18.4 Applying the Nursing Process

Now that we have reviewed the concepts related to spirituality and discussed beliefs and practices of common world religions, let’s apply the nursing process to promoting spiritual health.

Assessment

Subjective Assessment

Agencies often provide a standardized spiritual assessment tool to complete when a client is admitted. If a standardized assessment tool is not available, the FICA model can be used. The FICA model contains open-ended questions to ask clients about their personal spiritual beliefs in a way that is open and nonjudgmental^[1]:

• F-Faith or beliefs: What are your spiritual beliefs? Do you consider yourself spiritual? What things do you believe in that give meaning to life?
• I-Importance and influence: Is faith/spirituality important to you? How has your illness and/or hospitalization affected your personal practices /beliefs?
• C-Community: Are you connected with a faith center in the community? Does it provide support/comfort for you during times of stress? Is there a person/group/leader who supports/assists you in your spirituality?
• A-Address: What support can we provide to support your spiritual beliefs/practices?

The HOPE tool is also helpful for incorporating spiritual assessment questions into a medical interview. HOPE stands for^[2]:

• H: Sources of hope, meaning, comfort, strength, peace, love and connection
• O: Organized religion
• P: Personal spirituality and practices
• E: Effects of spirituality on medical care and end-of-life issues

The first part of the mnemonic, H, refer asking about the client’s sources of hope and basic spiritual resources, without focusing on religion. This approach initiates therapeutic communication with all clients regarding spirituality beyond traditional religion.

The second and third letters, O and P, refer to inquiring about the importance of religious rituals and specific aspects of their spiritual practices that are important to them. A useful way to introduce these questions is a normalizing statement such as: “For some people, their religious or spiritual beliefs act as a source of comfort and strength in dealing with life’s ups and downs. Is this true for you?”

The fifth letter, E, refers to the effects of a client’s spirituality and beliefs on decisions related to medical care and end-of-life issues. This may include barriers accessing preferred spiritual resources during medical treatment, fears related to end-of-life issues, and decisional conflicts related to the client’s values and beliefs and prescribed treatment.

Objective Assessment

In addition to asking open-ended questions, it is important for the nurse to observe clients for cues indicating difficulties in finding meaning, purpose, or hope in life. It is also important to monitor for supportive relationships.^[3]

Clients experiencing chronic or serious illness may make statements indicating spiritual distress that should cue the nurse that spiritual care is needed. Examples of these statements/concepts are as follows:

• Lack of Meaning: “I am not the person I used to be.”
• Hope: “I have nothing left to hope for.”
• Mystery: “Why me?”
• Isolation: “All my family and friends are gone.”
• Helplessness: “I have no control over my life anymore.”^[4]

Diagnoses

See Table 18.4 for selected NANDA-I diagnoses associated with spiritual health.

Table 18.4 Selected NANDA-I Nursing Diagnoses Related to Spiritual Health^[5]

Sample Nursing Diagnosis Statements

Readiness for Enhanced Spiritual Well-Being

A sample PES statement is, Readiness for Enhanced Spiritual Well-Being as evidenced by expressed desire to increase time outdoors and be closer to nature. The nurse could encourage clients to visit local parks and walk outdoors.

Impaired Religiosity

Hospitalized clients may be unable to attend religious services they are accustomed to attending. This contributes to impaired religiosity, which occurs when life circumstances, such as hospitalization, illness, stress, substance use disorder, or other factors negatively affect faith, spirituality, or the ability to maintain faith or spirituality practices.^[6] A sample PES statement is, “Impaired Religiosity related to environmental barriers to practicing religion as evidenced by difficulty adhering to prescribed religious beliefs.” The nurse could contact the client’s pastor to arrange a visit or determine if services can be viewed online.

Spiritual Distress

Events that place clients at risk for developing spiritual distress include birth of a child, death of a significant other, exposure to death or traumatic events, a life transition, or terminal care. Associated conditions that place a person at risk for developing spiritual distress include chronic disease, depression, loss of a body part, loss of function of a body part, or a treatment regimen.^[7]

For example, a client diagnosed with life-threatening medical diagnoses like cancer may experience spiritual distress as they move through the typical stages of loss. A sample PES statement is, “Spiritual Distress related to anxiety associated with illness as evidenced by crying, insomnia, and questioning the meaning of suffering.” A nurse would implement interventions to enhance coping.

Outcome Identification

Goals and SMART outcomes should be customized to each client and their situation.

