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DIALOGUE ON DOCUMENTING SPIRITUAL CARE

CLEDA MEYER – opened the discussion
Hi -
We've held previous discussions about teaching spiritual care in nursing. From my clinical experiences with students I am concerned about the lack of documentation related to spirituality. Even though JACHO mandates we address patient's spiritual needs, in the hospital used for our clinical setting, the only reference to spirituality is asking the patients if they would like to have a chaplain visit, during completion of the initial database. The computerized charting system provides a thorough physical assessment with only "Coping" to indicate the patient's psychological status. Even though the clinical preparation tool they use as students includes attention to spirituality, by the last week of the leadership experience they are no longer using this form and rely on the documentation system used by the hospital.

One suggestion I have for students is to ask their patients "What is your major concern for the day" after they establish rapport as part of their morning assessment, unless the patient has already identified a concern. This can lead to further discussion of concerns or fears the patient may be reluctant to address when trying to be a "good" patient that does not want to be any bother.

Has anyone else encountered the problem of great attention to physical needs and decreased attention to psychological and spiritual needs of patients? How many others are using computterized documentation systems? Even though the system allows the use of "free text" nurses and students tend to use the "pop up windows" with standardized choices - none of which include spiritual distress.

Thanks for your feedback. Cleda Meyer

GENIE FORD
The lack of documentation of spiritual care (which means that it probably isn't being addressed, even though mandated by JCAHO) is of concern to me. I like Cleda's question, "What is your major concern for today?" That is a wonderful open-ended question. Getting patients to open up is not usually a problem in my area (Peds), however. The patients and parents usually express their concerns without any prompting. My concern is the documentation. The clinical facility uses computer documentation and the questions r/t spirituality are few and vaguely worded. Free text is an option, but if you're not taught how to address spirituality within the nursing process, how can you document it? So, one of my topics to discuss with the students is how to address these needs. I only have each group for three weeks, so I don't have much time to address this issue. I do think that Peds is a great place to learn about spiritual care, because the spiritual needs are usually voiced in this area.

Genie S Ford who is about halfway through her master's--Thank God!!!!!!

MARSHA PEREIA
When I was a BSN nursing student at Bemidji State University, Bemidji, MN we had to write a nursing diagnosis complete with interventions. I and another student wrote one for Cultural Brokerage. The professor sent it into the committee of the Nursing Intervention Classification just to show them what was being done way up north. Consequentially I and my fellow student became contributors to the 2000 Nursing Intervention Classification(NIC)in the interventions of Cultural Brokerage and Spiritual Facilitator as they took some of our interventions for these two intervention classifications. There is work being done regarding spiritual interventions but it is being done almost in a whisper. The whole topic of spiritual interventions feels fraught with landmines. The nursing community finds it more comfortable talking about bowel movements than spirituality - and if it is so uncomfortable to dialogue about within the nursing community how uncomfortable is it to approach a client about - especially as there is no active provision for direction or documentation within the institutions of nursing care?

Marsha Pereira

MARTHA HIGHFIELD
I encourage my students to use NANDA diagnostic criteria and then simply document what patients say about what is helpful or unhelpful to them. I find this defensible in any setting.

JOANNE BECKMAN
My hospital experience is similar to Cleda's description; the chaplain question on the admission database. We used to have a NANDA-based computerized care planning system, but that has been replaced by a paper record system for nursing documentation. In fact, nursing diagnoses are even discouraged by some physicians and nurses in our institution, in favor of more medicalized terminology. However, that does not mean spiritual care is absent, just not documented.

In working with chronically ill adults with multiple health problems, I think spiritual and psychological needs tend to be conflated. Some advanced practice nurses and social workers spend enough time with patients to assess their needs more in depth. Sometimes the emotional needs suggest spiritual needs, e.g. hopelessness, despair, fear of dying, anger with God, etc., but they may be labeled "depression" or "anxiety". The assessment may or may not identify spiritual needs as such. Sometimes meditation is recommended as a kind of "relaxation" technique for stress management, and the patient's religious affiliation provides the context: for example, one advanced practice nurse suggests "The Lord is my shepherd" as a focus for meditation and relaxation to those with a Judeo-Christian faith.

