Exploring Nurse Communication About Spirituality

Abstract

Objective:

Although spiritual care is considered one of the pillars of palliative care, many health-care providers never receive formal training on how to communicate about spirituality with patients and families. The aim of this study was to explore the spiritual care experiences of oncology nurses in order to learn more about patient needs and nurse responses.

Methods:

A survey was circulated at a communication training course for oncology nurses in June 2015. Nurses recalled a care experience that included the initiation of a spiritual care topic and their response to the patient/family. Data were analyzed using thematic analysis.

Results:

Nurses reported that communication about spirituality was primarily initiated by patients, rather than family members, and spiritual topics commonly emerged during the end of life or when patients experienced spiritual distress. Nurses’ experiences highlighted the positive impact spiritual conversations had on the quality of patient care and its benefit to families. Spiritual communication was described as an important nursing role at the end of patients’ lives, and nonverbal communication, listening, and discussing patients’ emotions were emphasized as important and effective nurse communication skills during spiritual care conversations. Approximately one-third of nurses in the sample reported sharing their own personal spiritual or religious backgrounds with patients, and they reported that these sharing experiences strengthened their own faith.

Conclusion:

It is evident that patients want to discuss spiritual topics during care. Study findings illustrate the need to develop a spiritual communication curriculum and provide spiritual care communication training to clinicians.

Keywords

spirituality communication qualitative study

Introduction

Spiritual care, 1 of the 8 domains of palliative care, includes attending to the spiritual, religious, and existential issues in patient care. These domains are detailed in recommendations for the interdisciplinary implementation of spiritual care in palliative care.¹ The National Consensus Project for Quality Palliative Care (NCP) guidelines define spirituality as the aspect of humanity that refers to the way individuals seek and express meaning and purpose and the way they experience their connectedness to the moment, to self, to others, to nature, and/or to the significant or sacred.² Although the provision of spiritual care to critically ill and dying patients is mandated both in the United States and in the United Kingdom, many studies reveal that patients frequently do not receive the spiritual care that could most benefit them.^1,3,4

The provision of spiritual care to patients and families during critical illness and at end of life is beneficial both for health-care providers and for patients/families. In a recent study of spiritual care in patients with advanced cancer, both patients and providers were overwhelmingly positive about all types of spiritual care; not one provider or patient reported any spiritual care experience to be negative.⁵ There is also a significant link between supporting patients’ spiritual needs, their improved quality of life, and their need for less aggressive medical treatment.⁴ Several studies have shown that spiritual care positively affects health-care outcomes, including quality of life, coping, and end-of-life decision-making.¹ Clearly, patients and families want their spiritual needs acknowledged, addressed, and attended to by health-care providers.

Despite the emphasis on spiritual care, health-care providers do not receive formal guidance on how to effectively communicate with patients and families about spiritual concerns.⁶ Several studies that report the infrequency of spiritual care provision in clinical settings note that health-care providers’ inadequate education and training is an obstacle to patients’ receipt of such care.^3,7,8 Wittenberg et al in a survey of 193 nurses found that only 23% reported frequently discussing spiritual concerns with patients.⁹ In a recent study conducted in intensive care unit settings, 77% of surrogate decision-makers reported that religion or spirituality was important in their lives, yet only 16% of conferences with providers included a discussion of religious or spiritual considerations.¹⁰

Barriers to the provision of spiritual care include a lack of time and privacy to talk to patients and family members, physicians’ and nurses’ feelings of inadequacy about initiating spiritual care conversations, and health-care providers’ lack of education and training to engage in religious or spirituality discourse with patients/family.^3,4 Perhaps, the most commonly cited obstacle by researchers who study spiritual care is the nebulous, amorphous definition of spirituality itself.^3,4 Despite the NCP definition of spirituality, it is unclear whether health-care providers utilize these definitions in their attempts to provide spiritual care to patients/families. Wynne asserts, for example, that while assessing spiritual needs, along with physical, psychological, and social ones, is paramount, at end of life as these needs often go unrecognized and unmet, in part because providers are unclear on the definition of spirituality and how and by whom spiritual care should be delivered.

Overall, there is little known about how health-care providers communicate about spirituality. In the intensive care unit setting, health-care providers often redirect spiritual topics to medical considerations or they provide empathy, acknowledge spiritual statements with a closed-ended response, or ask the patient/family if they would like a chaplaincy referral.¹⁰ Providers rarely explore patients’ or families’ spiritual concerns. Similarly, spiritual care is infrequently provided in advanced cancer settings, with the most common type of spiritual care consisting of encouragement or affirmation of patients’ or families’ beliefs.⁵ Nurses reported the offer of prayer as the most common form of spiritual care; for physicians, taking a spiritual history, encouraging beliefs, and inquiring about how faith influences medical decisions were the most common forms.⁵ Despite this, only 10% of all spiritual care exchanges in one study involved taking a spiritual history.⁵

The aim of this study was to explore the spiritual care experiences of oncology nurses to learn more about nurse communication involving spirituality. Reviewing and reflecting on spiritual care discussions will aid in the development of communication curricula for health-care providers, an important step toward integrating spiritual care into standard oncology practice.

