Sample Nursing Research paper

Sample #1 - Spiritual Care at the End of Life

Faced with an increasing focus on provision of health care when life is ending, professionals and policy makers in healthcare are faced with the task of making death an expectation not an exception. Patients with terminal illnesses who are given spiritual care are said to have a better and improved life quality (Timmins & Calderia, 2017). A lack of awareness on how important a patient’s spiritual life is and how by being given great care spiritually can improve life’s quality and patient outcome has been a major setback in caring for terminally ill patients. According to Carey et al (2019), spiritual care is often provided by professionals who have knowledge in matters of religion as well as spirituality. At the end of life, patients walk through a spiritual environment that is unknown to them. The spiritual environment usually awaken a spiritual dimension that is unique in patients and caregivers. Thus, what most patients at this stage desire from health care workers is for their spiritual needs to be acknowledged and supported.

Although spiritual care was traditionally seen as the responsibility of caregivers with pastoral background, healthcare workers should take it upon themselves to provide patients with spiritual care at the end of life. It still remains controversial if professionals in health care should provide such care to their patients. It is hard to come up with a perfect definition of spiritual care as it has been given numerous interpretations. Theologically, it is defined as giving an individual meaning, connection to a spiritual being, and inner peace (Mesquitas &Chaves, 2017). The theological understanding is often associated with spiritual rituals and beliefs as practiced by different communities. In nursing practice, it is defined as making reference to others, availing spiritual practices and being available for patients. By being given spiritual care, patients are helped to cope with existential, social and spiritual matters and the emotions they cause (Fitch and Bartlett, 2019). Practicing spiritual care helps patients find meaning in life, be able to reconcile and pay attention to their relative’s spiritual issues and be able to say farewells. Apart from the spiritual issues, the caregivers also talk about medical care with the patients and their relatives, for example how they wish to be treated and if those options are available.

For spiritual care giving to be successful, there should be constant communication between the spiritual care givers and professional health workers. Spiritual care giving services are improved through education and constant promotions. Although spiritual care when life is ending has been promoted by various health care bodies such as the Institute of Medicine and World Health organization, it is still poorly understood and it is not clear how it is delivered (Brinkmann, 2019). However, the significance of spiritual care in palliative care cannot be underestimated. Therefore, health care professionals who don’t have the know-how on providing their patients with adequate care spiritually should incorporate the services of spiritual care givers. Although patients may have the will to discuss end-of-life matters with their nurses, providers of health care experience difficulty in providing the services. According to VanderWeele et al (2017), some of the factors contributing to the difficulty are low staffing causing workload on the available care givers, lack of importance in spiritual matters, and taking the spirituality of a patient as a personal matter. Failure to get training and caregivers perceiving spiritual caregiving as not their duty also hinder the practice.

Literature Review

            The importance of spiritual care for patients nearing death cannot be underestimated as it has significant results on a patient’s value of life. It is crucial to understand that patient who receive spiritual care at their critical moments live a more fulfilling life in their last days than those who do not (Henry, 2017, 113). According to Institute of Medicine (2015), at the end of life, a caregiver’s primary goal is not to prolong life rather it is to care, comfort, and alleviate pain. Ahmed (2018, 67), argues that it is the shift in goals that bring about an increase in the emphasis on other aspects of health, among them spirituality and religion. A patient’s concerns in matters of spirituality and religion are likely to be awakened as they near the end of life (Koper et al, 2019). In many countries, giving of spiritual care has become a vital part of holistic care where considerable amount of attention is put on spirituality in the healthcare platform (Kaufman, 2016, 220). Henry (2017, 111) states that the approach has allowed practitioners to meet the needs of their patients physically, socially, emotionally, and spiritually.

