18.4: Applying the Nursing Process

Now that we have reviewed the concepts related to spirituality and discussed beliefs and practices of common world religions, let’s apply the nursing process to promoting spiritual health.

Assessment

Subjective Assessment

Agencies often provide a standardized spiritual assessment tool to complete when a patient is admitted. If a standardized assessment tool is not available, the FICA model can be used.^[1] The FICA model contains open-ended questions to ask patients about their personal spiritual beliefs in a way that is open and nonjudgmental.

• F–Faith or beliefs: What are your spiritual beliefs? Do you consider yourself spiritual? What things do you believe in that give meaning to life?
• I–Importance and influence: Is faith/spirituality important to you? How has your illness and/or hospitalization affected your personal practices /beliefs?
• C–Community: Are you connected with a faith center in the community? Does it provide support/comfort for you during times of stress? Is there a person/group/leader who supports/assists you in your spirituality?
• A–Address: What support can we provide to support your spiritual beliefs/practices?^[2]

The HOPE tool is also helpful for incorporating spiritual assessment questions into a medical interview. HOPE stands for:

H: Sources of hope, meaning, comfort, strength, peace, love and connection

O: Organized religion

P: Personal spirituality and practices

E: Effects of spirituality on medical care and end-of-life issues

The first part of the mnemonic, H, pertains to a patient’s basic spiritual resources, such as sources of hope, without immediately focusing on religion or spirituality. This approach allows for meaningful conversation with a variety of patients, including those whose spirituality lies outside the boundaries of traditional religion or those who have been alienated in some way from their religion. It also allows those for whom religion, God, or prayer is important to volunteer this information. The second and third letters, O and P, refer to areas of inquiry about the importance of organized religion in patients’ lives and the specific aspects of their personal spirituality and practices that are most helpful. A useful way to introduce these questions is a normalizing statement such as: “For some people, their religious or spiritual beliefs act as a source of comfort and strength in dealing with life’s ups and downs. Is this true for you?”^[3]

Note

Read more information about using the HOPE tool.

Objective Assessment

In addition to asking open-ended questions, it is important for the nurse to observe patients for cues indicating difficulties in finding meaning, purpose, or hope in life. It is also important to monitor for supportive relationships.^[4]

Patients experiencing chronic or serious illness may make statements indicating spiritual distress that should cue the nurse that spiritual care is needed. Examples of these statements/concepts are as follows:

• Lack of Meaning: “I am not the person I used to be.”
• Hope: “I have nothing left to hope for.”
• Mystery: “Why me?”
• Isolation: “All my family and friends are gone.”
• Helplessness: “I have no control over my life anymore.”^[5]

Diagnoses

See Table 18.4 for common NANDA-I diagnoses associated with spiritual health.^[6]

Table 18.4 Common NANDA-I Nursing Diagnoses Related to Spiritual Health^[7]

NANDA-I Diagnosis	Definition	Defining Characteristics
Readiness for Enhanced Spiritual Well-Being	A pattern of experiencing and integrating meaning and purpose in life through connectedness with self, others, art, music, literature, nature, and/or a power greater than oneself, which can be strengthened	Connections to Self Connections with Others Connections with Art, Music, Literature, and Nature Connections with Power Greater than Self Expresses desire to enhance participation in religious activity Expresses desire to enhance prayerfulness
Impaired Religiosity	Impaired ability to exercise reliance on beliefs and/or participate in rituals of a particular faith tradition	Desires to reconnect with previous belief pattern Has difficulty adhering to prescribed religious beliefs and/or rituals Distresses about separation from the faith community
Spiritual Distress	A state of suffering related to the impaired ability to experience meaning in life through connections with self, others, the world, or a superior being	Anxiety Crying Fatigue Fear Insomnia Questioning identity Questioning meaning of life Questioning meaning of suffering

Sample Nursing Diagnosis Statements

Readiness for Enhanced Spiritual Well-Being

Many people experienced feelings of isolation as they sheltered at home during the COVID-19 pandemic. A sample PES statement for this shared experience is, Readiness for Enhanced Spiritual Well-Being as evidenced by expressed desire to enhance time outdoors. The nurse could encourage patients to visit local parks and walk outdoors while wearing a mask and maintaining social distancing.