Methods

A survey was distributed to oncology nurses attending a COMFORT (Communication, Orientation & Options, Mindful Communication, Family caregivers, Openings, Relating and Team) communication course in June 2015. COMFORT courses are 2-day training sessions that provide participants with a comprehensive curriculum about communication strategies (including spiritual care communication) and institutional processes that support patient-centered communication across the cancer continuum.¹¹ Nurses voluntarily completed surveys. This educational activity was determined to be exempt under the institutional review board at the supporting institution.

Survey

Nurses were given the NCP definition of spirituality and asked to describe a time when a patient or family member communicated with them about spirituality. Nurses were asked to summarize what happened, what the patient or family member said, how the nurse responded, and whether they shared their own spiritual beliefs during the interaction.

Data Analysis

Qualitative responses were transcribed and inductively analyzed using an iterative process of theme analysis.¹² First, members of the research team independently read all of the transcripts and identified unrestricted sections of text, suggesting a theme. Next, research team members met to integrate individual coding and come to consensus through discussion by connecting, collapsing, or associating coding to establish and finalize themes. Quotes were then extracted for each theme. Demographic items were summarized using the Statistical Package for the Social Sciences to produce descriptive statistics (frequency and mean scores).

Results

Fifty-seven nurses provided a summary of a spiritual care experience with a patient or family member. More than one-third of nurses were clinical nurses (36.8%), followed by advanced practice nurses (19.3%), with 25% serving as a manager, educator, and/or administrator. Two nurses did not report their positions. The majority of nurses came from the Western United States (61.4%) and worked in an acute care setting (71.9%). Nurses had an average of 15.9 years of clinical experience. Table 1 presents the nurses’ demographic characteristics.

Table 1.

Overview of Participant Demographics.

	N = 57 (%)
Position
Clinical nurse	21 (36.8)
APRN	11 (19.3)
Manager/supervisor	6 (10.5)
Educator	2 (3.5)
Administrator	1 (1.8)
Other	7 (12.3)
More than one	7 (12.3)
Not reported	2 (3.5)
Geographical regions
Northeast (Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, and Vermont)	5 (8.8)
Midwest (Minnesota, Illinois, Indiana, Iowa, Kansas, Michigan, Missouri, Nebraska, Ohio, South Dakota, and Wisconsin)	8 (14)
South (Florida, Georgia, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, and Washington DC)	4 (7)
West (Alaska, Arizona, California, Colorado, Montana, Nevada, Oregon, and Utah)	35 (61.4)
Not reported	5 (8.8)
Years of experience
1-5 years	9 (15.8)
6-10 years	7 (12.3)
11-15 years	11 (19.3)
15+ years	16 (28.1)
Not reported	14 (24.6)
Average years	15.9
Institution^a
Home care	1 (1.8)
Outpatient/ambulatory care	6 (8.8)
University/school of nursing	6 (3.5)
Hospital	42 (71.9)
More than one	10 (8.8)
Not reported	3 (5.3)

Abbreviation: APRN, advanced practice registered nurse.

^aCategory is not mutually exclusive, and 5 participants marked more than 1 category.

Nurse experiences with spiritual communication were summarized into 3 categories: initiating communication about spirituality, responding to topics about spirituality, and sharing personal spiritual background and religious preferences. Table 2 summarizes coding themes and specific communication features in each category, as described below.

Table 2.

Overview of Study Findings.

Category	Theme	Communication
Initiating communication about spirituality	Patients commonly initiated at end of life or when in spiritual distress	Viewed as part of nurse’s role during impending death Elaborated on patient’s emotions Encouraged talk about spirituality after it was initiated
Responding to topics about spirituality	Positive impact on patient care experiences Validate patient spiritual experience Reconcile family religious conflict Help family acknowledge impending death	Heightened nonverbal communication Considered “empathic opportunity”
Sharing personal spiritual background, beliefs, religious preferences	37% shared 15% did not share 48% did not reveal	Strengthened nurse’s own faith

Initiating Communication About Spirituality

Nurses’ recalled instances of spiritual communication with their patients/families revealed that patients rather than family members usually initiated such communication, and it generally occurred around patients’ impending deaths or when a crisis in the disease trajectory (eg, a recurrent or relapsed cancer) created spiritual or existential distress. The topics of spiritual communication included patients’ and family members’ beliefs (in miracles, in God’s care and healing, in suffering as their chance to witness for God), patients’ and family members’ anger and fear (anger at God for their cancer diagnosis, fear of not being “good enough” for God or for heaven), patients’ regrets (for past life choices), or patients’ questioning of God (belief that their disease was punishment for past sins). Many of the nurses’ narratives involved patients who were actively dying, as in these examples:

A patient on hospice, imminently dying, was “questioning and not sure” of his faith. “He said he wanted to believe but didn’t know how to go about it.” The nurse offered to pray with him and discovered he wished to be “saved” in the Christian sense.

