Using Spirituality in Health Care

What is your first reaction to using spirituality in health care? Fear of offending someone, or maybe fear of being recruited to go to worship services? Or, perhaps you would be concerned that a coworker would proselytize and preach to all your patients. In times of legitimate concerns about religious divisions, it is easy to ignore the spirituality and focus on caring for physical health. Yet, in doing so, we are doing a disservice to patients. As nurses, we care for the whole human being, and therefore, we need to wrestle with how to use spirituality in health care.

In discussing spirituality and health care, we need to address four points:

• What is spirituality and what are spirituality’s effects on health?
• What are the pitfalls of using spirituality in health care?
• How do I deal with my own uncomfortableness?
• How do I integrate spirituality in my daily practice?

Defining Spirituality

Spirituality is such an individualized experience that an exact definition is difficult to formulate. Spirituality does not have to be associated with an organized religion, though for many, spirituality and religion are synonymous. Most definitions say that spirituality is the search for a higher power or a divine purpose in life. This search can be as varied as there are people who have engaged in this search.

Despite this difficulty with an exact definition, we as nurses can know an individual’s spirituality by its effects on the individual’s health. Harold Koegnig at the Duke University Center for Spirituality, Theology, and Health and other researchers have shown that spirituality has three main effects on health. Spirituality can 1) provide meaning to life as a patient copes with illness and suffering; 2) help patients find social support when coping with the effects of illness; and 3) help promote healthy choices and behaviors. Though the studies vary in method and scope, there is a preponderance of evidence that patients who have spirituality are healthier than those who do not have spirituality. In short, it works.

The Pitfalls

There are pitfalls to spirituality. People have strong attachments to their spiritual beliefs. Even those who profess no spirituality, such as atheists or agnostics, strongly identify with their lack of beliefs in a higher power. Such strongly held beliefs can create defensiveness. A patient can react negatively to a well-meaning health nurse who unknowingly offends the patient. The nurse instinctively reacts defensively. This starts a cycle of poor communication and bad feelings. It does not take many such occurrences to make a nurse shy of discussing, let alone using, spirituality in health care.

Nurses themselves tend to have a strong spiritual background. Why else would we choose such an altruistic profession if it did not involve, at some level, spiritual reasons? When we are faced with a patient who does not have a spirituality, we want to provide comfort. We start to engage in giving advice to such patients. While this may seem helpful, it can come across as superficial to others who do not share our experiences. It builds up a block between the patient and caregiver. Spirituality develops through a lifelong process involving integration of meaningful life experiences. Advice offers a shortcut through this process when we really need to honor the patient’s starting point.

Dealing With Discomfort

A nurse’s uncomfortableness with spirituality in health care has its roots in lack of self-acceptance of our own current level of spirituality. When a nurse believes she should be more spiritual or have a different type of spirituality, the focus is on shame and not on hope. If our own experience of spirituality is shame-based we would naturally hesitate to use spirituality in health care. We really don’t want to do anything that will harm a patient and if our own experience with spirituality is negative we would hesitate to use spirituality in health care. The answer here is to practice the same acceptance toward our own spiritual being as we would give any patient.

Integrating Spirituality

Integrating spirituality into daily practice starts with the assumptions you make about a patient. The current assumption we make is that spirituality is akin to “Don’t ask, don’t tell,” (e.g., spirituality is something best avoided). Whereas, if we assume that a patient has spirituality, then the question becomes not how do we avoid talking about spirituality, but how do we as clinicians use spirituality.

As with any health intervention, we have to start with an assessment. I work in a low-income clinic with a diverse mix of patients. We have meta-conversations with patients about spirituality. A meta-conversation is a conversation about the conversation we are going to have about spirituality. It introduces the topic of spirituality and informs the patient why we are asking about spirituality. It starts out something like this: “Our clinic staff feels that belief in a higher power or divine being is important to health. We know that this can mean different things to different people, and we are not here to tell you what to believe, but we would like to know a little about your spiritual life so that we might find ways your beliefs may help you obtain the health you need. Is it okay if I ask you a few questions about your spirituality?”

We have very few patients turn us down; in fact most want to discuss this. We ask questions about three areas:

1. Describe for me your beliefs in a higher power. How important are these beliefs to you?
2. Do you pray? If so, how.
3. Have you ever used these beliefs to improve your own health? If so, can you give me an example?

We try to speak of these questions in a conversational manner, sharing our own beliefs and experiences as appropriate.

We had a woman who came to the clinic complaining of a headache. She had no access to primary care and little money. We did our assessment, including the questions about spirituality. The woman did have a strong belief system and went to church regularly. Her blood pressure was slightly high and her pulse was rapid. When asked about the cause of her headache, she said that her youngest son had just been murdered by another family member in a dispute over money. She had not only found the body, but she had to clean up the room where the stabbing occurred. How do you respond to such a situation, if not spiritually?

We offered to pray with the woman and her small child that was with her. This involved about five minutes of silence and then an asking for help and assistance for this family. The woman said a few things and then we concluded that part of the visit. After this prayer, the woman said her headache, which had been over her entire head, was much improved except for a muscle in the back of her neck, which was treated with ice and OTC pain relievers.

Making Healthy Decisions a Habit

We also use spirituality in health decision-making. To attain a higher level of health, patients have to make healthy decisions daily and, frequently, several times a day. Weight loss does not occur because of one decision no matter how firmly that decision is made. Weight loss occurs when patients make several decisions each day, at every meal or snack, to not eat too much. Similarly, smoking cessation is really a series of daily decisions to not smoke the next cigarette.

Unhealthy behaviors are largely habitual. Habits are unconscious, immediate decisions that have built-in positive reinforcement. Habits are all around us. The way we dress, the way we get into an automobile, the way we answer and dial our phone. Habits are good. They save time. We don’t have to learn something new each time we want to do something.

Unhealthy habits are those habits that hurt us over time, but which tend to self-perpetuate until the harm can kill us. No one gets up in the morning and says, “I am going to start smoking today and I will continue to do so until I smoke three packs a day for 10 years and die from emphysema.” Most unhealthy habits are a response to outside triggers that answer a need, even though the answer may only be short-term.

A smoker may smoke to relieve stress. So, when everyone is in a bad mood at work and the workload is increased, the smoker will take a break and grab a few puffs. The smoking does nothing to improve other people’s moods, but it does provide a temporary relief from this type of stress. The relief will make the smoker more likely to smoke the next time work becomes stressful. He is not smoking for the cigarette per se, but to get relief from stress. The same process occurs with over eating, lack of exercise, abuse of alcohol and drugs, and other unhealthy behaviors. This relief is very powerful and is reinforced with habitual thought patterns and physical cravings. Since spirituality is neither physical nor mental, it has the power to break habits.

Spirituality can be applied simply without a degree in theology. For example, we use meditation in our weight loss groups at my clinic. We encourage our participants to take a few moments each morning to sit quietly and think about what they will eat each day. It is that simple. Meditate and then plan a menu. Like all planning, this decreases habitual thinking. The plan puts another mental reference point during the day and the can help reassure someone that they have enough calories when they have stress-related hunger. In our last class there was an average weight loss of 6 pounds over a six-week period.

If you are interested in sharing your own experiences with spirituality in health care or would like to see more information about this subject, please visit Health Spirituality or the Duke University Center for Spiritual, Theology, and Health.