Recall that when a PES statement is created for a health promotion diagnosis, the defining characteristics are provided as evidence of the desire of the patient to improve their current health status.^[8]

Impaired Religiosity

Hospitalized patients may be unable to attend religious services they are accustomed to attending. A sample PES statement is, “Impaired Religiosity related to environmental barriers to practicing religion as evidenced by difficulty adhering to prescribed religious beliefs.” The nurse could contact the patient’s pastor to arrange a visit or determine if services can be viewed online.

Spiritual Distress

Events that place patient populations at risk for developing spiritual distress include birth of a child, death of a significant other, exposure to death, a significant life transition, severe illness or injury, exposure to natural disaster, racial conflict, or an unexpected life event.^[9] Associated conditions that place a person at risk for developing spiritual distress include actively dying, chronic illness, illness, loss of a body part, loss of function of a body part, or a treatment regimen.^[10]

For example, a patient diagnosed with life-threatening medical diagnoses like cancer may experience spiritual distress as they move through the typical stages of loss. A sample PES statement is, “Spiritual Distress related to anxiety associated with illness as evidenced by crying, insomnia, and questioning the meaning of suffering.” A nurse would implement interventions to enhance coping.

Outcome Identification

Goals and SMART outcomes should be customized to each patient and their situation.

When a patient has the nursing diagnosis Readiness for Enhanced Spiritual Well-Being, a sample goal statement is, “The patient will demonstrate hope as evidenced by the following indicators: expressed expectation of a positive future, faith, optimism, belief in self, sense of meaning in life, belief in others, and inner peace.”^[11] An example of a related SMART outcome is, “The patient will express a sense of meaning and purpose in life by discharge.”^[12]

When a patient has the nursing diagnosis Spiritual Distress, a sample goal statement is, “The patient will demonstrate improved spiritual health as evidenced by one of the following indicators: feelings of faith, hope, meaning, and purpose in life with connectedness with self and others to share thoughts, feelings, and beliefs.”^[13] A sample SMART outcome is, “The patient will express a purpose in life by discharge.”^[14]

Planning Interventions

Providing Spiritual Care

When providing spiritual care, the RN must not impose their religious or spiritual beliefs on the patient. There are several guidelines for therapeutically implementing nursing interventions to support patients’ spiritually:

• Take cues from the patient: When bringing up spiritual health with patients, understand this may be a difficult topic for them to discuss. Let them lead the conversation and do not press further than they want to share. Also, be aware of the patient’s nonverbal cues. They may be saying one thing but their body language is saying something different. Gently point out the contradiction and seek clarification. For example, a patient may state that they don’t blame God for their illness, but begin to tear up as they say it. By responding, “I noticed you became tearful when you said that…what is causing the tears,” the door is opened for them to share more of their thoughts and feelings.
• Ask the patient how you can support them spiritually: An important way to assist a patient with their spiritual health is to ask them what they need to feel supported in their faith and then try to accommodate their requests, if possible. For example, perhaps they would like to speak to their clergy, spend some quiet time in meditation or prayer without interruption, or go to the onsite chapel. Explain that spiritual health helps the healing process. Many agencies have chaplains onsite that can be offered to patients as a spiritual resource.
• Support patients within their own faith tradition: Because patients can sometimes feel as if they are a captive audience, it is not appropriate for the nurse to take this opportunity to attempt to persuade a patient towards a preferred religion or belief system. The role of the nurse is to respect and support the patient’s values and beliefs, not promote the nurse’s values and beliefs.
• Listen to a patient’s fears and concerns without adding your own stories: In an effort to empathize with a patient who is telling their story, it is easy for the nurse to start adding personal examples from their own life. Although this may seem helpful, it is usually only distracting and shifts the focus from the patient to the nurse. Focus on the patient’s fears and concerns. Name and validate the emotions that are heard when possible. Sometimes patients don’t realize what they are feeling until it is pointed out to them.
• Pray with a patient if requested (or provide someone who will): Some nurses may feel reluctant to pray with patients when they are asked for various reasons. They may feel underprepared, uncomfortable, or unsure if they are “allowed to.” Nurses are encouraged to pray with their patients to support their spiritual health, as long as the focus is on the patient’s preferences and beliefs, not the nurse’s. See Figure 18.14^[15] for an image of a nurse praying with a patient. Having a short, simple prayer ready, that is appropriate for any faith, may help in this situation. If a nurse does not feel comfortable praying, the chaplain should be requested to participate in prayer with the patient.
• Share an encouraging thought or word: Similar to the preceding prayer suggestion, a scripture verse (based on the patient preferences) or an inspirational poem may be helpful to share during difficult times. Having a few verses or thoughts readily available can be very helpful during critical moments.^[16]
• Use presence and touch: Sometimes the mere presence of a nurse is spiritually comforting for patients. Words are not always needed. It can be very comforting to know that someone will be sitting quietly next to them as they fall asleep or are in pain. Touch can also be a very powerful therapeutic tool to provide comfort (after asking permission of the patient).^[17]

