Spirituality

Undifferentiated faith

(infancy to 3 years): During this time, neonates and toddlers are acquiring the fundamental spiritual qualities of trust and mutuality, as well as courage, hope, and love. The transition to the next stage of faith begins when the child's language and thought start to converge, allowing for the use of symbolism. Sadly, these spiritual qualities can also be undermined, rather than developed, as may occur in situations of child abuse.

Religion

A set of doctrines accepted by a group of people who gather together regularly to worship that offers a means to relate to God or a higher power; an organized system of beliefs and practices.

Risk for Impaired Religiosity

A situation in which a medical condition presents a complication that is at odds with a patient's faith

Spirit titer

A way to "measure" spirituality

Religious Practices

Allow for the study and integration of these beliefs, and means and support for worshipping and connecting with what is divine.

Spiritual Therapy

Altruism Awe Expressive Artwork Dignity therapy Gratitude Mindfulness meditation Writing a prayer or spiritual expression

Characteristics common among all religions

Belief in god(s) or higher power. Belief that the god or higher power has influence over humanity. Direct communication. Members believe they communicate with the higher power, Community. Members typically worship collectively on a regular basis in a communal setting Ethical or moral codes.

Spiritual Practices Affecting Nursing Care

Beliefs Affecting Diet Beliefs Related to Healing Beliefs Related to Dress Beliefs Related to Birth Beliefs Related to Death

Christianity

Believe their body is a "temple" of God and life is a grace. They generally embrace Western medicine, although they may differ in their views about birth control, abortion, same-sex marriage, and end-of-life care.

How to be successful during a spiritual assessment as a nurse

Demonstrate sensitivity and personal warmth, earn some rapport with the patient before hand

Affect and Attitude Cues

Does the patient appear lonely, depressed, angry, anxious, agitated, apathetic, or preoccupied?

Behavioral Cues

Does the patient appear to pray before meals or at other times or read religious literature? Does the patient have nightmares and sleep disturbances or express anger at religious representatives or at a deity?

Environmental Cues

Does the patient have a Bible, Torah, Quran, other prayer book, devotional literature, religious medals, rosary, cross, Star of David, or religious get-well cards in the room? Does a church send altar flowers or Sunday bulletins? Is there a religious service that is televised or streamed over the internet that the patient would like to watch?

Verabal Cue

Does the patient mention God or a higher power, prayer, faith, a church, a synagogue, a temple, a spiritual or religious leader, or religious topics? Does the patient ask about a visit from the clergy? Does the patient express fear of death, concern with the meaning of life, inner conflict about religious beliefs, concern about a relationship with a deity, questions about the meaning of existence or the meaning of suffering, or questions about the moral or ethical implications of therapy?

Mythic-Literal faith

Found among school-age children (up to 12 years) but can linger even into adulthood. During this stage of faith, children are attempting to sort out what is fantasy from what is fact, by demanding proofs or demonstrations of reality. Stories become a critically important means for children this age to find meaning and to give organization to experiences. It is a task of these children to learn not only the stories but also the beliefs and practices of their community. They accept stories and beliefs literally rather than with abstract meanings. In this stage, for example, a Latter Day Saints child will begin learning the stories of the Bible and Book of Mormon, accepting them at face value; these stories will provide the child with a way of making sense of the community and the world of which he or she is a part.

Denominations

Groups of members that adhere to the same practices and beliefs.

Ethics

Guides the determination of what is "right" and "wrong" and deals with "oughts" and "shoulds"

Diagnosis: Religion

Impaired Religiosity, Risk for Impaired Religiosity, and Readiness for Enhanced Religiosity

Sacred Symbols

Include jewelry, medals, amulets, clothing, or body ornamentation (e.g., tattoos) that may be worn as a symbol of faith, for spiritual protection, or as a source of comfort and strength. Hospitalized patients or long-term care residents may wish to have their spiritual icons or objects with them as a source of comfort.