 Arutyunyan and Adetola (2018, 89), says that providing spiritual care is seen as a process of integrating all the needs of human beings. Spiritual care being deeply embedded in nursing involves being able to respect, care, love and support a patient’s search for life meaning (Alessandra, 2016, 115). According to Ho et al (2018, 103), by receiving spiritual care, patients are able to cope with terminal illnesses positively, cases of depression have reduced significantly, and improvement has been seen in health status generally. However, according to some studies, some patients experience difficulty coping religiously because they take sickness as God’s way of punishing them (Fitch and Bartlett, 2019). Fitch and Bartlett (2019), further says the negativity in religious coping causes distress and affects the quality of life in a negative way. When faced with life-threating conditions and complicated spiritual questions and needs come up, it is the wish of patients that they may be able to address the issues with their nurses (Van de Geer et al, 2018). Van de Geer et al (2018) adds that nurses attending to such patients ought to have the necessary knowledge and be in a position to answer the question patients and family members may ask. Henry (2017, 110) argues that nurses attending to patients in ICU units should be able to adapt easily and have the capability of providing care when life is ending which includes spiritual care. However, according to Koper et al (2019), apart from having been trained and possessing knowledge in provision of physical and curative care, many nurses in ICUs feel inadequate in providing care at the end of life. According to Kaufman (2016, 107), healthcare systems in many countries do not have policies on matters of patient spirituality which makes it hard for healthcare professionals to fully understand spirituality, thus hindering their ability to offer spiritual care to dying patients. According to Koper et al (2019), many caregivers have a difficult time differentiating spirituality from spiritual care. Spirituality has been described as “an umbrella term” as it has under it many and diverse interpretations that are used to bring out its meaning (Koper et al, 2019) (Alessandra, 2016, 233). Fitch and Bartlett (2019), adds that the many definitions serve as an element of confusing nurses as they try to understand the term and it is mostly coupled with religion. When life is about to end, the ability to identify patients spiritual needs most times depend on how well caregivers observed and communicated with the patients and members of their families (Henry, 2017, 112).

Van de Geer, (2018) states that talking to patients, listening to them and familiarizing with their environment helped caregivers to ascertain the spiritual needs of their patients. Arutyunyan and Adetola, (2018, 92) said most of the spiritual interventions were connected to religion such as praying for the patient daily, reading religious quotes from religious books for the patient, among others. Ho et al. (2018, 105) says interventions without religious attachment include, allowing long hours of visitation, allowing a member of the family to stay with the patient overnight, among others. All the above practices help in improving the quality of life (Ahmed, 2018, 66).  Ahmed (2018, 67) further says praying for patients has been associated with promoting health and giving patients hope at their critical conditions. Kaufman (2016, 200) says spiritual care follow three dimensions namely, existential questions, spiritual considerations, and interrelation considerations. The three dimensions are intertwined with the emotions of patients such as anger and anxiety that spiritual care givers deal with (Alessandra, 2016, 109). According to Ho et al. (2018, 104), diverse topics are discussed at patient care such as, life expectation, available options for treatment, and the place a patient prefer for death when the time comes. Henry (2017, 111), says providers of healthcare should take time to discuss spiritual issues with their patients in an open manner which will facilitate a relationship built on mutual trust and compassion. They should respect their own limitations when providing spiritual care services (Arutyunyan and Adetola, 2018, 88). Koper et al, (2019) says in a similar study about chaplains’ practice in the U.S, building of mutual relationships was identified as a major activity.

It was identified that general healthcare providers rarely cooperate with spiritual care givers in palliative care (Van de Geer et al, 2018). Suggestions have been made for multidisciplinary meetings to be held locally with the aim of familiarizing general healthcare providers with spiritual matters while also promoting the services of spiritual care givers (Koper et al, 2019). Koper et al, (2019) argues that spiritual care givers should be invited to join the multidisciplinary meetings permanently to ensure attention is given to palliative care’s spiritual aspect. By so doing, general caregivers are trained on the need to recognize and satisfy a patient’s spiritual needs (Koper et al, 2019). Training of general healthcare professionals in the need to recognize the need for spiritual care can lead to sufficient recommendations (Kaufman, 2016, 221). At the end of life, patients struggle with spiritual needs that are unmet (Ho et al. 2018, 101). Spiritual caregivers are not frequently concerned with primary care giving, thus healthcare givers should be familiar with spirituality and the role spiritual care givers play in provision of palliative care (Koper et al, 2019). Koper et al (2019) adds that the involvement enables one to understand the value a spiritual caregiver adds to a patient. Henry (2017, 113) describes presence as a basis for quality spiritual care. Compassionate presence comprises intention to be open, connect with others and find comfort in uncertainty (Ahmad, 2018, 66). Being present and able to share personal beliefs and life experiences are major themes on spiritual care (Ahmad, 2018, 67).

