The study was performed within the Dutch law and Good Clinical Practice guidelines. Because the study concerned observation of routine care, or the way nurses usually interact with patients, no permission of the medical ethical committee was required.
To guarantee anonymity, patient characteristics including quotes were adjusted to prevent recognition of the patient, and all nurses were mentioned or quoted alike and as a woman.
Initially, the data were read and reread for familiarization. We inductively identified and indexed themes and categories. Afterward, all the data relevant to each category were discussed with 2 other researchers (M.G. and Y.E.) until consensus was reached. The key point about this process was inclusiveness; categories were added to reflect as many of the nuances in the data as possible—rather than reducing data—and so moving toward hypotheses or propositions.16 The consolidated criteria for reporting qualitative research, that is, a checklist for explicit and comprehensive reporting of qualitative studies, was used.17
Four nurses were observed, 3 women and 1 man. Of these four, three had acquired the oncology specialization. The care the nurses provided took place in rooms for 4, 2, or 1 bed(s). The observation was conducted 3 times during a day shift and 1 time during an evening shift. At the start of their shift, each nurse confirmed being familiar with the 3 questions of the Dutch spiritual guideline as possible questions for exploring the spiritual dimension and to have taken note of the 3 subquestions of the study.
After each observed shift, the nurse was interviewed. When asked whether situations had occurred during the shift that had offered a clear entry or even an explicit invitation to explore or have a conversation about meaning, each nurse initially indicated not having recognized such situations. However, once the researcher offered examples she had observed that day and had herself even acted on a few times with or without the help of the 3 questions of the Dutch guideline, each of the nurses agreed to having recognized several of such occasions. The nurses proceeded by pointing out all sorts of barriers that often kept them from entering into a conversation. During these observations and the interviews, in which the observer and the nurse reflected on these observations, we concluded that no new barriers or deductive factors arose during the fourth interview. The barriers derived from observation and interviews could be subdivided into 3 main themes: lack of time, mindset, and reserve.
LACK OF TIME
Three of the 4 nurses indicated that there was little or no time to have a conversation about spirituality. All thought such a conversation would take a lot of their time.
I guess I cannot start such a conversation knowing I have to be on my way again. That is the dilemma sometimes; knowing things are waiting for me and then I will not inquire further.
According to the nurses, the afternoon usually offered more space and time for such conversations than the morning:
You should not try and do that in the rush of your work. (…) that to me is the professionalism of a nurse, that you plan to integrate that, as part of your care, later in the day. (n2)
The interviews revealed that the nurses' mindset also represented a limiting factor. They expressed how they spent a substantial part of their time completing and inquiring in service of checklists and scoring lists; during their shifts, this needed to have their full attention (“you will be held accountable through these lists” [n3]). This made it difficult to be able to hear a patient's question or comment as an unfolding of the spiritual dimension or as an entry or invitation to a conversation about spirituality. Most of the time, they carried a computer in which to directly insert scores. Watching patients and listening to them have, to a substantial degree, given way to keeping track of scores:
Not my clinical eye but the MEWS [Modified Early Warning Score] has to tell me how the patient is doing. Talking about this, this nurse realizes: “that I often primarily ask closed questions.” (n3)
Another barrier was that, because of personal circumstances or an incident, their mindset did not allow for a conversation about meaning:
It also depends on how I am going into my shift. Sometimes it has to do with me personally. (…) There are days when I am “doing my tasks” mostly and other days when I feel I have a bit more to give. (n3)
Another nurse said:
Sometimes I just do not succeed. Then I am already full (…) It has also happened; someone had passed away in a room. And then there was a new patient. But my feeling was that that room still belongs to that other patient. Then I could not start a conversation. That was actually like I did something really nasty. But I did not have the headspace yet. (…) I think with every patient, every room, you have to switch again (…) our admissions, our experiences of one to the other, are very quick. (n4)
Apart from lack of time and mindset, nurses mentioned a number of factors pointing to reluctance to engage in a conversation about meaning. All 4 nurses indicated that intruding on the privacy of the patient represented 1 such factor. Speaking about meaning, according to them, was difficult to reconcile with the possibility that fellow patients and others might be listening in. Considerations that the conversation could be overheard by a third party could be a reason not to enter into the conversation. Two nurses stressed specifically that they experienced this as an impeding factor to address the spiritual dimension.
In addition, all 4 nurses indicated that talking about meaning might be stressful to patients. Not every patient has a need for this, they said. They also wanted to avoid that different nurses would start a conversation with the same patient about his concerns:
You should be careful not to over ask people. (n2)
The nurses expressed as well that, because much work needed to be done during a shift, they often had to set other priorities.
The personality of the patient also could contribute to reservedness in the nurse with regard to entering into a conversation:
When you don't connect with people then I also do not feel like asking about it. Or when people are really bothersome. When you feel there is no rapport. (n2)
Patients were also said to choose to start a conversation with a certain nurse and not the other.
…that some people also know: with you I get along. So with you I like to share my story. (n3)
Finally, the nurses indicated in the interviews that it could be demanding for themselves as well to frequently have such conversations:
You cannot keep this up with all people, every day, at this rate…for it demands a lot of you because you have to reveal a lot about yourself too. (n2)
Sometimes, nurses deliberately let moments pass that presented possibilities for conversation:
You don't always feel like it, you see. (n2)
In the end, situations were presented to the nurses in which talks about spirituality during their shifts actually had taken place. The reactions that followed identified several factors conducive to conversations about spirituality: suggestions from the spiritual care provider, observation of the spiritual care provider, a renewed viewing of the situation, and continuity of care.