A patient with metastatic lung cancer asked the nurse what would happen to her when she died. In the ensuing conversation about life after death, the patient discussed with the nurse her belief in Heaven and hope that she would be there with her loved ones.

When patients at the end of life initiated communication about spirituality, nurses regarded being able to engage in these conversations as necessary in the rendering of quality end-of-life care. Nurses described their receptivity to the patient/family as in-the-moment, focused, and nonjudgmental. Even if they did not share the patient’s/family’s beliefs, they encouraged the expression of those beliefs. Frequently, nurses acknowledged and elaborated on patients’ emotions in order to offer comfort, as reported in the following instance:

An angry patient with recurrent larynx cancer threatened to pull out his NG feeding tube and claimed: “I don’t care if I smack the doctor cause I’m going to hell anyway.” The nurse asked why the patient believed he was “going to hell.” The patient responded by giving an account of having been Catholic and an altar boy before he lapsed and led a “bad life.” The nurse shared her own Catholic background which inspired the patient to disclose that St. Michael was the only “person” he could relate to in the church since the saint was also a fighter.

Responding to Topics About Spirituality

A striking finding in the narratives was that nurses frequently performed spiritual “work” by responding to patients’/family members’ religious/spiritual crises. Such spiritual/relational work helped comfort patients and family members who expressed fear and anger, reconcile conflicting religious beliefs within a family, reframe the patients’ spiritual questions/doubts, or clarify patients’/family members’ beliefs. Moreover, responses to the patient and family about their spiritual concerns and needs resulted in positive patient care experiences. In several notable instances, spiritual encounters with patients/families were transformative. For example, a patient dying of ovarian cancer continued to insist that Jesus would heal her (#10). Other health-care providers and her own daughter labeled her as “in denial.” The nurse made time to sit with the patient and her daughter. When the patient again stated that Jesus would heal her, the nurse explored this statement with the patient:

I held her hand and asked, “I know that healing comes in many ways. How do you see him healing you?” The patient started crying, joined by her daughter, and we paused for a bit. Then we talked about “healing through relief of suffering” and through dying. We talked for 30-35 minutes.

By acknowledging patients’ and family members’ need to discuss the spiritual and existential aspects of their cancer and/or impending deaths, these oncology nurses provided space for patients and family to clarify their beliefs, to discuss what was meaningful and purposeful in their lives, and to achieve a measure of comfort and peace.

Nurse responses to patient-initiated topics about spirituality validated patients’ spiritual experiences at the end of life, particularly when the patient’s family was not able to perform this function. A particularly dramatic example was reported by a nurse whose terminally ill patient awakened early one morning to tell his family/friends at his bedside that he had had a spiritual “encounter.” While the patient’s friends reacted to this dream as if he were losing his mind, the nurse told the patient that she truly believed in his experience. The patient continued to feel better and was later discharged.

Occasionally, spiritual discussions resulted in physical changes, such as the patient’s being able to fall asleep when his/her spiritual distress was quieted. Many patients expressed gratitude for a nurse’s willingness to engage them in spiritual discussions, to pray with them, and to reconcile their spiritual beliefs with a family member whose beliefs were dissimilar.

Nurses’ nonverbal behaviors appeared especially critical to patients’ openness to sharing their spiritual concerns/crises. Facilitative nonverbal behaviors such as active listening, sitting with patients/families, and holding a patient’s hand were all emphasized as important communication skills. For example, a nurse described an encounter with a dying patient who denied any spiritual practices or needs, yet the patient elaborated poetically to the nurse on the meaning of a tree in a field he had plowed. The nurse recalled: “I listened. I encouraged him to explore the meaning of this spiritual experience which obviously brought him peace and protection.”

Similarly, nurses described sitting on the edge of the patient’s bed, allowing time to let the patient cry, moving closer to the patient, “talking softly and slowly,” and sitting silently. Overall, nurses reported being open and present for whatever spiritual sharing the patient offered. Even if the nurses did not themselves believe in prayer, for example, they were willing to sit with patients while the patients prayed.

Sharing Personal Spiritual/Religious Background

Nurses’ own spiritual lives frequently were invoked as they attended to their patients’ spiritual stories, questions, and crises. In 21 (37%) of the 57 narratives, nurses acknowledged sharing their own religious or spiritual convictions with their patients. Some nurses reported a tendency to share personal beliefs “unless the patient does not want to discuss.” Yet in 15 (26%) of the narratives, nurses revealed that they did not share their own beliefs with their patients or, in a few instances, their spiritual beliefs did not align with those of their patients. One nurse (#12) said: “I normally do not share my own spiritual beliefs. I find that most patients don’t really care about my spiritual beliefs.”