Factors that Contribute to Spiritual Distress

Include physiologic problems, treatment-related concerns, and situational concerns Examples: Death or illness of a significant other, inability to practice one's spiritual rituals, or feelings of embarrassment when practicing them

Prayer

Is "human communication with divine and spiritual entities"

Atheist

Is an individual who does not believe in any god

Agnostic

Is an individual who doubts the existence of God or a supreme being or who believes that the existence of God has not been proved

Readiness for enhanced religiosity

Is defined as the ability to increase reliance on religious beliefs and/or participate in rituals of a particular faith tradition.

Polytheism

Is the belief in more than one god Example: Hellenism, Hinduism,Mahayana Buddhism, Confucianism, Taoism, Shintoism,

Monotheism

Is the belief in the existence of one god Examples: Judaism, Christianity, and Islam

Individuative-Reflective faith

Is typically observed among young adults, but may continue into later adulthood. This stage of faith is characterized by the development of a self-identity and worldview that is differentiated from those of others. The individual forms independent commitments, lifestyle, beliefs, and attitudes. The child who obediently attended Mom's Roman Catholic mass every Sunday will now examine independently what religious practices and beliefs to accept. Another characteristic of this stage of development is the demythologizing of symbols into conceptual meanings. To illustrate, the young adult who was taught as a child not to place anything on top of holy scriptures because of their sacredness, now understands that this is not religious edict, but rather an authority's attempt to teach respect for an object that informs the reader about what is sacred.

Spiritual Well-Being is Manifested by

Feeling of being generally alive, purposeful, and fulfilled

Spiritual Development of Older Adults

Many older adults frequently use and highly value religious coping strategies such as prayer. Older adults may be especially concerned about living a purposeful life, about maintaining loving relationships to avoid social isolation, and about leaving a legacy and preparing for a peaceful death.

Beliefs Related to Dress

Many religions have laws or traditions that dictate dress. Women who wish to comply with religious dress codes may find wearing hospital gowns uneasy and uncomfortable. Patients may be especially disconcerted when undergoing diagnostic tests or treatments that require body parts to be bared or removing body hair

Beliefs Affecting Diet

Many religions have proscriptions regarding diet. There may be rules about which foods and beverages are allowed and which are prohibited. Healthcare providers should assess and incorporate patients' dietary and fasting beliefs prior to providing meals or prescribing diet plans.

Categories of Prayer

Ritual (e.g., the Lord's Prayer, memorized prayers that can be repeated) Petitionary (e.g., "God, cure me!" or intercessory prayers when one is requesting something of the divine) Colloquial (i.e., conversational prayers) Meditational (e.g., moments of silence focused on nothing, a meaningful phrase, or a certain aspect of the divine).

Prayer and Meditation

Ritual and petitionary prayer experiences may be most comforting and appropriate for those who are ill. Individuals who are ill may want to continue or increase their prayer practices Nurses can help patients by ensuring a quiet time for them to pray or meditate.

Two-tiered approach to assessing patient spirituality

Screening Spiritual History and Observations

Judaism

Seek treatment from modern Western doctors Keep to a kosher diet to varying degrees Sabbath observance varies Pray three times a day in a group Nurse can pray with a Jew using "God" or "Lord" to address the divine. Burial customs require the dead to be buried as soon as possible, preferably within 24 hours.

General Spiritual Screening

Select a couple of general questions about the impact of spiritual or religious beliefs and practices on health and healthcare "What spiritual beliefs or practices are important to you now while you live with illness?" "How would you like your healthcare team to support you spiritually?"

Planning for Spiritual Distress

The nurse identifies interventions to help the patient achieve the overall goal of maintaining or restoring spiritual well-being so that the patient may realize spiritual strength, serenity, and satisfaction

Spirituality

The part of being human that seeks meaningfulness through personal connection, which may include belief in or relationship with some higher power, creative force, driving being, or infinite source of energy.

