are prohibited. Examples: Orthodox Jews not eat shellfish or pork Muslims not drink alcoholic beverages or pork Mormons not drink caffeinated or alcoholic beverages, and not eat pork Buddhists & Hindus generally vegetarians Jews requires kosher food (mixture of meat, milk, wine, or grape juice) - Some religions are marked by fasting which is the abstinence of food for a specified period of time. 6.) BELIEFS RELATED TO HEALING - Healing for some clients may appear to be unrelated to current treatment practices. 7.) BELIEFS RELATED TO DRESS Examples: Orthodox Jews heads are covered all the time and wear yarmulkes Muslim cover hair Mormons wear temple undergarments Hindu wear saris 8.) BELIEFS RELATED TO BIRTH Examples:

Muslim when a child is born, someones recites the call to prayer in the infants ear. Then, on the 7th day after birth, the child is named, and a tuft of hair is shaved from the head. Jews circumcision is done on male children on the 8th day after birth as an expression of the religious bond between the prophet Abraham - When nurses are aware of these needs, they can assist families in fulfilling their religious obligations. 9.) BELIEFS RELATED TO DEATH - Many believe that the person who dies transcends this life for a better place or state of being. Examples: Roman Catholic priests perform the Sacrament of the Sick (Last Rites) during near death Muslims when dying, they want their head or body turned toward Mecca Jews tradition of burial within 24 hours Hindus cremate body within 24 hours to release the soul from any unearthly attachment OTHER HEALTH RELATED INFORMATION ABOUT SPECIFIC RELIGIONS RELIGION INFORMATION Amish, Mennonite Wont have insurance coverage Rely on religious community for support Maybe vegetarian, lacto-ovo-vegetarian or semi-vegetarian, depending on the form of Buddhism and on the part of the country of Buddhist origin. No alcohol or tobacco products. Facilitate meditation Requires 5 times of prayer daily Prefer cremation Most do not eat beef (No pork, pork products, blood or carnivorous animals) Many are vegetarian Cleanliness highly valued (Seafood and fish Hindu are allowed from unpolluted water) No tobacco or intoxicants Rinse the mouth with water after eating Usually use the right hand for eating Jehovahs Witness Abstain from most blood products (Abstain from eating blood, foods with blood added, and the meat of animals from which blood has not been properly drained)

Jews Latter-Day Saints (Mormons)



Roman Catholics

Seventh-Day Adventists


Observe kosher diet to varying degrees Avoid alcohol, caffeine, smoking Prefers wearing temple undergarments Respect modesty; avoid nakedness Provide same-gender nurse if possible Prayers are 5 times daily Eat no pork (Abstain from eating blood, foods with blood added, and the meat of animals from which blood has not been properly drained) Last Rite for the ill/ dying Avoid unnecessary treatments on Saturday Vegetarian Abstain from caffeinated beverages Do not smoke or drink alcohol Does not eat pork (Often use meat analogues made of soy or gluten) Quiet time for reading the Bible

NURSING MANAGEMENT ASSESSMENT - obtain from general history - NURSES SHOULD NEVER ASSUME THAT A CLIENT FOLLOWS ALL THE PRACTICES OF THE CLIENTS STATED RELIGION - follow FICA: F (faith or beliefs) i.e. What spiritual beliefs are most important to you? I (implications or influence) i.e. How is your faith affecting the way you cope now? C (community) i.e. Is there a group of like-minded believers with which you regularly meet? A (address) i.e. How would you like your health care team to support you spiritually? - include also: Environment i.e. use of sacred symbols such as rosary, etc. Behavior i.e. scheduled prayers, etc. Verbalization i.e. mentions supreme being, express fears and meaning of life, etc. Affect and attitude i.e. lonely, depressed, anxious, etc. Interpersonal relationship i.e. who visits, does minister come?, etc. DIAGNOSIS Spiritual Distress impaired ability to experience and integrate meaning and purpose in life through self or others

Readiness for Enhanced Spiritual Well-Being wellness diagnosis that acknowledges that some people respond to adversity with increased sensitivity to spiritual or spiritual maturation. Risk for Spiritual Distress Impaired Religiosity impaired ability to exercise reliance on religious beliefs Risk for Impaired Religiosity impaired ability to exercise reliance on religious beliefs Readiness for Enhanced Religiosity ability to increase reliance on religious beliefs

PLANNING Help the client fulfill religious obligations. Help client draw on and use inner resources more effectively to meet present situation. Help client maintain a dynamic relationship with a supreme being in the face of unpleasant circumstances. Help client find meaning in existence Promote sense of hope Provide spiritual resources otherwise unavailable IMPLEMENTATION - A client with a good measure of spiritual health will find hope, meaning, purpose, and value in existence. Although nursing therapeutics that enhance spiritual health are diverse, some of the most common nursing implementation are the following: 1. PROVIDING PRESENCE Presencing is defined as being present, being there or just being with a client. It can is characterized through: giving of self in the present moment being available with all of the self listening, with full awareness of the privilege of doing so being there in a way that is meaningful to another person It is also a gift of self given by the nurse who maintains an attitude of attentiveness toward the client. It can be the best and sometimes the only intervention to support client who suffers under circumstances that medical interventions cannot address. 4 WAYS OF BEING PRESENT FOR CLIENTS: a.) Presence nurse is physically present but not focused on the client b.) Partial presence nurse is physically present and attending to some task on the clients behalf but not relating to the client on any but the most superficial level c.) Full presence nurse is mentally, emotionally, and physically present; intentionally focusing on the client.

