Effects of a Spirituality Training Program for Nurses on Patients in a Progressive Care Unit

Bradley Lind, Sue Sendelbach and Sue Steen

Crit Care Nurse 2011;31:87-90 doi: 10.4037/ccn2011372
2011 American Association of Critical-Care Nurses Published online http://www.cconline.org Personal use only. For copyright permission information: http://ccn.aacnjournals.org/cgi/external_ref?link_type=PERMISSIONDIRECT

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In Our Unit

Effects of a Spirituality Training Program for Nurses on Patients in a Progressive Care Unit
Bradley Lind, RN, BSN Sue Sendelbach, RN, PhD, CCNS Sue Steen, RN, MS

espite nursings historical commitment to spiritual care and to research that supports the desire of patients to have their spiritual needs addressed while hospitalized, many nurses today feel underprepared to meet the spiritual needs of their patients. Results of a survey of satisfaction among patients in our cardiovascular progressive care unit indicate that addressing the spiritual needs of patients is an area in which we could improve. In response, we decided to address the question How can staff nurses better assist patients and their families with spiritual concerns?

Authors
Bradley Lind is an assistant clinical nurse manager in a progressive care unit at Abbott Northwestern Hospital in Minneapolis, Minnesota. Sue Sendelbach is Director of Nursing Research at Abbott Northwestern Hospital. Sue Steen is a professor at Bethel University in Arden Hills, Minnesota. For questions related to this article, contact Bradley Lind at bradley.lind@allina.com.
2011 American Association of CriticalCare Nurses doi: 10.4037/ccn2011372

Systematic reviews support a relationship between religion/spirituality and health,1,2 and patients themselves also indicate a desire for a spiritual component in their care. Analysis by the Joint Commission of 2001 Press Ganey national inpatient data showed that (1) patients place a high value on emotional and spiritual needs while in the hospital, (2) a strong relationship exists between the care of patients emotional and spiritual needs and overall patient satisfaction, and (3) the lack of attention given to patients emotional and spiritual needs constitutes a significant opportunity for improvement for most hospitals.3 King and Bushwick4 reported that up to 77% of patients want spiritual issues considered as a part of their medical care. In addition, most nursing bodies recognize the need for spiritual care. The North American Nursing Diagnosis Association has identified spiritual distress as an approved nursing diagnosis,5 and the American Association of Colleges of Nursing6 recommends including spiritual care in educating nurses. Within the International Council of

Nurses Code of Ethics for Nurses,7 spiritual care is included under Nurses and People as one of their 4 principal elements of standards of ethical conduct. Additionally, the Joint Commission requires that spiritual care be provided to all patients.3 Although many nurses are aware of some spiritual needs in certain patients, only a small number of nurses think that they are meeting those needs and many nurses express a desire for further education in this area.8,9 In addition to lack of education and training, other barriers to providing spiritual care include lack of time and resources, lack of privacy, and personal attitudes/sensitivities on the part of the nurse.9 Even with adequate education and training, some nurses may remain uncomfortable broaching what is socially often considered a private subject. The purpose of our quality improvement project was to evaluate what effect, if any, a spirituality educational program has on satisfaction of our patients. The project was conducted as part of the evidencebased nursing practice fellowship program at Abbott-Northwestern

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Hospital in Minneapolis, Minnesota.10 The lead author (B.L.) participated in the fellowship program and was provided 8 hours paid time per month for 1 year to conduct this work. In this article, we describe the implementation and results of an educational intervention directed at increasing awareness of the spiritual needs of patients and providing nurses with strategies and skills to address those needs successfully. The spirituality educational program was pilot tested on 1 of the 3 cardiovascular progressive care units in our hospital.

Methods
The project began with an initial survey of nursing staff regarding their perceptions and comfort with addressing spiritual issues with patients and a review of the literature on spirituality in health care. We reviewed patients health care records to see how often the spirituality care plan was used. How the question on the patient admission forms, How can we support your religions/spiritual beliefs and practices of cultural practices? was answered by the patient and addressed by the nurse also was reviewed. In addition, expertise was sought from faculty at a local faith-based university where spiritual care was integrated into the nursing practice curriculum.

The Spirituality Educational Program (Intervention)

A 2-hour spirituality educational program was offered on a voluntary basis to staff nurses, with each participating nurse being paid for attending. Out of a staff total of 53 nurses, 37 nurses (70%) attended the class. All classes were instructed

by a faculty member from a local faith-affiliated university with expertise in spiritual care and the evidencebased practice fellow who designed the project. A hospital chaplain also participated in each session. Class content was delivered during a 2-hour didactic session and was based on the literature and results of the staff survey that assessed current perceptions and comfort with addressing spiritual needs. The class also included a 20minute break-out session facilitated by a chaplain and by the faculty partner, during which participants were asked questions to stimulate thinking and discussion about their own personal spirituality and how it may relate to their patients. The rationale for pursuing each nurses own spirituality was based on the work of Taylor,11 who demonstrated that the nurses awareness of his or her sense of the spiritual has a profound influence on the ability to provide effective spiritual care. In addition, the degree of nurses selfreported spirituality and religiousness is associated with the likelihood of assessing spiritual needs and providing spiritual care to patients.11 Key concepts in the education module included the following: Definitions of spirituality Mandates from the International Council on Nurses and the American Nurses Association about spiritual care How spirituality differs from religion What is spiritual care? The nurse as a healer Realities of practice Taking care of self Barriers and roadblocks to delivery of spiritual care