However, some nurses explained that spiritual care experiences with patients strengthened their own faith. This was particularly true when nurse and patient shared the same religious beliefs, and this commonality served to establish and foster a relationship between nurse and patient. For example, a nurse shared: “We were faith sisters. I learned and was supported more by her than I am sure she learned from me.” Another nurse reported: “I shared that I am a Christian also and that it was amazing to see someone so secure in their faith.” In other instances, nurses expressed feelings of amazement at the depth and strength of a patient’s/family’s religious faith and resilience.

Discussion

This study examined the spiritual care experiences of a group of oncology nurses and found that it was the patient who was most likely to initiate communication about spirituality and that nurses positively respond by being present. The nurses had received little training, if any, on communication about spirituality and relied on their own spiritual backgrounds and understanding to accommodate patients’ requests. Patients’ emotional affects generated by a spiritual/religious crisis or question were seen by nurses as an “empathic opportunity.”¹³ An empathic opportunity is described as a patient’s direct expression of an emotion that is explicitly acknowledged by health-care providers. In this study, oncology nurses sanctioned patients’ emotional expressions by inviting elaboration, asking clarifying questions, and assisting patients in interpreting the meaning of the emotions. Nurses seized on patients’ expressions of fear, anger, or despair to discuss their spirituality. In consonance with the compassion model in palliative care, nurses described using nonverbal communication to engage in relational communication and attend to the patients’ spiritual needs.¹⁴ Patients’ spiritual needs were a trigger for nurse compassion.

In nearly all of the self-reported instances of spiritual communication with a patient with cancer, patients and family members responded positively to nurses’ engagement with the topic of religious, spiritual, or existential concerns, whether the patient or the family initiated such talk. In an overwhelming number of narratives in our data set (95%), parties experienced behavioral and emotional outcomes that can be considered positive. However, patients, family members, and nurses can have distress when their spiritual views clash. Engaging in discussions of a spiritual nature thus cannot be offered as a panacea for a patient’s/family members’ angst in the course of life-threatening illness.

Although religious and spiritual conversations are often absent in end-of-life conversations,¹⁰ the vast majority of spiritual care experiences shared in this study concerned patients at the end of life. A critical gap in spiritual care remains as there is limited understanding of discussions about spirituality that occur during diagnosis, treatment, and survivorship. Future training efforts need to emphasize spiritual assessment and how to initiate a conversation about spirituality with patients and families.

Spiritual histories may be a key gateway to overall spiritual care provision.⁵ Communication about spirituality that is initiated by taking a spiritual history enables health-care providers to advocate for their patients’ spiritual and religious needs through chaplaincy referrals, support groups, and other resources. They have the potential to help explore patients’ identities and coping mechanisms as well as to strengthen the provider–patient relationship. Essential skills for spiritual communication include self-awareness, assessment of spiritual needs, compassionate presence, appropriate referral to spiritual care providers, and clinical conversations about a person’s spirituality.⁶ Prior research has established that confidence in spiritual care communication can be improved with short-term training.¹⁵ As nurses continue to receive training in hospice and palliative care, it is necessary that this training includes spiritual care communication.

Although 48% of nurses did not reveal whether they shared their own spiritual background with patient/family, it has been suggested that nurses should be attuned to their own spirituality before they offer spiritual care to their patients and families.¹ Nurses should attend to their own biopsychosocial and spiritual issues in the development of compassion and empathy, attributes that will serve them well in caring for others’ spiritual needs. The findings in a study of spiritual care offered by both palliative care and acute care nurses reiterate that nurses’ own spirituality impacted their practice of spiritual caring; nurses’ ease with their own spirituality was vital to providing spiritual care to their patients.¹⁶ Future research might examine whether nurses can respond proactively to spiritual distress in their patients/families even when they do not have strong belief systems themselves.

The study was limited to a select sample of nurses attending a communication course who voluntarily completed the survey. The sample also represented a group of experienced nurses, and thus, responses may not represent the general population of nurses.

Conclusion

This study demonstrated the awareness and demand for spiritual care communication and reinforces the need for spiritual care communication skills training for cancer care providers. The subtlety and variety of patients’ and families’ spiritual needs make them more difficult to assess and address, much more so than religious needs.⁴ Future curricula should be based on an interprofessional approach to care given the emphasis on cancer interdisciplinary care teams. Findings from this study suggest that training should also include providers’ own spiritual well-being.

Footnotes

Acknowledgments

The authors wish to thank the nurses who participated in this study. We thank Ellen Friedmann for editorial assistance.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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