It would be very hard to find a nurse who saw only the physical aspect of care as that which defines nursing. We all know that when a person is hurting emotionally, all sorts of physical ailments crop up. On the other hand, physical conditions can affect the mind and spirit. The nursing profession has traditionally viewed the person as holistic, though the term itself was only introduced into the nursing literature in the 1980s by Rogers, Parse, Newman and others. Today we speak of a person as a biopsychosocial unit.

Restoring wholeness is a legitimate goal of nursing, and so the term 'holistic' from the Greek 'Holos' meaning whole or complete, is a very appropriate way to describe what we aim to do. Yet we may not always stop to consider the full implications of that concept. Holism has been defined as "concerned with the interrelationship of body, mind and spirit in an everchanging environment".1 The American Holistic Nurses Association define wellness (health) as "that state of harmony between body, mind and spirit". The essence of holistic care is to help a person attain or maintain wholeness in all dimensions of their being. Consequently nurses need to be prepared to provide care in each of these areas. In this session I wish to consider the spiritual dimension - the nature of spirituality, the needs of the spirit, and the role of the nurse in caring for the spirit.

THE NEEDS OF THE SPIRIT

Spiritual needs, and psychosocial needs are much less tangible than physical needs because they are often abstract, complex and more difficult to measure. These more intangible needs have frequently been given a much lower priority than needs which are more obvious and more easily measurable. Spiritual needs, if expressed outside of a religious framework, are very likely to go unnoticed. So if we are to identify spiritual needs and provide spiritual care, it is necessary to have some understanding of the nature of spirituality and how it may be expressed by different individuals.

In Australian society, and therefore in our health care setting, we encounter not only a diversity of cultures, philosophies and religious traditions, but also individuals who have no clearly defined philosophy or belief system. Therefore it is important that we develop some general definitions which can help us to recognise spiritual needs when we encounter them in our clients. In recent years, some definitions have emerged which are helpful both for defining spirituality, and differentiating between spiritual needs and religious or psychosocial needs.

SPIRITUALITY... "The spirit is that part of man which is concerned with the ultimate meaning of things and with a person's relationship to that which transcends the material.." (Simsen, 1985, p.10). "The totality of man's inner resources, the ultimate concerns around which all other values are focussed, the central philosophy of life which influences all individual and social behaviour." (Moberg, 1979)

Spiritual need.. "Any factor that is necessary (requisite, indispensable) to support the spiritual strengths of a person or to diminish the spiritual deficits." (Simsen 1985, p.10). "The lack of any factor or factors necessary to maintain a person's dynamic relationship with God/Deity (as defined by that person)." (Stallwood, 1975, p.1088). "That requirement which touches the core of one's being where the search for personal meaning takes place." (Colliton, 1981, p.492).

As these definitions demonstrate, spirituality is not limited to religious affiliation and practices, but is a much broader concept. Thus spiritual needs may or may not, be expressed within a religious framework

Another difficulty in identifying spiritual need is that we can fail to make the distinction between spiritual needs and psychosocial needs, since they are not always opposites, and may in fact overlap. A model I find helpful in clarifying this is one that describes a person in terms of three dimensions: the physical or BIOLOGICAL dimension which relates to the world around us through our five senses; the PSYCHOSOCIAL dimension which relates to self and others, and involves our emotions, moral sense, intellect and will; and the SPIRITUAL dimension which transcends physical and psychosocial dimensions and has the capacity to relate to a higher being. (Stallwood, 1975, p.1087) These three dimensions are distinct but overlapping. They cannot be sealed in separate compartments. A crisis or illness affecting our physical body will invariably affect the other dimensions as well.

SPIRITUAL CARE IN NURSING TODAY

How does nursing today view spiritual care? For a long time, nursing literature concerning spiritual care was directed towards belief systems and religious practices. If considered at all, it was largely defined in a very narrow way as relating to frankly religious functions and intervention limited (at least officially) to calling the hospital chaplain. Regardless of that, we were often confronted with spiritual need and recognised at least the more overt expressions of this. for example, statements such as "God must be punishing me" or questions like "Nurse do you think there is anything after death?" were recognised as indicating a spiritual need.

Then in the late 1960s and 1970s the nursing literature began to reveal a growing interest in the spiritual, as well as the psychosocial and emotional aspects of nursing care. Nursing theorists of this era saw the human person as an integrated whole with different dimensions or capabilities for discerning the world around and within. Further, their writings suggest that when they spoke of spirituality or spiritual need, they had in mind a much broader concept than religious concerns and practices.