Figure 18.14 Nurse Praying with a Patient

See the following box for a summary of therapeutic interventions that nurses can implement to provide spiritual support. Review additional interventions for enhancing coping for patients and family members experiencing grief in the “Grief and Loss” chapter.

Therapeutic Nursing Interventions to Provide Spiritual Support ^{[18],[19],[20]}

• Use therapeutic communication to establish trust and empathetic caring.
• Be present and actively listen to the individual’s feelings and express empathy.
• Be open to the individual’s expressions of loneliness and powerlessness.
• Be open to the individual’s feelings about illness and/or death.
• Encourage the individual to reminisce and review their past and focus on events and relationships that provided spiritual strength and support.
• Provide privacy and quiet time for spiritual activities.
• Offer opportunities for the patient to practice their religion.
• Encourage the patient to engage in spiritual, meditative, or mind-body practices to promote spiritual healing.
• Arrange visits with the chaplain, patient’s pastor, or other spiritual advisor.
• Pray with the individual, as appropriate.
• Provide spiritual music, literature, radio, television, or online programs as appropriate.
• Promote hope however the individual defines it for their situation without providing false reassurance.
• Encourage forgiveness.
• Encourage participation in interactions with family members, friends, and others.
• Encourage participation in support groups

Implementing Interventions

Nurses should support patients’ spiritual and religious preferences when implementing interventions to support their spiritual well-being. The nurse should respect and listen to the patient’s expression of beliefs and not impose their own beliefs on the patient. Spiritual or religious practices should be accommodated if safe and feasible to do so. If a patient has a spiritual belief, value, or practice that conflicts with their treatment plan, the nurse should explain the rationale for the intervention or treatment. If the patient is not willing to complete the treatment as planned due to their spiritual or religious beliefs, the nurse should attempt to negotiate the treatment plan with the patient and/or health care provider. For example, a nurse can advocate for rescheduling a procedure after the Sabbath or modifying the dietary plan and medication administration times during Ramadan.

Evaluation

When evaluating the effectiveness of interventions in promoting a patient’s spiritual health, refer to the overall goal, “The patient will demonstrate spiritual health as evidenced by the following indicators: feelings of faith, hope, meaning, and purpose in life with connectedness with self and others.”^[21] From there, review the patient’s progress toward the personalized SMART outcomes that have been customized to their situation.

