Spiritual Care as a Core Component of Palliative Nursing

Abstract

Spirituality is one aspect of the human experience that is unique to each person and may become especially important in the face of life-threatening illness. While evidence supports the need to address spirituality as part of holistic palliative care nursing, it is hoped that “spiritual care” will not become another item on nurses’ to-do list, but rather will be part of nurses’ everyday lives and nursing practice. Taking time to assess personal needs, and consciously connecting to meaning, hope, and peace, can support nurses’ return to the deeper roots of nursing. Addressing spirituality as part of palliative nursing care can also acknowledge the complex and multidimensional experiences of the patients that nurses serve. Connecting, or reconnecting, with nurses’ unique sense of spirituality can serve as a powerful resource for resilience. This article highlights the relevance of spiritual care to palliative nursing and offers practical tips to incorporate spiritual care into everyday nursing practice.

At the end of a shift, you go in to check on Tracy, a 53-year-old woman with metastatic lung cancer. She is crying. She says she doesn’t know how she’s going to get through her next treatment, and she’s terrified of dying. She looks at you and asks, “What do you think happens after you die?”

For a palliative nurse, this is not an uncommon situation, and taking time to sit with a patient and provide much-needed support can be one of the most rewarding parts of our work. Tending to the diverse and holistic aspects of the human experience is at the roots of nursing.¹ While spirituality is inherently unique to each person, and many people do not identify with the notion of spirituality at all, dimensions such as connection, meaning, hope, and peace can be relevant to everyone.²

Addressing spirituality may become especially important in the face of a patient’s life-threatening illness. A spiritual perspective is associated with better tolerance of physical and emotional stress, and may reduce the risk of suicide and depression among patients with serious illness.³ Spiritual care can also be an important part of working with bereavement and grief. While evidence in this area is not conclusive, it is clear that many people turn to religious or spiritual beliefs and practices for solace, comfort, and understanding amid loss.⁴

Delivering spiritual care is an essential aspect of integrating a human-centered approach with evidence-based nursing practice.⁵ The purpose of this article is to highlight the relevance of spiritual care to palliative nursing, and to offer practical tips on incorporating spiritual care into practice—not only to support patients’ well-being, but also to nurture and sustain ourselves as nurses and help us find the deeper personal–professional meaning in our work.

PUTTING SPIRITUAL CARE INTO PRACTICE

Every nurse is tasked with being a spiritual care generalist—providing comfort and care to support the spiritual life and well-being of patients.⁶ Although evidence supports addressing spirituality as part of holistic palliative care nursing,^6–8 we need to be watchful that spiritual care doesn’t become another item on our to-do list, but rather is practiced as an embodied way of being, that is, as a part of our daily life and our moment-to-moment nursing activities.

COVID-19 has underscored the need for spiritual care generalists.^{9, 10} Nurses have never been asked to do more. Over time, the cumulative impact of caring for patients and witnessing the suffering they endure can lead to feelings of hopelessness, despair, moral distress (being unable to provide the quality of care we aspire to), and burnout^{11, 12}—and may even make us question why we became nurses. Many nurses are leaving the profession in hopes of getting a break from the intensity of suffering and grief. According to a survey of 8,080 critical care nurses, one-third said they intended to leave in the next 12 months, some because they reported experiencing moral distress “very frequently.”¹³

The pandemic has also pierced the thin veil between clinicians and patients, bringing more acute awareness of our shared vulnerability and mortality.¹⁰ The immense experiences of suffering, grief, loneliness, posttraumatic stress, and burnout among nurses today call for a reexamination not only of our care delivery systems, but also of the personal frameworks through which we approach our nursing practice. Taking time to assess personal needs, consciously cultivating meaning, hope, and peace, can support a return to the deeper roots of palliative nursing work. Connecting, or reconnecting, to a sense of spirituality can serve as a powerful resource for resilience in these challenging times.

WHAT IS ‘SPIRITUAL CARE’?

How should we define the complex concept of spirituality? An understanding of spirituality typically includes connection with self, others, nature and/or a higher power, and a sense of meaning or purpose.^{2, 14–16} Simply put, spirituality may be seen as our essential relationship with life—how we understand, make meaning of, and relate to events in our lives.