Goals: Religion

The patient will be able to participate in religious observances as the patient desires. The patient will be able to participate in prayer at prescribed times without interruption. The patient will receive meals in keeping with religious dietary restrictions or requirements. The patient will have access to religious resources, including ministers, prayer partners, sacred texts, and sacred objects.

Examples of Outcomes for Spiritual Distress

The patient will fulfill religious obligations. The patient will find meaning in existence and the present situation. The patient will feel a sense of hope. The patient will have access to spiritual resources as needed.

Conjunctive faith

Usually is found among adults past midlife. At this stage, adults find new appreciation for their past, value their inner voices, and become aware of deep-seated myths, prejudices, and images that are indwelling because of their social background. An individual with conjunctive faith "strives to unify opposites in mind and experience" and allows "vulnerability to the strange truths of those who are 'other'". For example, instead of trying to dissuade or avoid another with differing spiritual beliefs, a person in this stage of faith would embrace persons of other faith traditions, recognizing that in their faith may be new understanding. Also, an adult whose faith is conjunctive may practice prayer in a way that allows listening to the deeper self, instead of petitionary praying.

Examples of Spiritual Assessment Questions

What are your spiritual or religious beliefs or practices that would be important for your healthcare providers to know about? How is being sick or in the hospital challenging your spiritual or religious beliefs or practices? How is your faith helpful to you? In what ways is it important to you right now? What are your hopes and your sources of strength right now? What comforts you during hard times? In what ways can I boost your spirit? Would you like a visit from your spiritual counselor or the hospital chaplain?

Nursing Outcomes (Evaluation: Religion)

• The patient has been provided the opportunity to practice religious rituals, including prayers. • The nursing and dietary staff made appropriate considerations regarding dietary restrictions. • The patient successfully maintained connection with his or her religious practices and community of faith.

Evaluation of Spiritual Distress

• The patient identifies purposeful activities or ways of thinking. • The patient articulates a sense of hopefulness about the future. • The patient articulates how to access spiritual resources. The patient finds meaning and existence in the present situation.

Religion Beliefs

Begin to answer questions about what is the nature of humankind and, how it came to be, what its purpose is, what is suffering, and what happens after death

Presencing

Being present with a patient and being open, receptive, and available at all levels without judging or labeling.

Concepts Related to Spirituality

Comfort Culture and Diversity Legal Issues Nutrition Sexuality Stress and Coping

Intuitive-Projective faith

(infancy to 3 years): During this time, neonates and toddlers are acquiring the fundamental spiritual qualities of trust and mutuality, as well as courage, hope, and love. The transition to the next stage of faith begins when the child's language and thought start to converge, allowing for the use of symbolism. Sadly, these spiritual qualities can also be undermined, rather than developed, as may occur in situations of child abuse.

Spiritual Needs

- Needs Related to the Self - Needs Related to Others - Needs Related to the Ultimate Other -Needs Among and Within Groups

Spiritual Well-Being

A feeling of inner peace and of being generally alive, purposeful, and fulfilled; the feeling is rooted in spiritual values and/or specific religious beliefs.

Spiritual distress

A challenge to the spiritual well-being or to the belief system that provides strength, hope, and meaning to life; a feeling of being separated from interconnectedness with others or with a higher power.

Holy day

A day set aside for special religious observance.

Formal Definition of Spirituality

A dynamic and intrinsic aspect of humanity through which persons seek ultimate meaning, purpose, and transcendence, and experience relationship to self, family, others, community, society, nature, and the significant or sacred. Spirituality is expressed through beliefs, values, traditions, and practice

Chaplains

Are board certified are trained and credentialed in a religious tradition, as well as trained in counseling so that they can provide expert spiritual care regardless of a patient's spiritual or religious background. Provide assistance with religious rituals and support for patients and families with emotional, ethical, or spiritual concerns

Faith Community Nurse (FCN)

Are employed either by the congregation or by a local healthcare system. and provide individual and community-oriented care for the congregation (e.g., home visits to the sick or elderly, health education or screening during church events). typically have received additional training in spiritual care. Their care is thought to help reduce hospital readmissions and lower healthcare costs

Gather Data on a Patients Spirituality

Are obtained from the patient's general history (religious preferences or orientation) And by clinical observations of the patient's behavior, verbalizations, mood, and interactions with others.