d.) Transcendent presence nurse is physically, mentally, emotionally, and spiritually present for a client; involves a transpersonal and transforming experience 2. SUPPORTING RELIGIOUS PRACTICES Nurses need to consider specific religious preferences and practices that will affect nursing care, such as clients beliefs about birth and, death, dress, diet, prayer, etc. 3. ASSISTING CLIENTS WITH PRAYER It offers a means for someone to talk to, a mechanism for expressing care, and a sense of serenity and connection with something greater. In addition, nurses should ensure privacy and a quiet environment. 4. REFERRING CLIENTS FOR SPIRITUAL COUNSELING Sometimes necessary if a client refuses necessary medical intervention because of religious tenets.

References: Griffith, J.K. (2009). THE RELIGIOUS ASPECTS OF NURSING CARE. Edition.pdf Kozier & Erb (2008). Fundamentals of Nursing. (Vol. 1& 2, pp.1042-1057; pp.1517). New Jersey, Pearson Education Inc.

Questions & Answers (w/ Rationales): 1.) When planning care for an elder residing in your skilled nursing facility who is searching to make life meaningful, which nursing action would be most beneficial? a.) Assess for depression. b.) Diagnose and document that the client has spiritual distress. c.) Keep the client busy with social activities. d.) Explore with the client their desired legacy. Answer: D Rationale: Option A and B involves assessment and diagnosis, not planning. Option C, simply keeping the client busy, does not necessarily contribute to feeling fulfilled or purposeful. 2.) A clients wife asks the nurse to pray for her. What would be the best initial nursing response for a nurse who believes in prayer? a.) May I call the chaplain to come and pray with you? b.) I know your faith is important to you. It is to me, too. c.) What should I pray for? d.) Isnt it wonderful that we have a God whom we can share our concerns? Answer: C Rationale: The best initial response is to assess. Option A may be interpreted as distancing by the client. Option B inserts the nurses experience, which is generally inappropriate. Option D is not appropriate for someone in spiritual distress. 3.) A client is experiencing severe pain that cannot be controlled by analgesics. An appropriate intervention is full presencing, which involves which of the following? a.) Physical presence. b.) Physical presence with mental awareness of the client. c.) Physical, mental, and emotional presence. d.) Physical, mental, emotional, and spiritual presence. Answer: C Rationale: The key term is full. Option A would be inadequate; Option B is only partial presencing; and option D is transcendent presencing. 4.) A client reports, Cancer was the best thing that happened to me! It is making me appreciate life so much more. This statement fits best with which NANDA diagnosis? a.) Spiritual Distress b.) Readiness for Enhanced Spiritual Well-Being c.) Risk for Spiritual Distress d.) Cognitive Denial Answer: B

Rationale: The client portrays no distress or risk for distress, but rather the potential for enhanced spiritual health as a result of the transformative illness experience. Option D is not a valid diagnosis. 5.) A dying client states, Part of what makes dying so hard is that I dont know for sure where I m going. Nurse, what do you believe happens in the hereafter? What ethical guideline should I guide your response? a.) Never share personal spiritual beliefs. b.) Share all spiritual beliefs, favoring none. c.) Share only your beliefs. d.) First assess client beliefs. Answer: D Rationale: Assessment is always the first step of the process of spiritual care giving or any nursing activity. The other options may not respect the spiritual beliefs of either the nurse or the client. While an assessment may lead the nurse to share personal beliefs, these are never urged on the client. 6.) Research evidence that supports providing spiritual care to elders suggests that: a.) Elders are not very religious, but are very spiritual. b.) Elders who are more religious have more illness. c.) Spiritual health and mental health are correlated. d.) Increased spiritual well-being is found among elders with depression. Answer: C Rationale: Many elders are frequently religious and spiritually aware. The other answers are disputed by recent research evidence. 7.) A client in the emergency department, who needs immediate blood transfusion, is a Jehovahs Witness who believes it would be medical rape for the nurse to give the prescribed blood transfusion. Which of the following statements would most likely lead to a resolution for this conflict? a.) You must accept the transfusion or else leave. b.) I understand your position Ill be here with you as you die. c.) Dont worry, you can ask for pardon after taking the blood. d.) May I please call a representative of your religion so that I can understand your position better? Answer: D Rationale: The other options are potentially uncaring and unethical. Jehovahs Witnesses have a well-developed network of representatives who can be called to explain and explore medical options with their fellow believers and medical staff. 8.) An 88-year-old woman has just been admitted to a skilled nursing facility. She tells the nurse that she has been a Sunday school teacher and volunteers for many of her churchs projects. Which of the following NANDA diagnoses is most appropriate?

a.) b.) c.) d.)

