Build a foundation for nursing students and practicing nurses to care for their patients and themselves compassionately.
Takeaways:
- Incorporating contemplation, connection, and collaboration into the workplace or classroom can improve nurses’ ability to provide compassionate care.
- Applying innovative practices from disciplines outside of healthcare can promote spiritual care competence and provide emotional support to nurses and nursing students.
- As experienced nurses, sharing our stories with nursing students or new nurses creates a safe space in which they feel supported.
Adam* was 63 years old and suffering with emphysema. As I followed the trail of his oxygen tubing into the kitchen, he and his wife Betty greeted me as they always did, with a glass of apple juice and a hug. The kitchen counter displayed an array of flowers and cards from former colleagues and bosses. Adam’s declining health had forced him to take an unplanned early retirement.
It was unusually warm and humid for early fall in Wisconsin, and Adam was having more difficulty breathing. “Julie, I can’t do this to her any longer,” he said, glancing at Betty. “I used to take care of everything for Betty. Now I’m helpless and she needs to do everything for me. I’m too sick to work, so now we can’t keep up with these bills. If I don’t die by spring, we’ll lose the house.” He held up a finger and pursed his lips to exhale what little breath he could. Leaning forward, he sputtered, “A man is supposed to take care of his wife, not the other way around.”
That conversation took place nearly 25 years ago, when I was a young home care and home hospice nurse. The image of Adam’s face has long faded from my memory, but my inability to help him led to feelings of guilt and shame that lasted long after his death. Adam was suffering from extreme spiritual distress that I wasn’t equipped to address.
Although no official definition of spirituality in healthcare exists, it’s frequently used to refer to that which brings a sense of meaning or purpose to a person’s life, including important connections or relationships.
According to Puchalski and Ferrell, the strongest predictor of patients’ perceived quality of care and overall patient satisfaction in hospitals is the degree to which spiritual needs are attended to. Several studies show that integrating spiritual care training for healthcare professionals decreases staff burnout and turnover, and it increases both staff and patient satisfaction.
One might ask: If caring for spiritual needs is so beneficial to patients and healthcare professionals, why is so little formal education provided on the subject?
Setting the stage for spiritual care education
Caring for patients at the end of their lives deepened my belief in something larger than myself and renewed my faith in humanity. It also required witnessing an enormous amount of grief, which took an emotional toll. After years of hospice nursing, I made a decision to step back from direct patient care, seek therapy, and return to school.
While pursuing a master’s degree in nursing, I scoured the literature, searching for anything that might provide me with insight into how healthcare professionals can address patients’ emotional and spiritual needs without increasing their own emotional pain or risking compassion fatigue. I found answers in the research, in my own professional experience, and in some very unexpected places outside of healthcare. (See What we can learn from others.) In the end, I identified three key elements:
- contemplation—relationship with oneself
- connection—relationship with patients and families
- collaboration—relationship with professional partners, inside and outside of healthcare.
These elements provide the foundation needed to teach nurses—both students and those already in practice—how to provide compassionate, spiritual care. Anecdotal evidence suggests that implementing these practices improves patients’ and nurses’ emotional and spiritual health.
Looking outside of nursing sometimes helps us gain insight into how we can provide more compassionate care. Live theater and 12-step programs offer examples of spirituality in practice.
Theatre and spirituality
In a world where so much of our communication takes place via technology, live theater remains a haven for true connection. My teenage daughter belongs to a theater program where students “learn life skills through stage skills.” One of the many benefits of participating in this program has been her ability to become fully present with others. Not only do actors connect with one another on stage, but a sense of community also develops between the actors and the audience. Research led by the University College London’s Division of Psychology and Language Sciences in 2017 found that watching live theater synchronizes audience members’ heart beats, even if they’re strangers. In my classes, I’ve created a variety of interactive exercises between nursing and acting students that have been mutually beneficial to both groups.
12-step programs and spirituality
Although living with active addiction is filled with pain and suffering, many who find recovery in programs such as Alcoholics Anonymous (AA) are given a second chance at life. The 12-step meeting format allows members to take turns sharing what’s affecting them emotionally. The freedom comes in knowing no “cross talk” will occur and no advice will be given. Participants are never required to speak, and everyone understands that the purpose of sharing isn’t to fix one another, but to provide space for individuals to begin to heal in their own way. Sharing these common experiences creates a foundation for spiritual and emotional resilience and growth.
As nurses, we understand how it feels to experience stressors related to caring for patients. By adapting some aspects of a 12-step meeting format into the classroom, nursing students are given a sacred space in which they can share their own emotional or spiritual pain. Though the details of the stories may differ, the feelings and emotions are common to us all. In connecting at this intimate level, we learn that we’re not alone.
Contemplation
Spirituality is a dynamic process that evolves throughout a lifetime. Frequently, the spiritual beliefs we hold as children differ from those we hold in adulthood. Without periodically reflecting on our own personal spiritual beliefs, we can’t fully address patients’ spiritual needs.