Lived experiences of spirituality can be highly variable, expressed through our beliefs, values, rituals, traditions, and practices. Some people may reject the concept of spirituality altogether, preferring terms like connection, meaning, and purpose when considering existential aspects of life. Here, though, we’re using the term spirituality in a broad and inclusive way, acknowledging unique experiences of connection and meaning or purpose.

Caring for the spiritual needs of another human is one of the most privileged aspects of the nursing profession.¹⁷ Spiritual care is an essential component of whole-person palliative nursing care.^{6, 8, 18, 19} In fact, “spiritual, religious, and existential aspects of care” is one of the eight domains in the recent Clinical Practice Guidelines for Quality Palliative Care from the National Coalition for Hospice and Palliative Care (NCHPC).⁸

A unique generalist–specialist spiritual care model has been proposed, where all palliative care providers serve as spiritual care generalists.⁷ In this model, palliative care team members have a responsibility to recognize their limits and refer patients to specialist spiritual care team members when needed, typically board-certified chaplains.⁷ Specific generalist spiritual care competencies have been proposed based on the 2009 Spiritual Care Consensus Conference¹⁹ and the National Consensus Project Clinical Practice Guidelines for Quality Palliative Care.⁶ These competencies, compiled by Beaussant and colleagues,⁷ include the following:

• recognizing spirituality as an integral component of the human experience of illness, healing, and health

• collaborating closely with spiritual care professionals

• practicing compassionate presence and active listening

• performing spiritual histories in a patient-centered, confidential, and respectful manner

• screening for spiritual concerns and needs

• recognizing patients’ unique beliefs, values, practices, and support communities

• respecting patient autonomy

• having a basic understanding of the spiritual beliefs/values of major faith traditions

• recognizing and addressing one’s own spirituality

Notably, the NCHPC guidelines also highlight the importance of nurses tending to our sense of spirituality as part of our professional role,⁸ acknowledging the reality that self-care and self-knowledge are necessary when providing authentic, high-quality palliative nursing care.

Spiritual care recognizes and responds to our spiritual needs and to those of our patients as we cope with trauma, illness, or sadness. It also addresses the need for meaning, self-worth, self-expression, faith support, and prayer or sacrament.^{20, 21} Spiritual care within nursing practice can begin by encouraging human contact, an authentic connection, between the nurse and the patient.²⁰ It may then be guided by unique patient needs,²⁰ which can vary based on patient and family age, developmental needs, culture, traditions, and spiritual preferences.⁸ Sometimes spiritual care simply requires sensitive listening.²⁰

Cornerstones of spiritual care include presence, intentionality, and compassion.²² Presence is a practice of approaching patients in a way that acknowledges and honors their holistic nature, focuses on creating an interpersonal environment of authenticity, and interacts with patients as unique individuals.²³ Intentionality includes performing an action with compassion and a desire for the greatest good.²³ Compassion involves bearing witness to a person’s lived experiences, seeking to understand their suffering, as well as acting in alignment with an intention to reduce suffering.²⁴

Given the increasing demands on nurses, cultivating presence, intentionality, and compassion in clinical care may feel elusive or idealistic, especially when considering limitations on time and capacity. Yet even within hurried clinical environments, it’s possible to bring these tenets into action in small and creative ways.

WHAT CAN YOU DO AS A SPIRITUAL CARE GENERALIST?

Here are some of the ways nurses can serve as a powerful resource to support our patients and sustain our well-being in our work.

Connect with your sense of spirituality, meaning, and purpose.

When considering how to provide spiritual care, it is important to recognize our own spiritual care needs. This can lead to deeper connection with ourselves and the patients we serve, but also to reconnection with the essence of nursing. It can be helpful to reflect on how the suffering witnessed at work and in the world impacts the care we provide—and how it affects us. We can ask ourselves, for instance, “When do I feel most connected to patients and families? What happens in those interactions?” (See Questions to Guide Self-Reflection: How Do I Really Feel?)

Questions to Guide Self-Reflection: How Do I Really Feel?

Supporting connection to nurses’ unique sense of spirituality.

