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    Until recently, contemporary medicine has historically given little attention to the spiritual dimension, despite its importance in the fundamental goal of healing. Nursing has done somewhat better caring for the whole person. Florence Nightingale in her manuscript, Suggestions for Thought, attempted to integrate science and mysticism. She wrote that the universe is the incarnation of divine intelligence that regulates all things through law. For Nightingale, the laws of science are the "thoughts of God. Her idea of spirituality as intrinsic to human nature and compatible with science can guide the development of future nursing practice and inquiry.

    Spirituality is reflected in everyday life as well as in disciplines ranging from philosophy, literature, sociology, and health care. Medical schools have begun offering courses in spirituality, religion, and health. Several schools of nursing have incorporated into their programs issues of spirituality and holistic health care. Trends that appear to be driving this new interest in spirituality include many studies that demonstrate the connection between spirituality and health improvement. Also there is a high demand from clients or patients that their spiritual needs be addressed along with their physical, mental, and emotional needs.

    Definitions regarding exactly what spirituality is may vary on some points, however, they all seem to agree that all people are spiritual beings. Everyone has a spiritual dimension that motivates, energizes, and influences every aspect of life. Spirituality can be considered a basic human quality that transcends gender, race, color, and national origin. According to Savary (2006, Prayer Ways) spirituality is a person's way of being, thinking, choosing, and acting in the world in light of that person's ultimate values.

    While health care providers may describe themselves as religious or spiritual, many may lack the formal education that could prepare them to administer effective spiritual care. In addition, they may not know where to obtain that education or where to enhance the education and information they already have. (There are a number books on spirituality, however, there are very few workshops or other programs dedicated to the spiritual health care of the individual.)

    This lack of education may cause nurses or other health care providers to be uncomfortable when assessing their clients and providing spiritual care. They may also worry about inappropriateness of addressing spiritual needs, hold the belief that spirituality is synonymous with religion; they may also have difficulty separating the client's spiritual dimension from their psychosocial dimension. There are a vast number of health care professionals that believe that the spiritual care of the patient or client is the domain of the chaplain, priest, imam, rabbi, or other trained clergy person. It is true that the fore mentioned individuals certainly do provide spiritual care, however, it is not exclusively their domain. The nurse, who provides bedside physical care has also the right and responsibility to provide spiritual care. He or she cares for the whole person, mind, body, and spirit.

    According to O,Brien (Spirituality in Nursing 2003) there are three key activities for spiritual caring: being with patients in their experiences of pain, suffering, or other problems or needs; listening to patients verbally express anxieties or emotions, such as fear, anger, loneliness, depression, or sorrow, which may be hindering the achievement of wellness; and touching patients either physically, emotionally, or spiritually to assure them of their connectedness with other in the family of God. In and of themselves the acts of being with, listening to, or touching a patient may not constitute spiritual care. These behaviors, however, grounded in a nurse's spiritual philosophy of life such as that articulated in the parable of the Good Samaritan (Luke 10:25-37), take on the element of ministry; they constitute the nurse's theology of caring.

    Spirituality can be expressed through rituals, meditation, guided imagery, visualization, practicing gratitude, spending time in nature, viewing and engaging in art, and through various other endeavors that have meaning to the patient or client. To simplify how individuals express and experience spirituality we look at: expression of feelings, forgive, or be forgiven, have connections to others or a higher power, find meaning in life, and have hope.

    Spirituality has importance in the realm of nursing so much so that NANDA has included it as part of a nursing diagnosis. NANDA definitions Carpenito Moyet (2004 Nursing Diagnosis: application to clinical practice (10th ed.)

    Spiritual distress: Impaired ability to experience and integrate meaning and purpose in life through the individual's connectedness with self, others, art, music, literature, nature, or a power greater than oneself.

    Risk for spiritual distress: At risk for altered sense of harmonious connectedness with all of life and the universe in which dimensions that transcend and empower the self may be disrupted.

    Readiness for enhanced spiritual well-being: Ability to experience and integrate meaning and purpose in life through connectedness with self, others, art, music, literature, nature, or a power greater than oneself.

    A question that may puzzle nurses is how to assess a client regarding their spiritual needs. Certainly there are many physical assessment tools. In my research I have encountered any number of authors who present various spiritual assessments tools. The following is a mnemonic that can be adapted to be included in the intake assessment of the client.

    S - Spiritual belief system - what is your formal religious affiliation? Name and describe your spiritual belief system.

    P - Personal spirituality - describe the beliefs and practices of your religion or personal belief system. Describe the beliefs or practices you do not accept. What is the importance of spirituality/religion in your daily life.

    I - Integration with a spiritual community - do you belong to a spiritual/religious group or community? Does or could this group provide help in dealing with health issues?

    R - Ritualized practices and restrictions - are there specific practices that you carry out as part of your religion/spirituality? Are there certain lifestyle activities or practices that your religion/spirituality encourages or forbids?

    I - Implications for care - what aspects of your religion/spirituality would you like me to keep in mind as I care for you?

    T - Terminal events planning - as we plan for end-of-life care, how does your faith affect your decisions?

    The art of spiritually caring for individuals can be nebulous, therefore I have included examples of spiritual care: being present (physically, psychologically, or spiritually) active listening, prayer, reading religious texts, reminiscence, touch, creative arts, religious support, meditation.

    The spiritual rituals or prayer, meditation, guided imagery, gratitude, spending time in nature, and art can all help people connect to their inner being, to others and to a divine spirit or higher power. As part of spiritual and cultural traditions, rituals help to provide awareness, meaning, intention, and purpose in life. There are various types of prayers that clients may engage in. Rituals on the other hand, are practices that are often repeated and can provide a way for people to make life experience meaningful. There are many types of rituals, but an important aspect of healing is creating personalized rituals such as prayer before meals, meditation time, or eating of specific foods and avoiding other foods, and perhaps a ritual hand washing.

    The environment or physical space that our clients occupy can either enhance or deter from our client's spirituality. The question can be asked is this space a spiritually healing environment providing adequate room, proper plumbing, safe surrounding, low levels of noise. A spiritually healing environment can be created in an institutional or personal setting. Spiritually healing environments engage all five senses. Noise is one of the most noxious stimuli in most health care settings.

    Many more individuals remain in the home rather than leaving the home for health care. As nurses we should have the ability to spiritually care for our patients or clients in all settings.

    I will end with a prayer for healers (Prayer of St Francis modified by Charles C. Wise)

    Lord, Make me an instrument of your health:
    Where there is sickness, let me bring cure;
    Where s injury, aid;
    Where there is suffering, ease; where there is sadness comfort;
    Where there is despair hope;
    Where there is death, acceptance and peace

    Grant that I may not:
    So much seek to be justified, as to console;
    To obey as to understand;
    To be honored as to love
    For it is in giving of ourselves that we heal,
    It is in listening that we comfort, and in dying that we are born to eternal life.


    Carpenito, Lynda, J. et. al. Nursing Diagnosis: Application to Clinical Practice.
    2004, Lippincott, New York

    Hickman, Janet, S. Faith Community Nursing, 2006, Lippincott, New York

    O'Brien, SFFC, Mary Elizabeth, Spirituality in Nursing: Standing on Holy Ground
    2003, Jones and Bartlett Publishers, Boston, MA

    Savary, Louis, M., Berney, Patricia, H., Prayer Ways, 1988 Harper and Row, San Francisco