In 1971, Joyce Travelbee declared, "A nurse does not only seek to alleviate physical pain or render physical care - she ministers to the whole person. The existence of suffering, whether physical, mental or spiritual is the proper concern of the nurse".2 Here we see clear evidence of a return to the traditional focus of nursing, a concern for the whole person. This focus is even more evident today. The NANDA3 approved list of Nursing Diagnoses which is widely used in Australia as well, includes SPIRITUAL DISTRESS which is described as: "Distress of the human spirit; disruption in the life principle that pervades a person's entire being and integrates and transcends one's biological and psychosocial nature.4 This classification, approved in its present form in 1988, also recognises that suffering extends beyond the physical, mental and emotional.

I believe that Spiritual care can be a natural part of total care which fits easily into the nursing process of assessment, nursing diagnosis, planning, implementation and evaluation. Placing spiritual need and spiritual care within the framework of the nursing process, has proved to be very helpful, for both philosophical and practical reasons. Firstly spiritual care can become more tangible as well as more assessable. Secondly, the types of knowledge utilised by the Nursing Process - practice wisdom, ethics of practice, and scientific knowledge. (Ziegler et al, 1986) - are all relevant to assessing spiritual needs and planning spiritual care. It can also then be documented in nursing care plans, to ensure a continuity of care. Like all other areas of care, spiritual care should be a team effort. If spiritual needs are accurately assessed and documented all staff will be encouraged to see that care is provided. Members of the team who for some reason, do not feel comfortable about providing that care themselves, will be able to use referral. Thus spiritual care can be a natural part of holistic care.

SOME IMPORTANT PRINCIPLES

Nursing diagnosis is intended to identify strengths as well as actual and potential problems. Our primary goal in spiritual care is to mobilise the patients spiritual resources Nursing staff should be aware that spiritual care is not an attempt to proselytise or win converts to a particular point of view. Rather, it is responding to a patient's expressed needs. Interventions are by their request or permission. Spiritual assessment and care should be sensitive and based on a relationship of trust between patient and nurse. It will involve awareness of the person's culture, social and spiritual preferences, as well as a respect for their beliefs and religious practices.1 Recognising our own limitations and knowing when to make a referral, or utilise other members of the team is as important for spiritual care as it is for other aspects of care. The importance of documenting spiritual care in nursing plans must be recognised, since this will ensure that care is systematic, well thought out, and consistent.

MEETING THE CHALLENGE

Spiritual care can still be a daunting prospect for many nurses. How can we become more confident and better equipped to meet this challenge?

First I think we need to consider the myriad of personal resources nurses use in their day to day work. Many nursing interventions already provide a degree of spiritual support. Simply being with clients, listening to their concerns, empathising and responding is therapeutic when it comes to meeting the needs of the human spirit: the need for love and relatedness, meaning and purpose, and hope. Often nurses fail to recognise and document this excellent and appropriate care.

Second, we must recognise that as with all other aspects of nursing, providing quality care in this dimension requires that we are continually increasing our knowledge and developing our skills. Attending ongoing education courses and workshops dealing with this aspect of nursing, reading relevant literature, interacting with colleagues and liaising with hospital chaplains can all increase our awareness of spiritual needs and our ability to integrate spiritual care into our nursing practice.

Other factors which will affect our confidence and competence in providing spiritual care include an understanding of our own beliefs and values, and the degree to which our own spiritual needs are being met. It is difficult to respond to spiritual needs of others if we ourselves are experiencing unresolved spiritual concerns or distress. Sometimes we will need to seek out help and support for ourselves so that we are more able to help others.

An elderly lady suffering from dementia, paced the corridors of the nursing home restlessly - repeating over and over, just one word. The staff were disconcerted, but no one seemed quite sure how to calm her and put her mind at rest. In fact they were at a loss to understand the reason for her distress. The word she repeated over and over again was God - and that was all she said. One day a nurse got alongside her and walked with her up and down the corridors until eventually in a flash of inspiration she asked the lady, "Are you afraid that you will forget God? "Yes, Yes!" she replied emphatically. The nurse was then able to say to her, "You know even if you should forget God, He will not forget you. He has promised that." For this lady who was forgetting many things, and was aware of it, that assurance was what she needed to hear. She immediately became more peaceful, and that particular behaviour ceased. She was responding positively to care which extended beyond the needs of body and mind - care of the human spirit..

The fundamental goal of nursing is to assist another to achieve what they would normally be able to achieve for themselves in preventing illness or maintaining or restoring health, or in the case of terminal illness, to achieve a peaceful death. Fulfilling this goal will necessarily involve us in caring for all dimensions of a person's need. This can be a rewarding experience for both nurse and client so may I encourage you to become prepared to include this dimension in your nursing practice.

Margaret G. Hutchison, 1997

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