• How do you care for yourself at work and elsewhere?

• How do you make sense of suffering, and how does that impact your ability to connect with your patients?

• What do you need from your employer and yourself to be able to provide care for your patients in a way that is sustainable for you?

• Notice when you feel most connected to patients and families; what happens in those interactions?

• When do you feel renewed?

• Reflect on why you went into nursing, what is the essence of the profession?

• Where do you need support to be able to continually reconnect with what makes your work meaningful?

Acknowledge spiritual care as a core component of holistic palliative care.

The NCHPC guidelines outline the responsibility of all clinicians to assess and respond to spiritual care needs in the context of serious illness.⁸ Spiritual distress is a term often used to refer to impairment(s) in one or more dimensions of spirituality (such as threats to one’s beliefs, sense of meaning, or purpose),¹⁸ underscoring the importance of addressing spirituality as part of holistic palliative nursing care.

Spiritual care can help people cope with serious illness, for example, by finding meaning in their experience, staying connected to themselves and their community, and preparing for the end of their life.²⁵ Skillful spiritual care can also benefit family members and lay caregivers,²⁶ and may help them to be more present for the patient.

Finally, when we acknowledge the spiritual care needs of patients and families by taking the time to listen to what gives their lives meaning, what is most important to them, and what they are most afraid of, these moments can affirm our shared humanity and teach us about ourselves.

Cultivate intentional presence.

Noticing and practicing letting go of our judgments, as well as embracing our personal fears of illness and death, can allow us to have a more balanced perspective and thus be more fully available to address the needs of patients and families.²⁷ Even in a busy environment, it’s possible to start the day with intention: Am I bringing an intention of kindness and self-care for myself today, as well as for my patients? By creating time to acknowledge the importance of our own well-being, we can become more aware of how our feelings shape our care.

Incorporating simple rituals into daily tasks can be a powerful way to cultivate intentional, mindful presence.^{28, 29} For example, taking a deep breath, thinking of an image that brings comfort or peace, or repeating a mantra or word can act as cues to remind ourselves to return to present-moment awareness. These reminders may be helpful in clinical nursing care, especially as we are often present alongside patients or family members when they are expressing intense emotions.

Also consider: What do I need in order to continue to show up for my patients? When we identify our own needs, we make it easier to approach each patient encounter as if we have the time to fully devote to our patients, even if we know the day is full. These needs might be met with simple rituals for transitioning into and out of the workday, a moment of deep breathing between patient care tasks, or a regular movement practice to release tension and stress.

Authentic presence also involves being open to whatever emerges without judgment or assumptions. It can be helpful to bring a curious mind to each interaction. Having awareness of or a willingness to explore our own beliefs can help us become more conscious of when our biases might influence our ability to be present for and compassionate toward what emerges from a patient’s unique experience and needs.

Practice compassion.

Compassion is a sacred human virtue, and the basis of many faith traditions.²² It is often used synonymously with sympathy, which focuses on our ability to “feel for” a patient, and empathy, or the degree to which we can personally relate to a patient’s suffering. But compassion takes these attitudes and emotions a step further and is distinguished by intentional action to reduce suffering.²⁴

The importance of practicing compassion cannot be overstated. Evidence supports the positive effects of compassion on patient-reported outcomes, such as increased sense of responsibility and control over one’s health, increased trust in relationships with providers, and improvement in symptoms,²⁴ as well as on palliative care health professionals’ well-being in areas such as anxiety, burnout, and emotional exhaustion.³⁰ Compassion is not a weak or soft emotion, but a strength. It may provide the courage to stay present in challenging times, and to prioritize moments of shared humanity. In intimate moments of connection with our patients, we have the opportunity to learn so much. We may learn what it means to live and to die—what it means to be human. Compassion opens space for people to share their regrets and tragedies, as well as to grieve the loss of their greatest joys and love.²⁴

When we can practice being compassionately present for ourselves and our own needs, leaning in and getting closer to patients’ suffering can build resilience instead of burnout.³⁰ Compassion can also help us stay grounded in moments that stretch our capacities. Through compassion, we can view our everyday work with appreciation, recognizing the courage it takes to be a nurse, especially in this moment. Cultivating compassion allows us to reflect, grieve, and celebrate the lives we touch as nurses.