A qualitative study conducted by a group of researchers states that being there, sympathizing, showing importance and loving the patients is part of the process (Alessandra, 2016, 215). Henry (2017, 115) explains that by being present to dying patients and their families, spiritual caregivers act as promotes in creating awareness of the patient’s illness. According to Arutyunyan and Adetola (2018, 88), the importance of the mutual relationship between spiritual caregivers and their patients is encouraged which involves a caregiver making a connection between him and the patient. The connection helps the dying patient to connect or reconnect to his principal beliefs, principles and practices. The purpose of the relationship between a patient and his spiritual care give is to open the eyes of the patient to his spiritual side (Van de Geer et al, 2018). When caregivers and their patients recognize each other’s humanity mutually, they can engage in cocreating (Fitch and Bartlett, 2019). Cocreating focuses on formulating a plan of care for patients, their families and their healthcare givers (Fitch and Bartlett, 2019). Brinkman, (2015) says extrinsic components of spiritual care are described as appraisal and communication of a patient’s spiritual needs and incorporating them in the care plan. Although cocreating shares various features with the mentioned elements, it tends to be more inclusive and integrative. Constant communication significantly contribute to how accurately caregivers collect and interpret information and how the information is further conveyed to the patients and their family members (Ho et al. 2018, 99).

 

Research and Methodology

Research Design

            The objective of the research is to examine how healthcare givers understand spirituality and the need for providing patients with spiritual care. The research will also seek to identify if spiritual care improve the quality of life for patients with critical conditions in any way. The data for research will be collected and analyzed qualitatively by use of questionnaires in order to test its hypothesis. The methodology of data collected from both care givers and patients will be discussed so as to present the rationale of integrated variables. The findings of the research will be interpreted to explain how spiritual care at the end of life was found to impact the life of patients with life threating conditions.

Data Collection Method

            The research will be conducted in a qualitative method whose approach will be interpretive-descriptive, which is formulated to give answers to specific questions pertaining to a specific phenomenon. The participants of this study will be ICU nurses who the researcher will recruit online. The criteria to be used on recruiting the nurses will be based on the experience they poses in the intensive care units handling patients who are about to die in the course of their careers. The nurses will be allowed to decide if they want to participate in answering the research questionnaire and share their thoughts on spiritual care based on their experiences.

            The number of nurses who met the research criteria were 21. All the 21 nurses, 11 males and 10 females were willing to take part in the study. Their fell in the age gap between 27 to 48 years, with a mean of 36.6 years. Their work experience in ICUs ranged from 4 to 16 years. All the participants held master’s degree in nursing. The group had a mixture of both Christians and Muslims. Before starting collecting data, the researcher sort approval from the ministry of health and every participant was provided with information about what the study was all about. Each participating nurse wrote a letter of consent. Data collection was done through in-depth and well-structured questionnaires which was emailed to the participants. Some of the questions used to collect data were:

• What does spirituality and spiritual care mean to you? Define each.

• What methods do you use to identify the spiritual needs your patients have?

• How do you approach your patients’ spiritual needs?

• How do you meet the spiritual needs you identify in your patients?

The questionnaire was sent out privately to each participant and each participant was given a maximum of one week to answer and email back the filled questionnaire. After all the participants had emailed back their filled in questionnaire, the researcher went through them and organized them in one folder for ease of review. In order to ensure that qualitative research is free from bias, it is recommended that a research sources the services of at least two experts on the area of research to go through the research findings (Carey et al, 2019). The researcher asked two expert nurses to go through the filled in questionnaires to identify themes provided by the data. The researcher then sat with the experts and discussed the findings until a consensus was reached on the major themes of the research.

Results/Findings

Critical Review and Theoretical Framework

Under this section, the report gives a critical analysis of the findings on the data collected on the importance of spiritual care at the end of life. Data was collected online from willing ICU nurses and the research adopted the CASP framework of qualitative research where an in-depth interview by use of questionnaires was conducted. The data was then analyzed to identify the underlying themes. The identified themes for the study were nurses’ ability to identify their patients’ spiritual needs, how they understood spirituality and spiritual needs, and the various actions they took to satisfy those needs. The themes will later be discussed and illustrated by use of a figure in the research findings section. The Critical Appraisal Skills Program (CASP) helped to ensure that the data collected was evidence-based. The framework also helped the researcher to identify the experiences the interviewed nurses have had when providing spiritual care in the ICU as well as the beliefs they held about spiritual care at the end of life. Participants’ verbatim quotes were used to explain the themes. An example is Sadia who was quoted saying, “To my understanding, spirituality is the belief one has in Allah. Therefore, spiritual care is all about incorporating religion in the services we provide,” when asked her understanding of spirituality and spiritual needs. From a critical analysis of the data collected, the study identified that spiritual care is vital to patients nearing the end of life as it helps in improving the quality of life.

