Accepting spirituality and spiritual care as core parts of nursing practice, various respondents identified key factors that (would) enable best practice. These factors were explored as the separate sub-themes of ‘Collaboration’, ‘Responding to a changing society,’ and ‘Competency, confidence and professional development.’
Some nurses expressed a need for collaboration on multiple levels: with community-based spiritual and religious groups, by way of multidisciplinary care teams, and amongst nurses themselves.
Many participants perceived a need for formal pathways to access appropriate resources and services for the widely varied needs of their multi-ethnic and multi-faith communities:
I think it would be quite nice to work more with churches and spiritual groups in the community in getting their help with some of our patients… Spiritual groups are often not connected with the healthcare system. It would be better if they were. Female, nursing administration and management, Other European.
Make it easier for health professionals to access a list of different spiritual support systems to assist all patients with “religious and non-religious beliefs.” Female, nursing administration and management, NZ European.
The establishment of working relationships with community-based spiritual and religious groups would specifically assist in the continuity of care post-discharge, where there was a perceived gap in the ability of patients to access resources and services once back in the community.
The need for multidisciplinary teams (MDT) to consider quality spiritual care was also frequently mentioned. Such teams, it was suggested, could provide the various skill sets needed to address the widely varied spiritual needs encountered. More importantly, however, a team approach was thought to ensure patients were provided with sufficient opportunities and contact time for quality spiritual care.
Time is a huge challenge and probably the most important element to being able to connect with a person where we can begin to discover their spiritual needs. One person alone can never provide this. Team! Female, continuing care (elderly), NZ European
Social work is one paid service that we actually have that is quite important to us and would be beneficial to have 24/7. People don’t necessarily identify that they have a spiritual need, but they have it! They have a need and the social worker is an interdenominational multi-cultural touch-point. They are really undervalued in our health system for providing that. Female, emergency and trauma, NZ European.
To improve the efficacy of a team-based approach, some participants suggested that spiritual needs be more openly discussed during MDT meetings, and that a member of the team take on the role of ‘spiritual care champion’ and guide others in the provision of best practice spiritual care.
Some respondents also considered that collaboration amongst nurses themselves was a useful way to learn from others experience and promote consistency regarding the identification of spiritual needs and the practice of spiritual care.
4.2.2. Responding to a Changing Society
Respondents identified a need for religious and spiritual resources as a way to navigate the “huge scope of spiritual/cultural/religious beliefs”
of the increasingly diverse NZ society.
With the ever growing Indian community, and their beliefs of Hindu, Sikh, Christian, it would be helpful to be familiar with these beliefs so as to ensure their safety as well as for the nurses. Female, public health, NZ European.
It would be useful to have practical values included e.g. is it considered disrespectful to look in the eye when talking to this group of people? Female, perioperative care (theatre), NZ European.
Such comments suggest a significant gap regarding the skills and knowledge of nurses to practice with competence. For some respondents there was concern regarding the management of professional boundaries around involvement in religious practice and rituals with patients and their families.
In addition to the provision of resources, increased education and discussion opportunities were seen as a way to transform understanding of spirituality and provision of spiritual care.
4.2.3. Competency, Confidence and Professional Development
To fulfil professional expectations, roles and responsibilities regarding spiritual care, many participants suggested a need for training and education opportunities, alongside the development of professional competencies and guidelines.
Participants painted a picture of an inadequate history of training opportunities: “This is an area of nursing that has very little training, resources, support. Even after more than 20 years in nursing I can feel ill equipped to meet the clients’ needs in this area.” (Female, family planning/sexual health, NZ European). Such training was not seen as an ‘optional extra’, due to the “need for nurses to have a minimum level of awareness and skill to navigate the various situations they find themselves in.” (Female, intensive care/cardiac care, NZ European).
The lack of training and education opportunities appeared to be exacerbated by the lack of informal discussion around spirituality: “It would be nice if it became a common topic of conversation. The problem is that the majority of people in the workforce are not spiritual; it is a neglected part of life.” (Female, nursing administration and management, Other European). Participants’ comments pointed to a gap between the awareness and practice of spirituality in the traditionally secular NZ society and the needs that arise in the healthcare context.
For those who wanted training, many were unsure where to access it outside of the palliative care setting. Understandably, the provider of such education and training opportunities was considered to be of particular importance. Various participants stated it would have to come from a source they would feel confident using, ideally provided by way of “protected time and support with trained, trusted and respected colleagues.” (Female, medical, NZ European). E-learning modules were suggested as an easy initial platform for foundation education and training.
Various participants commented on what appeared to be the debatable question of whether spiritual care could be taught:
Nurses need to know their spiritual beliefs, before they can educate other nurses, or aid patients. Not all staff able or willing to give spiritual support. Choice of individual. Female, continuing care (elderly), NZ European.
Nurses are beautifully positioned to provide practical, effective spiritual care intervention and support...It does, however, depend upon organizational support, resource allocation and a requirement for maturity and insight on the part of the practitioner which is a lifetime journey. Male, nursing education, NZ European, Māori.
Whilst not all participants thought spiritual care could be taught, they believed that a respect for it and awareness of how spiritual needs may manifest could be. The above comments also point to the significant contribution of institutional support to the ability of spiritually-inclined nurses to provide effective spiritual care.
Participants also suggested that small interventions may spark changes in attitudes towards and practice of spiritual care:
I will discuss having a spiritual care policy within our general practice as this is something that has never been discussed. Female, practice nursing, NZ European
Wow, this made me reflect on my practice. This is something I don’t really address—I’ve always just thought that referring to the chaplain was all that I could do. I had never thought that by listening to the patient and providing guidance I’m providing spiritual care. Female, surgical, NZ European.
That this short survey induced re-evaluations of some nurses’ scope of practice suggests a short and affordable nursing workforce intervention may be efficacious.
In addition to training and other educational opportunities, various respondents considered spirituality-related competencies, policies and guidelines valuable. These were seen to provide clarity around professional boundaries, normalise spiritual care practices, and extend spiritual care outside the scope of the palliative context. However, others disagreed with the need for the explicit specification of spiritual care practices by nursing professional bodies:
I would not like to see spirituality put ‘in a box’ with guidelines and policies from any of our governing bodies. If this happens we run the risk of missing out a lot of people. Female, assessment and rehabilitation, NZ European.
I believe that some nurses don’t feel they want to be involved in the spiritual elements of nursing—I don’t think these nurses should be forced to do this as more damage than good could be done for both the patient and the nurse. Female, medical, NZ European.
These comments indicate the need for clarification that the goals of spiritual care education, policies and competencies ought not to impose the provision of spiritual care on nurses.
Overall the metatheme ‘Enabling best practice’ illustrates the nuanced complexities of establishing a common understanding and practice of, alongside professional processes around, spiritual care. The key message again appears to be that, if a more formalised approach is muted, a blanket approach is ill-suited to this task.