Risk for Spiritual Distress Risk for Impaired Religiosity Readiness for Enhanced Spiritual Well-Being Impaired Religiosity

Answer: B Rationale: Residing in the skilled nursing facility likely will curb the clients participation in her church. It is not known if the relocation or an alteration in religious practice will affect her spiritual well-being in either a negative or positive way. 9.) Which of the following is an appropriate spiritual screening or assessment question? a.) Tell me more about your religion. b.) How can we support your spiritual beliefs and practices? c.) How has your prayer experience been affected by your illness? d.) What do you see as the purpose or mission for your life? Answer: B Rationale: The other options are appropriate for a more specific assessment, if the screening suggests it is necessary. A nurse does not have time or authority to conduct a complete spiritual assessment for every client. What is important for the nurse to assess, however, is how the clients spiritual beliefs and practices may affect the response to illness and how the healthcare team can support spiritual health. 10.) The mother of a pediatric client states, I cant understand why God would allow this to happen to my innocent child! Which NANDA diagnosis is most accurate? a.) Spiritual Distress related to searching for meaning of childs illness b.) Impaired Religiosity related to anger at God c.) Ineffective coping related to anger d.) Risk for Spiritual Distress related to threatened sense of hope Answer: A Rationale: Although the mother is arguably angry (Option B & C), it is unknown whether this anger is impairing her religiosity or her coping. More data are needed before determining that either Option B or C is the best nursing diagnosis. The mother is experiencing distress versus being at risk for it (Option D). 11.) Before meeting with a client with a terminal illness, a new graduate nurse reviews information on spirituality. Which of the following is the best explanation of spirituality? a.) That which gives people purpose and meaning in their lives. b.) A formalized religious dogma. c.) A nondenominational community service. d.) People being responsible for their life patterns.

Answer: A Rationale: Spirituality gives as purpose and meaning in life; involves a relationship with oneself, others and a higher power; and involves finding significant meaning in the entirety of life. Spirituality is much a broader concept than religion and religious services. Responsibility to life patterns is a concept of humanism. 12.) A nurse who provides culturally competent care would expect to: a.) Find out where the client used to live. b.) Schedule treatments around a clients need to pray at certain intervals. c.) Be knowledgeable about one foreign language. d.) Involve Social Services in the plan of care.

Answer: B Rationale: Cultural competence requires respect for holistic needs of the client in all aspects of care. Where a client used to live is not relevant to culturally competent care, because many people have lived in several places. Social workers do not provide nursing care, and nurses do not need to know another language to provide culturally competent care. 13.) Which statement about religion is most accurate? a.) Religious teachings tend to oppose cultural values and norms. b.) Religion is a system of beliefs, practices, and ethical values regarding the creator(s) or ruler(s) of the universe. c.) Socialization must take place before religion can be accepted. d.) Religion generally is not related to ethnicity.

Answer: B Rationale: Culture, religion, and ethnicity shape a person's worldview. Religion often is determined by one's cultural and ethnic group. Religious teachings may begin in early childhood, before the individual is acclimated to society's norms. 14.) For which of the following religious groups is all meat prohibited? a.) Hinduism b.) Seventh Day Adventism c.) Judaism d.) Islam

Answer: A Rationale: Option A prohibits consumption of all meats and animal shortening. Options B & C prohibit the consumption of pork only. The last option prohibits the consumption of pork and animal shortening. 15.) Assessment of a palliative care patient's spiritual or religious beliefs should encompass which of the following? a.) Screening for spiritual beliefs that may conflict with the palliative care nurse's religious practices

b.) Encouraging the patient to join a religious community if they do not already belong to one c.) Asking about spiritual customs or rituals around illness and death that are meaningful to the patient d.) Assessing spiritual or religious beliefs only if the patient volunteers information about religion and spirituality Answer: C Rationale: Spirituality and religion may play a large part in how the terminally ill patient experiences and responds to the dying process. Assessing the role of religious or spiritual beliefs in each patient's life is an important component of a patient's assessment and should, ideally, take place as early as possible in the relationship between patient and palliative care providers. Some patients may have extensive involvement in a religious or spiritual community, while others may have deep personal beliefs, which are not necessarily associated with an official organization or community. Patients who do not identify strongly with spiritual or religious beliefs should not be urged to do so. Spiritual and religious beliefs may influence a patient's beliefs about why they are ill, which medical interventions they are willing to pursue, rituals they would like around the time of death, and potential sources of comfort during the dying process. Although, at times, a patient's religious and spiritual beliefs may differ from the nurse's personal beliefs, the primary purpose is not to seek out differences but to discover what will be most meaningful and helpful to the patient.