Editorial: Critical reflections on the current state of spirituality-in-nursing
This special edition of the Journal of Clinical Nursing is devoted solely to the subjects of spirituality and spiritual care. The fact that a major nursing journal has taken this dimension of nursing practice and human experience seriously enough to give it this amount of attention is indicative of a general movement within nursing, which seeks to see spirituality taken seriously as an important aspect of nursing practice. There has been a noticeable and well documented intensification of interest in spirituality throughout Western culture (Davie 1994) and nursing has been a significant locus for translating that general interest into particular practices of caring. Indeed, of all the caring professions, nursing is probably the most advanced and forward thinking within this area of care. Nursing academics, educators, researchers, and of course most importantly practitioners, have offered new, rich and challenging insights and clarifications in relation to this vital and sometimes contentious area of research and practice.
At this level, nurses could be forgiven for being quite optimistic and buoyant; the key conceptual arguments have been addressed thoroughly (if not conclusively) and many issues relating to the practice of spiritual care are now cemented firmly within the fabric of nursing history and contemporary nursing practices. Viewed from this perspective the future appears to look quite positive.
A dynamic yet ailing system
If we scratch the surface a little it soon becomes clear that all in the garden might not be as rosy as it at first appears. The importance of spiritual and cultural competence is central in many professional regulatory body codes of conduct (Nursing and Midwifery Council 2004) guidelines (Nursing and Midwifery Council 2002) and Codes of Ethics (International Council of Nurses 2000). Health Boards and government policies (SEHD 2002) have been put in place aimed at ensuring the continuing emphasis on spiritual care. The legislation is clear: not to ensure the care of a person in their spiritual and religious needs is to act without due professional integrity. Indeed not to support spiritual care is to breach patient's human rights in a significant way (Article 9, Human Rights Act 1998). However, behind the official rhetoric there is a significant dissonance between what is required by such legislation and what governing bodies are prepared to do in order to actually facilitate and enable meaningful spiritual care. It has been noted that nurses, while officially taking responsibility for spiritual care, in practice often deal only with the psychological and physical dimensions of patient's illness experiences (Oldnall 1996). We feel strongly that this should not be interpreted as a criticism of nurses or even necessarily of nurse education. The roots of this theory-practice gap with regard to the practice of spiritual care go much deeper.
The role of the nurse is rapidly expanding. Nurses are now expected to meet the needs of individuals, families and communities across an ever-lengthening life span continuum. They are expected to deliver physical, psychological, social and religious (holistic) modes of care which are, ethnically and culturally appropriate for people, from the cradle to the grave! Asking them to take seriously issues of spirituality and spiritual care can sound remarkably oppressive within a context which already demands more than can ever be achieved. Take for example the issue of time. In our research into spirituality, both of the editors of this journal have encountered nurses and other caring professionals, who see very well the importance of spirituality, but simply do not have the time to focus on it. But, lack of time has to do with what is prioritized by nurses, and what is prioritized by nurses is determined by the type of healthcare systems within which they work.
We often assume that spirituality and spiritual care have to do simply with the interpersonal encounter between the nurse and the patient. This is not the case. That encounter takes place within a system which (despite official rhetoric) may well militate against the prioritization of spiritual care and the importance of time-consuming one–one encounters. In other words, spiritual care is an interpersonal and a systemic and political concept that needs to be addressed at all of these levels if it is actually to take place. If the system is militating against the practice of spiritual care, then it is the system that needs to be changed and not just the individual disciplines working within the system. Nurses’ apparent neglect of the spiritual may well be a symptom of a deeper spiritual problem, which has infected the whole system. It is interesting and significant how little work has been done on exploring these wider socio-political dimensions of spiritual care.
Within such a context, it is not surprising that, despite the rhetoric of official bodies and even politicians, nurses might not want to accept responsibility for this aspect of patient care, not because it is not perceived as important, but because the political, economic and financial constraints placed on many health care systems inevitably deprioritizes the spiritual and despiritualizes those who work within it. Having to deliver effective and efficient care to individuals in such a climate of insecurity, over-work, continuous change, and uncertainty about their own future can make spirituality appear nothing more than an added burden (Walter 2002).
The net effect of all of this is that the spiritual needs of all, patients, service users, nurses and indeed every one working in health care appear to be neglected. Bearing in mind the fact that the people who deliver the best spiritual care are those who are themselves spiritually fulfilled, this is a serious state of affairs (Harrington 1995). Apparent contradictions such as these need to be recognized and addressed creatively and constructively if we are to prepare nurses and the health care workforce to meet the challenges of delivering spiritual care in institutions that are themselves spiritually bereft.
It is therefore timely to be in a position to begin to reflect thoughtfully on the current state of spiritual care in nursing. Initiating and facilitating such reflection is the primary aim of this issue of the journal. The contributions within this special edition pick up on some of the issues we have highlighted and begin to work through their implications for the motivation for delivering spiritual care and types of spiritual care that nurses’ are currently offering. The research and discussion presented in the papers demonstrate the diverse perceptions and understandings of spirituality which are being debated, refined and challenged, by nurses, and others and offers some critical pointers to new ways in which this vital aspect of nursing can be developed despite the types of socio-political constraints we have highlighted.
Themes of the special edition
The issue falls into four sections:
- 1Conceptual and theoretical (making sense of spirituality);
- 2Evaluating the evidence;
- 3Implications for nurse education (achieving educational competence);
- 4Progressing spirituality and spiritual care (the way forward).
Each section engages with a different aspect of spirituality-in-nursing and examines how it relates to the practice of nursing in a rapidly changing social, economic and spiritual climate. These papers offer fresh insights and new challenges, which we hope will begin to open up new areas for reflection and revised forms of spiritual practice. Taken together we hope that the papers that comprise this special edition of the journal will move the discussion on and that despite the complexities, problems and challenges, the field of spirituality-in-nursing will continue to flourish and perhaps even act as a vital catalyst for the types of changes that are needed to ensure that the health service we provide is just that: a health service which seeks to promote health and spiritual well-being as effectively as it does the search for cure, economic viability and efficiency.