Assessment for Spiritual Distress

Ask questions (Open ended) to determine the patient's spiritual beliefs and practices and how they affect or are affected by the patient's health condition

Beliefs Related to Death

Bereavement rituals likewise vary across faith traditions. Postmortem rituals and practices such as bathing and preparing the body for interment (e.g., especially for Jews and Muslims), saying specified prayers, and beliefs regarding methods for body disposal and what happens in an afterlife likewise vary by religion and culture. The nurse can help to support family members of the deceased by providing an environment conducive to the performance of their traditional death rituals

Refer Patients for Spiritual Counseling

Can be made for hospitalized patients and their families through the hospital chaplain's office if one is available. May be necessary when the nurse makes a diagnosis of spiritual distress. A nurse and religious counselor can work together to meet the patient's needs. One situation the nurse may encounter is patient refusal of necessary medical intervention because of religious tenets. The nurse's major roles are to provide information the patient needs to make an informed decision and to support and advocate for the patient's decision.

Sacred Writings

Each religion has sacred and authoritative scriptures that provide guidance for its adherents' beliefs and behaviors. In most religions, these scriptures are thought to be the word of God or the Supreme Being as written down by prophets or other human representatives Individuals often gain strength and hope from reading religious writings when they are ill or in crisis.

Synthetic-Conventional faith

Emerges when the individual begins to reflect on incongruities observed between stories. This stage of faith usually applies to adolescents and teens, but it can also characterize some adults. The synthetic-conventional stage accompanies the individual's experience of the world that is now beyond the family unit (e.g., school, media), and must provide a helpful understanding of this extended environment. While faith "must synthesize values and information; it must provide a basis for identity and outlook". At this stage, individuals generally conform to the beliefs of those around them, because they have yet not reflected or studied these beliefs objectively. Thus, beliefs and values of teens are often held tacitly. For example, an adolescent or teen raised by observant Jews will likely continue to observe the Jewish practices of parents and accept parents' beliefs.

Factors Nurses can observe for cue's about patient's spiritual preferences

Environment Behavior Verbalization Affect and attitude Interpersonal Relationships

Spiritual Self-Care for Nurses

Learn and practice mindfulness. That is, be tuned in mentally, emotionally, and physically to what you are experiencing in the present moment; do so without judgment about whether it is right or wrong. It will boost compassion for others and for yourself. • Recognize your own woundedness (e.g., fears, longings, obstructed goals). Know that it is this woundedness that allows you to be present to another's spiritual wounds. Although you do not need to have had the same experiences as your patients, you do need to be able to understand their emotions if you are to be compassionate—spiritually caring. • Be as compassionate to yourself as you are to patients. • Experience self-compassion, the sacred source (a.k.a. God's love), when you are fully present to your woundedness. This may be felt as a softening of your "heart" when you are still. • Remember there is a compassionate core in every person: "Call it the Buddha nature of love and compassion, the divinely bestowed image of God, the ever-present Beloved Lover, or simply the steady ember of our truest Self, a compassionate connection resides within every human heart—no matter how damaged or hardened that heart may become" . • Notice the opening of your heart with compassion toward others when you realize that their woundedness essentially mirrors yours (e.g., you also have fears, longings, and obstructed goals). • When you find yourself irritated or lacking compassion for a patient or colleague, appreciate that that person is functioning as a mirror and can teach you what needs compassion within yourself.

Factors that influence one's spirit titer

Life experiences, coping skills, social supports, and individual belief systems Note: Nurses can aid healing when they assist patients in attaining and maintaining a high spirit titer.