Nursing interventions for spirituality Recommendations on when to consult with a hospital chaplain The educational session also included presentation of a short segment from the movie Wit12 that depicts the interaction between a nurse and patient discussing a do not resuscitate option for care. Upon completion of viewing, participants were asked to discuss how the nurse addressed spiritual care in the scenario. The final segment of the educational session was a case presentation where nurses were asked to consider how they would intervene to meet the spiritual needs of a patient in a particularly complex care situation. As an aid to facilitate provision of spiritual care by participating nurses, the HOPE (see Table) assessment for spiritual care was introduced.13 We adapted the HOPE assessment, originally developed as a teaching tool to assist physicians in initiating a spiritual assessment as part of the patient interview, as a framework for nurses to use to assess patients spiritual needs.13 Key components of the HOPE assessment were printed on small cards that were distributed to the nurses after the educational sessions were completed. The cards were designed to be attached behind the nurses identification badges for easy access. A follow-up survey was conducted after the education to solicit feedback from nurses about other resources and support that might be helpful as they work to meet the spiritual needs of patients better. Based on the responses, work on an intranet Spirituality Web site has commenced. The site will offer further

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Table

HOPE assessment for spirituality13

H: Sources of hope, meaning, and connection. What would you say gives you support for hope, strength, comfort, and peace? This might be related to religious beliefs or it could be a particular family member(s), friend(s), or other group(s), etc. O: Organized religion. Do you consider yourself part of an organized religions/spiritual community? Which one? P: Personal spirituality/practices. What aspects of your spirituality or spiritual practices do you find most helpful and important to you personally? (For example, medication, prayer, listening to music, reading sacred text, attending religious services, communing with nature, etc.). E: Effects on medical care and end-of-life issues. Are you worried about any conflict between your beliefs and your medical care? Can we help you access the resources that usually support you spiritually?

spiritual care plan increased from no previous use to 1 to 4 uses per month during the 3 months after the training. Anecdotally, nurses said that they are more comfortable with assessing and intervening with spiritual care issues since the training.

Conclusions
Patients want to have their spiritual needs addressed while hospitalized. Given the proper resources and education, nurses can be positioned to address the spiritual care of patients appropriately. CCN

materials and aids, including short video clips of speakers with expertise on faith beliefs not frequently encountered.

Results
The primary outcome for this work was patients satisfaction with spiritual care during hospitalization, which was monitored by the use of the Avatar patient satisfaction survey (Avatar International, Lake Mary, Florida). Avatar uses a Likert scale for responses that ranges from 1 (strongly agree) to 5 (strongly disagree). Surveys are sent out monthly to all patients who were discharged the preceding month. The questionnaire item that was evaluated combines spiritual care with emotional care, that is, Thinking of your overall care, please rate how well the hospital staff addressed your spiritual and emotional needs. In the 4 quarters preceding and during the education (3rd quarter 2009 through 2nd quarter 2010), the monthly percentages of respondents who strongly agreed that the hospital staff had addressed spiritual and emotional needs was between 62% and 69% (progressive care unit) and 62% to 65% (hospital wide). For the first 2 quarters following

the education (3rd and 4th quarters 2010), the progressive care unit percentages were 74% and 71%, compared with the hospital-wide percentages of 65% (see Figure). As secondary end points, we also checked the medical records for the number of times nurses in our unit consulted with pastoral care services and how often the spiritual care plan was used. The number of pastoral care consultations increased from an average of 16 per month to 27 per month, and recorded use of the

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Financial Disclosures
None reported.

References
1. Mueller PS, Plevak DJ, Rummans TA. Religious involvement, spirituality, and medicine: implications for clinical practice. Mayo Clin Proc. 2001;76(12):1225-1235.

90 85 Strongly agree, % 75 70 65 60 55 50 3rd quarter 2009 4th quarter 2009 1st quarter 2010 2nd quarter 2010 3rd quarter 2010 4th quarter 2010

Quarter and year Progressive care unit Hospital wide

Figure Comparison between hospital-wide data and progressive care unit data of patients who strongly agree that their spiritual and emotional needs were addressed.

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2. Townsend M, Kladder V, Ayele H, Mulligan T. Systematic review of clinical trials examining the effects of religion on health. South Med J. 2002;95:1429-1435. 3. Clark PA, Drain M, Malone MP. Addressing patients emotional and spiritual needs. Jt Comm J Qual Saf. 2003;29(12):659-670. 4. King DE, Bushwick B. Beliefs and attitudes of hospital inpatients about faith healing and prayer. J Fam Pract. 1994;39:349-352. 5. McFarland G, McFarland E. Nursing Diagnosis and Intervention: Planning for Patient Care. St Louis, MO: A Times Mirror Company;1997. 6. American Association of Colleges of Nursing. The Essentials of Baccalaureate Education for Professional Nursing Practice. October 20, 2008. www.aacn.nche.edu/education/pdf /baccessentials08.pdf. Accessed April 1, 2011. 7. International Council of Nursing. The ICN Code of Ethics for Nursing. 2006. www.icn .ch/about-icn/code-of-ethics-for-nurses. Accessed April 1, 2011.

8. Cavendish R, Luise BK, Russo D, et al. Spiritual perspectives of nurses in the United States relevant for education and practice. West J Nurs Res. 2004;26(2):196-212; discussion 213-221. 9. McSherry W. Nurses perceptions of spirituality and spiritual care. Nurs Stand. 1998; 13(4):36-40. 10. Graner T, Sendelbach S, Boland L, Koehn K. An evidence based practice fellowship: changing practice one clinical question at a time. Nurs Manage. In press. 11. Taylor EJ. Spiritual Care: Nursing Theory, Research and Practice. Upper Saddle River, NJ: Pearson Education Inc; 2002. 12. Nicols M (Director). Wit. Los Angeles: Avenues Picture Production; 2000. 13. Anandarajah G, Hight E. Spirituality and medical practice: using the HOPE questions as a practical tool for spiritual assessment. Am Fam Physician. 2001;63(1):81-89.

In Our Unit
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