When a client has the nursing diagnosis Readiness for Enhanced Spiritual Well-Being, a sample goal statement is, “The client will demonstrate hope as evidenced by the following indicators: expressed expectation of a positive future, faith, optimism, belief in self, sense of meaning in life, belief in others, and inner peace.”^[8] An example of a related SMART outcome is, “The client will express a sense of meaning and purpose in life by discharge.”^[9]

When a client has the nursing diagnosis Spiritual Distress, a sample goal statement is, “The client will demonstrate improved spiritual health as evidenced by one of the following indicators: feelings of faith, hope, meaning, and purpose in life with connectedness with self and others to share thoughts, feelings, and beliefs.”^[10] A sample SMART outcome is, “The client will express a purpose in life by discharge.”^[11]

Planning Interventions

Providing Spiritual Care

When providing spiritual care, the RN must not impose their religious or spiritual beliefs on the client. There are several guidelines for therapeutically implementing nursing interventions to support clients’ spiritually:

• Take cues from the client: When bringing up spiritual health with clients, understand this may be a difficult topic for them to discuss. Let them lead the conversation and do not press further than they want to share. Also, be aware of the client’s nonverbal cues. They may be saying one thing, but their body language is saying something different. Gently point out the contradiction and seek clarification. For example, a client may state that they don’t blame God for their illness but begin to tear up as they say it. By responding, “I noticed you became tearful when you said that…what is causing the tears,” the door is opened for them to share more of their thoughts and feelings.
• Ask the client how you can support them spiritually: An important way to assist a client with their spiritual health is to ask them what they need to feel supported in their faith and then try to accommodate their requests, if possible. For example, perhaps they would like to speak to their clergy, spend some quiet time in meditation or prayer without interruption, or go to the onsite chapel. Explain that spiritual health helps the healing process. Many agencies have chaplains onsite that can be offered to clients as a spiritual resource.
• Support clients within their own faith tradition: Because clients can sometimes feel as if they are a captive audience, it is not appropriate for the nurse to take this opportunity to attempt to persuade a client towards a preferred religion or belief system. The role of the nurse is to respect and support the client’s values and beliefs, not promote the nurse’s values and beliefs.
• Listen to a client’s fears and concerns without adding your own stories: In an effort to empathize with a client who is telling their story, it is easy for the nurse to start adding personal examples from their own life. Although this may seem helpful, it is usually only distracting and shifts the focus from the client to the nurse. Focus on the client’s fears and concerns. Name and validate the emotions that are heard when possible. Sometimes clients don’t realize what they are feeling until it is pointed out to them.
• Pray with a client if requested (or provide someone who will): Some nurses may feel reluctant to pray with clients when they are asked for various reasons. They may feel underprepared, uncomfortable, or unsure if they are “allowed to.” Nurses are encouraged to pray with their clients to support their spiritual health, as long as the focus is on the client’s preferences and beliefs, not the nurse’s. It is helpful to ask the client what they would like you to pray about. See Figure 18.14^[12] for an image of a nurse praying with a client. Having a short, simple prayer ready, that is appropriate for any faith, may help in this situation. If a nurse does not feel comfortable praying, the chaplain should be requested to participate in prayer with the client.
• Share an encouraging thought or word: Similar to the preceding prayer suggestion, a scripture verse (based on the client preferences) or an inspirational poem may be helpful to share during difficult times. Having a few verses or thoughts readily available can be very helpful during critical moments.^[13]
• Use presence and touch: Sometimes the mere presence of a nurse is spiritually comforting for clients. Words are not always needed. It can be very comforting to know that someone will be sitting quietly next to them as they fall asleep or are in pain. Touch can also be a very powerful therapeutic tool to provide comfort (after asking permission of the client).^[14]

See the following box for a summary of therapeutic interventions that nurses can implement to provide spiritual support. Review additional interventions for enhancing coping for clients and family members experiencing grief in the “Grief and Loss” chapter.

Implementing Interventions

Nurses should support clients’ spiritual and religious preferences when implementing interventions to support their spiritual well-being. The nurse should respect and listen to the client’s expression of beliefs and not impose their own beliefs on the client. Spiritual or religious practices should be accommodated if safe and feasible to do so. If a client has a spiritual belief, value, or practice that conflicts with their treatment plan, the nurse should explain the rationale for the intervention or treatment. If the client is not willing to complete the treatment as planned due to their spiritual or religious beliefs, the nurse should attempt to negotiate the treatment plan with the client and/or health care provider. For example, a nurse can advocate for rescheduling a procedure after the Sabbath or modifying the dietary plan and medication administration times during Ramadan.

Evaluation

When evaluating the effectiveness of interventions in promoting a client’s spiritual health, refer to the overall goal, “The client will demonstrate spiritual health as evidenced by the following indicators: feelings of faith, hope, meaning, and purpose in life with connectedness with self and others.”^[17] From there, review the client’s progress toward the personalized SMART outcomes that have been customized to their situation.