Beliefs Related to Birth

Many religions have specific ritual ceremonies for a newborn that consecrate the infant to God Religious dictates about circumcision vary. Whereas Hindus do not practice it, Muslims and Jews circumcise male infants. Christian traditions vary but generally leave the decision to parents When nurses are aware of the religious needs of families and their infants, they can support families in fulfilling their religious obligations if necessary. This is especially important when the newborn infant is seriously ill or in danger of dying, because some individuals believe that if religious obligations are not fulfilled the infant will not be accepted into the community of the faithful after death.

Engaging Community-based Spiritual Care Experts and Resource

Many religious traditions have systems in place for providing social support services to members in need. These services may include respite care for caregivers, financial support, weekly visitations, or organizing meals and help with household duties.

Core facets of Spirituality

Meaning (having purpose, making sense of life, having explanatory beliefs) Connecting (relating to others, nature, Ultimate Other, Higher Power, or God) Transcendence (appreciating a dimension that is beyond the self)

Spiritual Caregiving for Patients With Dementia

Nurses can help those with early stages of dementia to focus on the positives, the "haves" rather than the losses. Allowing Them tell their stories helps them to maintain some identity in the face of a disease that threatens the very sense of self. These patients can also worship and express their hope and creativity through various art forms (e.g., movement, painting, music). These patients are often able to experience the compassion of others when they feel their caring touch or hear their soothing voice.

Support Religious Practices (Implementation)

Nurses need to consider specific religious practices that will affect nursing care, such as the patient's beliefs about birth, death, dress, diet, prayer, sacred symbols, sacred writings, and holy days Review Box 30-3

NANDA-I Definition of Spiritual Well Being

Pattern of experiencing and integrating meaning and purpose in life through connectedness with self, others, art, music, literature, nature, and/or a power greater than oneself that is sufficient for well-being and can be strengthened

Hinduism

Practice in India and Souther Asia Embrace Western medicine, but they will also employ alternative therapies from their culture such as yoga and various Ayurvedic remedies Don't eat beef or much meat May prefer not to use medications that are derived from animals May have food preferences and will want to achieve balance between foods thought to generate heat versus coolness within the body Greatly value cleanliness May choose not to participate in organ donation because of belief of reincarnation Has ceremonial rites that are practiced at the time of dying and immediately after death.

Assisting Patients with Prayer (Implementation)

Praying with patients should be done only when there is mutual agreement between the patients and those praying with them. Because prayer can evoke deep feelings, the nurse may need to spend time with the patient following a prayer to enable the patient to express these feelings. Patients may choose to participate in private prayer or may want group prayer with family, friends, or clergy. In these situations the nurse's major responsibility is to ensure a quiet environment and privacy. See Box 30-4

Buddhism

Prefer Eastern medicine, believing that most illnesses can be cured through the mind and the use of herbs. May be vegetarian, maintain an altar to Buddha, and practice a form of meditation

Nursing Actions for Spiritual Distress (Implementation)

Provide Presence Refer Patients for Spiritual Counseling

Writing a prayer or spiritual expression

Rationale: Writing about negative life events is known to improve emotional and physical well-being. Writing about negatives in the form of a prayer or as a spiritual expression may contribute to similar positive outcomes. Practice Suggestions: • Encourage the patient to express feelings as well as facts; authenticity of expression may be an indicator of depth of the relationship with the divine • Writing can be put in a diary, laptop, or scratchpad; ensuring privacy for the written work is paramount When writing a prayer (e.g., questions about suffering) to God, one can do so with the dominant hand; next, write with the nondominant hand any spontaneous thoughts that occur in response. These may be divinely inspired.