Assess spirituality and spiritual care needs regularly.

The NCHPC recommends completing an indepth spiritual screening and history at the initial patient encounter and regular spiritual assessments in tandem with other clinical assessments, especially if the clinical status has changed.⁸ While many structured tools exist for this purpose, screening can include broad questions like, “What are your sources of spiritual strength and support?” and “How would you describe your belief system and/or spiritual practices?” This regular spiritual assessment is part of an ongoing process of building trust and communication, and it can normalize exploring various spiritual concerns.

Since spirituality can be a unique and dynamic phenomenon, employing broad, inclusive assessments can be particularly valuable.³¹ It is possible to build confidence and improve our ability to assess for and talk about spiritual care needs with patients, including those who do not identify as religious or spiritual.³² Despite a presumption by the chaplains in one community that most or all patients were Christians within the same denomination, nearly one-fifth of the population reported not being religious at all.³² The reality is that many of the patients we work with will have unique spiritual beliefs and needs, yet some will not use the word “spirituality.” Phrases such as “whatever gives you strength,” “what grounds you,” “what helps get you through,” and “what gives your life meaning” may be useful.³³

Many online tools are available to support assessing and addressing patients’ spiritual needs (see Guides for Assessing Aspects of Spirituality).^34–36 One of these, the FICA Spiritual History Tool, has been recently adapted with COVID-19–specific considerations and questions to ask as part of a spiritual assessment, such as, “How has COVID-19 challenged your spiritual beliefs and practices?”¹⁰

Guides for Assessing Aspects of Spirituality.

• Spirituality and Medical Practice: Using the HOPE Questions as a Practical Tool for Spiritual Assessment: www.aafp.org/pubs/afp/issues/2001/0101/p81.html

• The Spiritual Distress Assessment Tool: An Instrument to Assess Spiritual Distress in Hospitalised Elderly Persons: https://bmc-geriatr.biomedcentral.com/articles/10.1186/1471-2318-10-88

• Evaluation of the FICA Tool for Spiritual Assessment: www.sciencedirect.com/science/article/pii/S0885392410003258

• The Urgency of Spiritual Care: COVID-19 and the Critical Need for Whole-Person Palliation: www.ncbi.nlm.nih.gov/pmc/articles/PMC7332903

Learn how to assess for and recognize a spiritual crisis—in patients and in yourself.

Hearing a patient say, “I feel like all hope is gone,” “What is there left to care about?,” or “What have I done to deserve this?” can create feelings of helplessness and lead to moral distress in nurses.³⁷ These types of comments may require a referral to someone who has specialist skills in spiritual care.

But just as it’s important to know when we are at the limits of our training and skills and need to refer a patient to a spiritual care specialist, it is also important to be able to recognize when we need support. For example, we may notice feelings of irritability, a sense of losing meaning in our work or everyday lives, or trouble experiencing relaxation and pleasure. For nurses, it can be hard to recognize these feelings and ask for help—especially if we tend to put others’ needs ahead of our own. Sometimes feelings of burnout may be a transient experience, and a day off or a good night’s sleep is all that’s needed. Yet these feelings may also signal a deeper level of depletion, or compassion fatigue.³⁸ It can be helpful to understand the signs that we are about to reach our limit, and to know how—and specifically where—to ask for help.

Identify spiritual care resources and foster partnerships with spiritual care specialists.

It’s a good idea to identify the tools and supports that are available to help us feel renewed before we need them. This could include knowing what services your hospital or clinic offers and having a pager or phone number for the spiritual care department.

One resource is the hospital chaplain. Chaplains are spiritual care specialists who can assess and address spiritual issues and help facilitate continuity with a patient’s faith community.⁸ However, according to the National Palliative Care Registry, as of 2018, only 56% of adult and 59% of pediatric palliative care programs in the United States had a chaplain member.³⁹ Therefore, other referral resources, such as a mental health clinician, may be needed.