In my role as an educator, I introduce the concept of spirituality to students and facilitate connection and collaboration into their professional and personal practices. Building on that foundation, I use a tiered approach to promote understanding and implementation. This gradual process allows students to explore potentially overwhelming concepts in small, manageable steps. With my guidance and support, students gain the confidence and skills necessary to become exceptional compassionate nurses.
To promote self-reflection, I require students to complete individual spiritual inventories and answer reflective journal questions each week. These exercises allow students to identify personal strengths and barriers to addressing others’ spiritual needs. The insights students gain help them understand how their personal experiences may affect their ability to provide compassionate patient care.
Self-reflective exercises have an impact on students not only in the classroom and clinical setting, but also in their personal lives. Students frequently report that self-reflection opens the door to meaningful conversations with family members and therapists, allowing them to move through grief and pain and experience true personal growth.
Connection
Storytelling is the bridge between reflection and connection. Effective stories must be engaging, relevant, and honest. Many educators fear sharing their own stories and owning their “mistakes.” The error is not in sharing the story itself, but the lens through which these stories are viewed. When we treat our mistakes as cautionary tales, we fuel fear and insecurity in those we teach. But when we share them with the intention of exploring our common humanity, we create true connection. Being curious instead of cautious enables us to walk alongside students on their journey, empowering them to step into their own truth.
Sharing personal stories about moments in which I provided compassionate, spiritual care, as well as times I failed to do so, creates a safe nonjudgmental space that encourages meaningful participation. A 2015 study by Kilgo and colleagues found that true learning occurs when people engage. Active and engaged learning not only promotes connection, but also improves critical thinking, confidence, and communication skills. In the classroom setting, role-playing with classmates allows students to practice administering spiritual screenings and engage in compassionate communication in a safe and realistic environment. When students feel supported rather than judged, they’re empowered to connect.
Collaboration
Patients receive better care when members of the interdisciplinary team collaborate. However, the roles of some team members, such as the palliative care provider and chaplain, commonly are misunderstood. This lack of understanding results in underutilization of these valuable resources. To successfully meet patients’ spiritual needs, nurses should be equipped with the knowledge and confidence to advocate for these disciplines.
Creating experiences where nursing students interact with palliative care providers and chaplains (including small group activities, simulations, and question-and-answer sessions) can deepen students’ understanding of these team members’ roles. Clinical shadowing further enhances this knowledge by allowing students to see the disciplines in action. Nursing students report that the insights gained from these collaborative opportunities provide them with the skills necessary to be true patient advocates.
Final thoughts
In the end, Adam received his final wish. He died shortly after Christmas, long before the snow of winter melted into spring. Although his body was beyond repair, it was Adam’s spirit that needed care. Adam’s final gift to me was to ignite my passion to promote change in how we provide spiritual care to both patients and nurses. When we have the courage to contemplate, connect, and collaborate, we transcend the physical dimension of care. It is in this spiritual place that true healing can occur.
*Names are fictitious.
Julie Lepianka is an instructor at Moraine Park Technical College in West Bend, Wisconsin, and a speaker and compassionate care consultant. She originally created this course while she was an assistant professor at Cardinal Stritch University in Milwaukee, Wisconsin.
References
Adamson E, Dewar B. Compassionate care: Student nurses’ learning through reflection and the use of story. Nurse Educ Pract. 2015;15(3):155-61.
Bone N, Swinton M, Hoad N, Toledo F, Cook D. Critical care nurses’ experiences with spiritual care: The SPIRIT study. Am J Crit Care. 2018;27(3):212-9.
Ho JQ, Nguyen CD, Lopes R, Ezeji-Okoye SC, Kuschner WG. Spiritual care in the intensive care unit: A narrative review. J Intensive Care Med. 2018;33(5):279-87.
Kilgo CA, Ezell Sheets JK, Pascarella ET. The link between high-impact practices and student learning: Some longitudinal evidence. High Educ. 2015;69(4):509-25.
Parveen Rasheed S. Self-awareness as a therapeutic tool for nurse/client relationship. Int J Caring Sci. 2015;8(1):211-6.
Primack BA, Shensa A, Sidani JE, et al. Social media use and perceived social isolation among young adults in the U.S. Am J Prev Med. 2017;53(1):1-8.
Puchalski CM, Ferrell BR, O’Donnell E. Spiritual issues in palliative care. In: Yennurajalingam S, Bruera E. Oxford American Handbook of Hospice and Palliative Medicine and Supportive Care. 2nd ed. New York: Oxford University Press; 2016: 257-72.
Ruzek EA, Hafen CA, Allen JP, Gregory A, Mikami AY, Pianta RC. How teacher emotional support motivates students: The mediated roles of perceived peer relatedness, autonomy support, and competence. Learn Instr. 2016;42:95-103.
Stocker C, Cooney A, Thomas P, Kumaravel B, Langlands K, Hearn, J. Schwartz rounds in undergraduate medical education facilitates active reflection and individual identification of learning need. MedEd Publish. October 15, 2018.
University College London Psychology and Language Sciences. Audience members’ hearts beat together at the theater. November 17, 2017. ucl.ac.uk/pals/news/2017/nov/audience-members-hearts-beat-together-theatre