Gratitude

Rationale: Affirming goodness and appreciating that this goodness comes from outside of yourself creates gratitude. It is associated with prosociality, emotional well-being, and other positive outcomes Practice Suggestions: • Intentionally look for opportunities to verbally express thanks to others (e.g., write a letter of gratitude) • Journal or make lists of graces for which one is thankful (e.g., journal five events at the end of each day that created meaning or gratitude) • Breathe deeply in a sense of grace and breathe out gratitude • Savor for 15 seconds the feeling accompanying acknowledgement of the grace and gratitude

Awe

Rationale: Awe is "an emotional response to perceptually vast stimuli that transcend current frames of reference", and something that leaves one "feeling small." Awe is associated with greater prosociality, generosity, and ethical decision making. Awe may activate spiritual/religious feelings. Practice Suggestions: • Provide virtual or real experiences in nature (e.g., video about galaxies, trip to local gorgeous place, sit under the night sky, National Geographic series) • Provide awe-inspiring music or other form of art, or stories that create a sense of awe (e.g., about a heroic act) • Remember that even gazing at the clouds out a hospital window or studying the dew on a blade of grass can stir awe • Recognize and cherish the feeling of awe for at least 15 seconds

Expressive Artwork

Rationale: Creating art is a means for self-expression and meaning making. It has been used in acute and community care settings with children, adolescents, individuals with mental health and disabilities, older adults, and individuals who have experienced trauma or displacement. Creative acts appear to lower cortisol (stress) Practice Suggestions: • Expressive artwork can be completed individually or in a group setting • Depending on patient preferences, setting, and available resources, a type of art can be selected (e.g., digital media, drama, poetry, visual art) • An art, music, or play therapist, or recreation director may facilitate, or a nurse can simply provide materials and support • After the artwork is completed, it can be verbally discussed or performed—or kept private. If a patient wants to share, the nurse can ask the patient about what the artwork means or symbolizes for her • Reactions to the artwork are best if neutral and observational in nature

Dignity Therapy

Rationale: Developed by psychiatrist Chochinov and evaluated in numerous settings and found to be effective for improving spiritual and emotional outcomes for patients at the end of life primarily. Encourages patients to tell their life story and construct meaning, and leave a legacy. Practice Suggestions: • Listen deeply to patient's life stories, recognizing that they are attempts to make sense of one's life • Life stories can be recorded, transcribed, and compiled with photographs or other life mementos • Prompts can address what individuals view as important aspects or times in their lives, how they wish to be remembered, salient roles they have played in life, achievements, what they still want to say to others, what life lessons they wish to pass on • Whereas such extensive life storytelling is likely beyond the time resources of a nurse, a nurse can adapt the process or facilitate others (e.g., trained volunteers) to do this work

Mindfulness Meditation

Rationale: Of Buddhist origin yet pervading Western societies, mindfulness meditation techniques have been adapted for Christian prayer and as a nonreligious lifestyle strategy for improving health and overall well-being. Numerous studies document various physical, psychologic, and spiritual benefits for those who practice mindfulness regularly Practice Suggestions: • Mindfulness techniques vary, but key elements include: • Focused attention on the present moment, the body's experience • Awareness, depth, and steadiness of breathing • Put judgmental and intrusive thoughts "on hold" • Mindfulness can be taught individually or in groups by a mindfulness expert; manualized training to nurses can prepare them to support patients to meditate

Altruism

Rationale: Oxytocin promotes altruism and altruism contributes to prosociality; it also is observed to predict life satisfaction and emotional and spiritual well-being Practice Suggestions: • Do a "random act of kindness" without expecting a reward, preferably one that involves some interaction with the recipient of the kindness • Savor the feeling of happiness the action provides (thereby creating a feedback loop) • Patients with limited abilities can phone or write to encourage others; smile at, listen empathically to, or pray for others; create inexpensive gifts to meet others' needs; and so forth

Spiritual care examples

Recognize and validate the inner resources of an individual, such as coping methods, humor, motivation, self-determination, positive attitude, and optimism. Assist the patient to leave a legacy by storytelling and/or recording life stories for family and friends, and encouraging creative expression through art, music, and writing. Foster ways for patients to keep in touch with nature and maintain a sense of wonder. Facilitate a reunion with an estranged child. Provide a story about how someone in similar circumstances maintained hope and grew spiritually. Recognize that the seasons, the emergence of flowers in spring, the phases of the moon, and the migrations of birds provide examples of orderliness in the universe, even in the midst of chaos and loss.