For patients who do not identify as spiritual, we can bring a sense of curiosity to their broader existential beliefs, their lived experiences of meaning and purpose, and the role of connection in their lives (such as with nature, important relationships, and the broader community). Visits with nondenominational chaplains and mental health professionals may be supportive, based on a patient’s identified needs and preferences.

Partnerships with spiritual care specialists may be fostered by inviting them to present to the rest of the clinical team, or just by talking with them, asking what they do, asking how they approach patients, and exploring how to support patients after their visits.

Similarly, we may need to reach out to a spiritual care specialist for ourselves. Spiritual care teams are for everyone—staff, patients, and families. They are available for debriefing intense patient interactions, supporting staff who have experienced patients who have died, and helping teams cope with the emotional intensity of daily work.

Integrate spiritual assessment and spiritual care into training and education.

Research shows that patients and families often perceive the nurse’s role as supporting spirituality.⁴⁰ But despite the central relevance of spiritual care to nursing, nurses have reported a lack of training in providing spiritual care⁴¹ and have expressed a desire to receive more comprehensive training focused on spirituality.⁴²

Providing comprehensive spiritual care for patients is a skill, just like managing iv medications or wound care, and it can require practice and training. The NCHPC’s spiritual, religious, and existential aspects of care domain emphasizes the need for training providers to care for patients, families, and themselves using flexible approaches. Such approaches include tailoring spiritual assessments to unique patient needs and priorities, supporting patient and family desires to display meaningful spiritual and/or cultural symbols and engage in spiritual practices, and recognizing the need for spiritual care to evolve based on changing needs.⁸

Spiritual care can be incorporated into nursing training at all levels. To continue expanding knowledge and skills in this area, learning to appraise the literature on spiritual care and assessment can be one place to start. Setting up auto emails to send recent spiritual care literature directly to nurses’ inboxes can be a wonderful resource. Continuing education opportunities, such as the Interprofessional Spiritual Care Education Curriculum, focus on deepening understanding of spirituality.⁴³

Incorporate evidence-informed interventions to support spiritual well-being in the workplace.

There are many ways to support spirituality as a standard of care. Consider incorporating evidence-informed interventions, such as mindfulness meditation, gratitude practices, prayer, and visualization (see Modalities for Tending to the Human Spirit).^{22, 31} Staying updated on the latest spiritual care literature can inform the selected interventions and guide the implementation process.

Modalities for Tending to the Human Spirit.

• Being present with loving family, friends, and/or caregivers

• Contemplative practices, prayers, and readings

• Creating and/or viewing art

• Engaging in service activities for positive social change

• Imagery or visualization practices

• Meditation practices (such as breath-based meditation, body scan, loving–kindness meditation)

• Mindful exercise/movement (such as yoga, walking meditation, dance, tai chi, qigong)

• Seeking pastoral care, counseling, therapy

• Self-massage

• Specific practices, services, rituals, and celebrations from a religion or spiritual tradition

• Spending time in nature or with animals and pets

• Writing and/or reading poetry

Creating a policy on how a team manages spiritual care crises can ensure that resources are readily available. Quality improvement initiatives can include assessing and addressing spirituality regularly as part of the patient and family experience. It can also be helpful to start the workday once a week with the clinical team, reading the mission statement, having a moment of silence for patients who have died, discussing a challenging or uplifting experience, and perhaps asking a chaplain to be present. Identifying a spiritual care champion on the unit could help streamline a process to support team members when they have questions.

CONCLUSION

The concept of wounded healers has been explored in relation to the traumatic grief and posttraumatic stress of frontline workers.¹⁰ In this context, nurses are called to recognize the universal experience of suffering, and to create a depth of intimacy with our own suffering as well as our own healing, making this a starting point from which to engage in our nursing practice.¹⁰ Recognizing and tending to our own spiritual care needs is instrumental to sustaining our work of providing nursing care from a place of authentic presence, intention, and compassion.

Reflecting on personal beliefs and exploring ways to make meaning and find hope can be essential practices in nursing care during these times of intense uncertainty, fear, and anxiety. By recognizing that suffering is a universal human experience, this shared vulnerability can connect us more deeply with the patients and families we serve. Spiritual care starts with us.