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1. Dameron, C. M. (2005). Spiritual assessment made easy… With acronyms! Journal of Christian Nursing, 22(1). https://www.nursingcenter.com/journalarticle?Article_ID=725343&Journal_ID=642167&Issue_ID=725337↵
2. Dameron, C. M. (2005). Spiritual assessment made easy… With acronyms! Journal of Christian Nursing, 22(1). https://www.nursingcenter.com/journalarticle?Article_ID=725343&Journal_ID=642167&Issue_ID=725337↵
3. Anandarajah, G., and Hight, E. (2001). Spirituality and medical practice: Using the HOPE questions as a practical tool for spiritual assessment. American Family Physician. 63(1), 81-9. https://www.aafp.org/afp/2001/0101/p81.html↵
4. Ackley, B., Ladwig, G., Makic, M. B., Martinez-Kratz, M., & Zanotti, M. (2020). Nursing diagnosis handbook: An evidence-based guide to planning care (12th ed.). Elsevier, pp. 869-872. ↵
5. Puchalski, C. M., Vitillo, R., Hull, S. K., & Reller, N. (2014). Improving the spiritual dimension of whole person care: Reaching national and international consensus. Journal of Palliative Medicine, 17(6), 642–656. https://doi.org/10.1089/jpm.2014.9427↵
6. Herdman, T. H., & Kamitsuru, S. (Eds.). (2018). Nursing diagnoses: Definitions and classification, 2018-2020. Thieme Publishers New York, pp. 365, 372-377. ↵
7. Herdman, T. H., & Kamitsuru, S. (Eds.). (2018). Nursing diagnoses: Definitions and classification, 2018-2020. Thieme Publishers New York, pp. 365, 372-377. ↵
8. Herdman, T. H., & Kamitsuru, S. (Eds.). (2018). Nursing diagnoses: Definitions and classification, 2018-2020. Thieme Publishers New York, pp. 365, 372-377. ↵
9. Herdman, T. H., & Kamitsuru, S. (Eds.). (2018). Nursing diagnoses: Definitions and classification, 2018-2020. Thieme Publishers New York, pp. 365, 372-377. ↵
10. Herdman, T. H., & Kamitsuru, S. (Eds.). (2018). Nursing diagnoses: Definitions and classification, 2018-2020. Thieme Publishers New York, pp. 365, 372-377. ↵
11. Ackley, B., Ladwig, G., Makic, M. B., Martinez-Kratz, M., & Zanotti, M. (2020). Nursing diagnosis handbook: An evidence-based guide to planning care (12th ed.). Elsevier, pp. 869-872. ↵
12. Ackley, B., Ladwig, G., Makic, M. B., Martinez-Kratz, M., & Zanotti, M. (2020). Nursing diagnosis handbook: An evidence-based guide to planning care (12th ed.). Elsevier, pp. 869-872. ↵
13. Ackley, B., Ladwig, G., Makic, M. B., Martinez-Kratz, M., & Zanotti, M. (2020). Nursing diagnosis handbook: An evidence-based guide to planning care (12th ed.). Elsevier, pp. 869-872. ↵
14. Ackley, B., Ladwig, G., Makic, M. B., Martinez-Kratz, M., & Zanotti, M. (2020). Nursing diagnosis handbook: An evidence-based guide to planning care (12th ed.). Elsevier, pp. 869-872. ↵
15. “Praying_with_Patient.jpg” by Ahs856 is licensed under CC BY-SA 4.0↵
16. Nourian, F. (2018, March 16). 9 ways to provide spiritual care to your patients & their families. AdventHealth. https://careers.adventhealth.com/blog/9-ways-to-provide-spiritual-care-to-patients-and-their-families↵
17. Nourian, F. (2018, March 16). 9 ways to provide spiritual care to your patients & their families. AdventHealth. https://careers.adventhealth.com/blog/9-ways-to-provide-spiritual-care-to-patients-and-their-families↵
18. Johnson, M., Moorhead, S., Bulechek, G., Butcher, H., Maas, M., & Swanson, E. (2012). NOC and NIC linkages to NANDA-I and clinical conditions: Supporting critical reasoning and quality care. Elsevier, pp. 222-223. ↵
19. Butcher, H., Bulechek, G., Dochterman, J., & Wagner, C. (2018). Nursing Interventions Classification (NIC). Elsevier, pp. 351-353. ↵
20. Ackley, B., Ladwig, G., Makic, M. B., Martinez-Kratz, M., & Zanotti, M. (2020). Nursing diagnosis handbook: An evidence-based guide to planning care (12th ed.). Elsevier, pp. 869-872. ↵
21. Ackley, B., Ladwig, G., Makic, M. B., Martinez-Kratz, M., & Zanotti, M. (2020). Nursing diagnosis handbook: An evidence-based guide to planning care (12th ed.). Elsevier, pp. 869-872. ↵