Morality

Refers to the rules a society has created for promoting ethical conduct, or right and virtuous behavior

Belief Related to Healing

Some patients attribute illness to a spiritual etiology. The most common attributions with spiritual or religious overtones may be those that construe benefit and punishment. Many religions offer healing rituals that symbolize the patient's choice to place their illness outcomes in the care of the divine .

Nonreligious Approaches to Spiritual Health

Spending time in nature Experiencing art and beauty Gaining self-awareness through reflection and conversation

Diagnosis Related to Spiritual Distress

Spiritual Distress Readiness for Enhanced Spiritual Well-Being (which recognizes that some individuals respond to adversity with an increased sensitivity to spirituality or spiritual maturation), Risk for Spiritual Distress (which may be appropriate for a patient who currently shows no indication of this disruption of spirit yet may if a nurse fails to intervene)

Key components and expressions of spirituality

Spiritual well-being, spiritual distress, spiritual needs, religion, and morality and ethics.

Spiritual Caregiving for Older Adults

Support meaning-making activities. Some examples of meaning-making activities include conducting a life review or reminiscence therapy that allows the patient to weave together the strands of lived life; encouraging the patient to become dedicated to some social, political, religious, or artistic cause; and supporting the patient to leave a legacy or do an altruistic deed. Nurses may also support older adults to reframe the "losses" of aging as "liberations." For example, older adults possess great wisdom and are in a season of life that promotes spiritual growth.

Spiritual development

The development of the personality towards a religious or spiritual desired better personality.

FICA

The most common spiritual history tool created by Puchalski This tool prompts the clinician to inquire about these four aspects of spirituality Faith or beliefs ("What spiritual beliefs are most important to you?") Implications or influence ("How is your faith affecting the way you cope now?") Community ("Is there a group of like-minded believers with whom you regularly meet?") Address ("How would you like your healthcare team to support you spiritually?")

Spiritual Screening (Fitchett )

The protocol involves first asking the yes/no question, "Is spirituality or religion (S/R) important to you as you cope with illness?" If Yes then, the clinician can ask, "How much strength/comfort do you get now?" If spirituality or religiosity is important to the patient, but he is currently not receiving adequate strength or comfort from it, then the nurse can assume that spiritual distress is present and make a referral If the patient responds that S/R is unimportant, then ask, "Has there ever been a time when S/R was important?" If the patient indicates that S/R has been important in the past, then the nurse can ask if the patient would like to visit with a chaplain. If S/R was never important or the patient receives adequate strength/comfort, then the nurse can infer there is no immediate spiritual crisis requiring support.

Universalizing

This is infrequently reached. Those in this stage of faith have a "sense of an ultimate environment [that] is inclusive of all being. They have become incarnators and actualizers of the spirit of an inclusive and fulfilled human community" . These persons work to unshackle social, political, economic, or ideologic burdens in society. They fully love life, yet simultaneously hold it loosely. Fowler identified Martin Luther King, Mahatma Gandhi, and Mother Teresa as examples of those having developed this level of faith.

Religious Rules of Conduct

Typically influenced concurrently by culture, may also apply to matters of daily life such as dress, food, social interaction, childrearing, menstruation, and sexual relationships

When to take a more detailed spiritual history

When a more thorough assessment is needed (e.g., the patient is being admitted to the healthcare system and a more general assessment is appropriate, or the screening protocol reveals spiritual need), the nurse can assess further by conducting a spiritual history It is best taken at the end of the assessment process or following the psychosocial assessment, after the nurse has developed a relationship with the patient and/or the patient's support person.