Findings/Results

The various themes that the analysis of data identified are presented in figure 1 below. In this section, each theme will be analyzed in turn. Pseudonyms were used to replace the names of the participants in order to protect their identity. In qualitative research, pseudonyms are commonly used so as to present data in a rich and detailed manner while protecting the identity and confidentiality of the respondents.

 

 

Figure 1. The figure below shows the themes of the study.

 

 

Understanding of spirituality and spiritual needs.

            Most participants had a hard time defining spirituality and spiritual care as they couldn’t tell the difference between the two concepts. A male participant, Ian wrote, “I don’t know exactly what spiritual care means. I would say it is putting into consideration the religious needs a patient have.” However, participants defined the two concepts in terms of religion and the religious practices they have seen used in the process of healing such as praying for the sick. They described it as the art of integrating religious beliefs and practices when providing holistic care in nursing. Sadia wrote, “To my understanding, spirituality is the belief one has in Allah. Therefore, spiritual care is all about incorporating religion in the services we provide.” A number of participants explained spiritual care as any other intervention that goes beyond caring for the patient physically. Others understood it to be the same as care given emotionally and psychologically.

Identifying Spiritual Needs

The participants identified various means they have used in identifying the spiritual needs of their patients. Some of the means they identified are:

• Communicating with patients and members of their families.

• Patients’ conditions and diagnosis.

• Observing the patients’ environment closely.

• Letting patients express their feelings directly.

• Communicating with patients and their families.

            Participants said that by communicating with their patients, they have been able to identify the patients who need spiritual care. Some wrote that it helps to know which religion a patient belongs to before starting a spiritual care program with them. They added that speaking to family members of the patient also helps in knowing the spiritual history of a patient.

• Patients’ condition and diagnosis

From their experience, the nurses said that the condition of a patient and their diagnosis show their needs for spiritual care. They said most patients with terminal illnesses and nearing the end of life need spiritual care more than other patients. They said that when all hope is lost and death seems near for a patient, spiritual care is most important than physical care.

 

 

• Observing the patients’ environment closely

Most participants argued that if the patient’s environment was observed and studied diligently, while putting into consideration their expressions, it was easier to identify the spiritual needs they have. Ahmed, one of the participants said that once he observed a patient who could not speak as he was moving his fourth finger in his right hand. Ahmed understood this to mean that the patient was trying to recite a player in Islam. He moved the patient’s bed to face Mecca and started to recite the prayer. The patient was extremely happy with the nurse’s gesture. Therefore, closely observing a patient’s environment can help a caregiver to identify his spiritual needs.

• Letting patients express their feelings directly

The participants wrote that in some instances, patients express their feelings directly. They ask the nurses to pray for them directly when they feel that they have lost all hope and ask the nurses to pray that they will pass on peacefully without experiencing pain. Patients’ feelings are expressed in both verbal and non-verbal ways.

Actions taken to satisfy spiritual needs.

            Most participants said that they shift the goal from curing to comforting when they realized that treatment will not yield the desired results of curing the patient. They identify and put in place measures that will help to comfort the patient. In so doing, they become more in touch with helping the patient spiritually and psychologically. The nurses spend more time with the patients when they are not very busy just to listen to them and hold their hands. They also allow members of the family to prolong their visits and stay with the patients. Some facilities also provide screens where patients can watch religion related programs. Some participants, especially Muslims said that they help their patients to prepare for prayer time by helping them clean their body parts, providing them with necessary materials, and assisting them recite prayers. According to them, spiritual care is entangled with religion to a great extent.