More often, I observe spiritual care by staff nurses in response to recognizing faith as a strength. In my practice, I often pick up cues on the faith of the patient and create a segway by commenting positively on a poem, book title, religious item like a rosary or angel pin, or a music or TV program they are watching. Many patients readily express their faith (or indicate a lack of desire to pursue discussion of it). Often faith is demonstrated or discussed during visits with family and friends, especially on Sundays. I find patients receive encouragement from my acknowledging and, when appropriate, sharing our mutual experiences of faith in God, Scripture verses, or worship services on TV. Another nurse I work with sings to patients when led, as a comfort measure and encouragement to them (she truly has a gift for her singing ministry). However, little of this is documented in relation to a "spiritual" need.

Cleda, Your question has stimulated me to consider how to more clearly document faith as a strength, as I find that Christian faith is a strong and supportive belief system for many of our patients and staff. Joanne

MARTHA HIGHFIELD
My hospital experience is similar to Cleda's description; the chaplain question on the admission database. We used to have a NANDA-based computerized care planning system, but that has been replaced by a paper record system for nursing documentation. In fact, nursing diagnoses are even discouraged by some physicians and nurses in our institution, in favor of more medicalized terminology. However, that does not mean spiritual care is absent, just not documented.

In working with chronically ill adults with multiple health problems, I think spiritual and psychological needs tend to be conflated. Some advanced practice nurses and social workers spend enough time with patients to assess their needs more in depth. Sometimes the emotional needs suggest spiritual needs, e.g. hopelessness, despair, fear of dying, anger with God, etc., but they may be labeled "depression" or "anxiety". The assessment may or may not identify spiritual needs as such. Sometimes meditation is recommended as a kind of "relaxation" technique for stress management, and the patient's religious affiliation provides the context: for example, one advanced practice nurse suggests "The Lord is my shepherd" as a focus for meditation and relaxation to those with a Judeo-Christian faith.

More often, I observe spiritual care by staff nurses in response to recognizing faith as a strength. In my practice, I often pick up cues on the faith of the patient and create a segway by commenting positively on a poem, book title, religious item like a rosary or angel pin, or a music or TV program they are watching. Many patients readily express their faith (or indicate a lack of desire to pursue discussion of it). Often faith is demonstrated or discussed during visits with family and friends, especially on Sundays. I find patients receive encouragement from my acknowledging and,when appropriate, sharing our mutual experiences of faith in God, Scripture verses, or worship services on TV. Another nurse I work with sings to patients when led, as a comfort measure and encouragement to them (she truly has a gift for her singing ministry). However, little of this is documented in relation to a "spiritual" need.

Cleda, Your question has stimulated me to consider how to more clearly document faith as a strength, as I find that Christian faith is a strong and supportive belief system for many of our patients and staff. Joanne Speaking of JCAHO, some of you might be interested in an article that I and a PT colleague published in the Journal of Healthcare Quality. They put the full article online as a CE at: http://www.allenpress.com/jhq/123/123.html

Not part of the dialogue but relevant to giving of spiritual care – written in response to a welcome letter after Donald Marsh signed onto Fac/Grad website Oct. 10-2003

Thank you for your email message. I do have my D.Min. dissertation on the NCF website already. The topic was training nurses in how to be spiritual care givers. My full time job is as Director of Pastoral Care at Avista Adventist Hospital in Boulder County, north of Denver. I have been involved with bioethics for 13 years, most of that time as chair of our hospital ethics committee. I am an affiliate faculty member at Regis, teaching the Ethics for Medical Professionals class. So far, I have just taught on-line, but I really love mentoring students. The ethics course director and developer is Deb Bennett-Woods, Ed.D.

A former colleague here at Avista, Phyllis Graham-Dickerson, Ph.D., is another Christian faculty member at Regis and got me connected with the program there. She and I have discussed doing some further research regarding nursing and spiritual care, but we have not found time or funding to proceed in the last year.

I firmly believe that most spiritual care in hospitals is given by nurses and other health care professionals, and is definitely not the sole domain of trained chaplains. God places various people with a variety of gifts in healthcare, as well as in the church, and we are all ministers of God's good news. God is at work in all of us to accomplish His good purpose.

Donald P Marsh, DMin, CCC, CT

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