Spiritual Development of Adults

When the plan is ruined, and the individual's sense of the world as safe and good is shattered, the person begins to reconstruct meaningfulness. Whereas some patients will "get stuck" asking existential questions and "Why me?", others will find illness to be a sacred journey and suffering to prompt spiritual transformation Fowler observed, some adults maintain the spirituality of their adolescence and young adulthood, while others grow spiritually.

Interpersonal Relationship Cues

Who visits? How does the patient respond to visitors? Does a minister or other spiritual mentor come? How does the patient relate to other patients and nursing personnel?

Guidelines for nurses to help understand patient spiritual needs

Winslow and Wehtje-Winslow • First seek a basic understanding of patients' spiritual needs, resources, and preferences (i.e., assess). • Follow the patient's expressed wishes regarding spiritual care. • Do not prescribe or urge patients to adopt certain spiritual beliefs or practices, and do not pressure them to relinquish any of their beliefs or practices. • Strive to understand personal spirituality and how it influences caregiving. • Provide spiritual care in a way that is consonant with personal beliefs.

Impaired religiosity

is the impaired ability to exercise reliance on religious beliefs and/or participate in rituals of a particular faith tradition. Illness or injury that disrupts religious practice can impair the patient's religiosity and result in emotional distress.

Characteristics of Spiritual Well Being

trusting relationships, inner strength, meaningfulness, and motivation and commitment directed toward ultimate values of love, meaning, hope, beauty, and truth

Assessment: Religion

• Diet (e.g., "What dietary preferences do you have? Are there specific foods or drinks you avoid, or certain diets for certain days that you try to keep?") • Prayers, devotions, or worship desires (e.g., "What do you like to do to keep hopeful or find comfort?" or "How can we support you with any spiritual practices you like to do regularly? For example, do you like to pray, meditate, or read to be inspired or comforted?") • Sacred objects (e.g., "Are there any personal items [sacred or religious objects or books or things] that we should make sure do not get lost here?") Prohibitions regarding medical procedures or treatments (if any).

Nursing Diagnosis for Spiritual Distress (Examples)

• Fear related to apprehension about the soul's future after death and unpreparedness for death • Chronic or Situational Low Self-Esteem related to failure to live within the precepts of one's faith • Disturbed Sleep Pattern related to spiritual distress • Ineffective Coping related to feelings of abandonment by God and loss of religious faith • Decisional Conflict related to conflict between treatment plan and religious beliefs.

Before sharing personal beliefs or practices, a nurse must consider questions such as the following

• For what purpose am I sharing my beliefs or practices? By doing so, am I meeting my needs or my patient's? • Is my spiritual care reflecting a spiritual assessment? • Am I preying on a vulnerable patient? • Am I offering my beliefs or practices in a manner that allows my patient to comfortably refuse? • Does my spiritual care hurt or contribute to a therapeutic relationship with the patient?

Needs Related to the 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 the Ultimate Other

• Need to be certain there is a 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 one's community • Need to be respected and valued • Need to know what and when to give and take.

Needs Related to Others

• Need to forgive others • Need to cope with loss of loved ones.

Strategies for Presencing

• Slow down. Calm yourself. • Make sure that in your "heart" you are willing to be present. Taking deep, slow breaths to center yourself. Nurses who listen attentively to patients yet fail to give of self (i.e., inwardly "make room") diminish their effectiveness. • Sit down; keep your eye level at the same level as the patient's. • Allow silence. • Smile or exude positive energy while remaining respectful of the patient's emotional state (e.g., convey quiet, inner courage if the patient is experiencing sorrow or despair). Follow the patient's nonverbal cues. • Focus. With whatever brief or long amount of time you have available, use it maximally by focusing completely on the patient. Be physically, emotionally, and mentally present. • Empathize with the patient; actively and deeply listen • Self-disclosure (e.g., telling the patient about how you overcame a similar situation) is never appropriate unless the patient requests it and it is shared with therapeutic intent rather than for self-serving reasons. (Ask, "Whose needs are being met here?")