Thematic Analysis

            The findings of the research collated with the reviewed literature. Many participants had difficulty getting the true meaning of spirituality and spiritual care. A research conducted by Ho et al. (2018, 99) stated that issues of spirituality and spiritual care were uncertain to nurses. Most scholars and experts in the field of spiritual care for life threatening illnesses encountered difficulty in defining the two concepts (Brinkman, 2015). Several of them confirmed that it was difficult to tell the meaning of the terms and said that attempting to do so was like trying to explain supernatural things that cannot be seen or touched (Sekhon, 2017) (Carey, 2019,80) . The nurses who participated in answering the research questionnaires exhibited confusion in the fact that they connected spiritual matters to religion. Some participants failed to include other elements of spirituality and spiritual care such as comforting, being present, and caring for the patients in their explanations. The confusion indicated that the research findings were compatible with various researches that have been conducted on the past because they connected spirituality with religion (Arutyunyan and Adetaola, 2018, 86). Just like the participants, the terms have been used interchangeably in various studies.

Other studies also tied spirituality to religious beliefs and practices and believed them to be the key values of spirituality and spiritual care (Mesquitas and Chaves 2017, 336). According to the data collected, participants shared that the ability to identify a patient’s spiritual needs was dependent on nurses communicating with patients and their families. It was also dependent on observations made by the nurses. In other studies, the same strategies were evident (Gijsberts, 2019)). The study identified that most of the spiritual interventions made by nurses are primarily based on practices based on religion, coupled with few interventions that were not based on religion. Many other studies also found out that spiritual care was based on religious principles (Arutyunyan and Adetola, 2018, 92). For example, literature identified that praying for patients at the end of life promotes health and gives them hope (Fitch and Bartlett, 2016). Participants of the research mentioned other interventions such as listening to them and holding their hands show patients they are loved and respected, thus creating a sense of connection between patients and their nurses. Ho et al. (2018, 102) advised nurses to have compassion for their patients and be available to them while listening to them.

Conclusion and Recommendation for Practice.

Recommendation for practice

The research was restricted to Christian and Muslim participants, therefore the findings will be inadequate for people of other religions. The system of religious belief may alter results in other religions. Future studies should seek to collect data from populations of other religions to identify if nurses in other religions would identify with similar themes. Further research should be conducted to identify how often spiritual care should be provided to patients. Several factors such as work load, lack of interest in spiritual matters, low staffing, and the belief that spirituality is a personal matter has to a great extent been identified as hindrances to provision of spiritual care (VanderWeele et al, 2017).  Efforts should also be made towards bridging the barriers in provision of spiritual care and ways to overcome such barriers formulated. According to VanderWeele (2017), educating nurses on the importance of spiritual care to patients especially when they are just about to die can be effective in eliminating barriers to provision of spiritual care..

It should also be noted that, the research was restricted to only one theoretical framework CASP, despite there being other available frameworks for qualitative research available such as Kay Caldwell, Lynee Henshaw, Gina Taylor (2015), among others (Sekhon & Cartwright, 2017). Future researchers should base their research on other available frameworks so as to achieve more concrete results. From the findings of the research, it is critical for nurses to understand that patients have spiritual needs and the needs are more intense as they approach the end of life. Therefore, they should take it upon themselves to satisfy those needs for the patients. Spiritual practice becomes more important to patients are nearing death as it has significant effects on suffering at the end of life (Broadhurst & Harrington, 2016). Another study indicated that spiritual care have been able to reduce cases of depression in terminally ill patients (Timmins & Caldeira, 2017). Since spirituality and spiritual care has been highly linked to religion, it would be recommended that nurses familiarize themselves with their patients’ religious beliefs and practice in order to provide effective spiritual care.   

Conclusion

            Provision of holistic care to patients is one of the major responsibilities of nurses. The practice entails the incorporation of physical and emotional care as well as spiritual care for the patients. End of life care is used to refer to the care given to patients who are approaching their death. When approaching death, patients are likely to focus more on their spirituality other than their physical health. It is essential for nurses to note that spiritual care and matters of spirituality are perceived differently by different patients as it is mostly entangled with one’s religious beliefs and faith. A basic definition of spirituality and spiritual care has not been identified as the two issues are approached from one’s own experiences. Therefore, each patient’s spiritual needs should be treated with respect. Spiritual needs are mostly driven by the desire to understand one’s meaning and purpose in life. Spiritual care at the end of life is more important than physical care to patients approaching their death. Patients who are provided with spiritual care feel more loved and appreciated, thus their quality of life is significantly improved. This conclusion was made through reading available books from the university library on the importance of spiritual care and searching for journals on the topic on internet through Cumulative Index of Nursing and Allied Health Literature (CINAHL) database, which provided a wealth of information.

Appendix

Figure 1.

 

 

 

 

 

References

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