SUGGESTIONS FROM THE SPIRITUAL CARE PROVIDER
On occasion, the researcher, upon explicit request of the relevant nurse, pointed to a clear effort a patient had made to engage in a conversation about meaning. The nurses knew the researcher first and foremost as spiritual care providers. They interpreted being shown instances and opportunities for entering conversations as suggestions from the discipline of spiritual care. These suggestions seemed helpful for engaging in a conversation.
In the interview, looking back to this conversation (Table 1), the nurse in question was asked whether this exploration brought her or the patient anything:
Yes, it makes a difference. Especially that the woman showed her vulnerability; what motivated her to act in such a way. (…) Now that I know what caused her to be so on top of the therapy, then that offers an explanation. (n4)
Another nurse remarked, after a similar encouragement to explore and the resulting conversation:
You also get useful information from there. Also just to be able to better care for your patients. Small pieces of personal information also enable you to develop a certain connection with someone. It also ensures that you can support people in another way. I now like knowing that this man is expecting his second child and does not know what the future holds for him and whether or not he is going to be able to see it. It gives me a lot of information on him. (n3)
This nurse spontaneously made notes in the electronic patient file after her conversation with the patient:
Sure! But to me it's not just about that information but also about him being able to be here as the person he is. (n3)
OBSERVATION OF THE SPIRITUAL CARE PROVIDER
The researcher occasionally had short conversations with the patients; whenever possible, she used the 3 questions from the MVCN (see Tables 2–4). In the interviews, nurses indicated that they had heard these conversations, either completely or in part. During the interview, a nurse informs the researcher that she had already observed her before this in her work as a spiritual care provider:
I have often seen you talking to patients; I then did not stand close, but now my idea has been confirmed: people quickly feel like they can share their story with you. I then try to analyze what that is; that interests me. (…) I admire that. (n3)
During the interviews, the researcher discussed several situations (Tables 5–7) with the nurses, which might have been an opening to (further) explore the spiritual dimension but where this exploration did not occur. By analyzing these situations, they recognized opportunities that they had not noticed during their service. Opportunities presented themselves while speaking with patients, through visual images/objects and during nursing actions.
This first situation (Table 5) contains an explicit invitation to talk by a young woman. The nurse responded in the interview: “Yes, that's right. Now that I hear you say it. I did not pick up on that (…).” (n1)
The researcher recalled with the nurse (situation, Table 6) that she had not given attention to the spiritual dimension the entire day, although she had intended otherwise at the start of her shift. Nurse: “I think you're right. I now wonder: why did I not do that? I can say well, I was busy with other things, which is the easiest way out. But I guess what you're telling me now about this patient, for me did not carry that charge.” (n1)
The researcher assesses a situation (Table 7) with the nurse where, during a simple nursing act, a patient tells her that she experiences a restless mind. Reviewing this together, the nurse informed the researcher that “What I notice about you: you are very observant, to what you see in people, and you respond to that. And that way you create an entry with people. And what I observe in myself, now that I walk with you: I actually ask closed questions pretty often. I notice: you often let the story come from the people themselves. That's a big difference.” (n3)
CONTINUITY OF CARE
The interviews showed that providing care to the same patients on consecutive days promotes intimacy between nurses and patients and facilitates conversation, also on the spiritual dimension. In the words of one of them: “Then you can keep an extra eye on this one this day, on that one the following, and that other one the next day. (…) Especially in terms of this dimension. I would really like to see that more attention was paid to continuity of care on all dimensions!” (n2)
During the participant observations in an oncology ward, there were no (care) situations where nurses explored spirituality with patients. Multiple situations occurred in which patients gave nurses explicit or implicit signals to discuss existential issues. In most cases, nurses seemed not to have spontaneously recognized these signals. However, when the researcher mentioned the situations during feedback, they acknowledged all of them. Accompanying the nurses, the researcher detected signals that patients often offered as an opening to engage in a conversation about what preoccupied them the most. Because the nurses did not, several times, she then asked the 3 questions of the Dutch Spiritual guideline.4 Besides, patients shared their concerns spontaneously to the researcher during moments of silent presence. Nurses indicated that they experienced 3 barriers that made them not to engage in this type of conversation: lack of time, a mindset unattuned to exploring, and reluctance to burden patients or others, including themselves, with exploring the spiritual dimension. Similar results were found in a survey among physicians in academic hospitals in the Netherlands.18
In line with Balboni et al,6 the nurses observed in our study proved to be sympathetic to discussing spiritual issues. However, this attitude was different from the actual spiritual care they rendered.5 Molzahn and Sheilds7 also mentioned that it is not clear why nurses are reticent to discuss spiritual issues with people for whom they provide care, despite evidence of the positive effects of spirituality on well-being. According to Molzahn and Sheilds,7 nurses providing spiritual care are expected to be able to use language of human experience (such as the formulation of the 3 questions), to understand language belonging to institutionalized religions, and to be sensitive to the “unspokenness” that pertains to the mystery and the mysticism inherent in spirituality. McSherry and Ross8 state that, in nursing, there is a need for the concept of spirituality to be developed in a meaningful and rigorous manner. Our observation indicates that nursing practice offers multiple opportunities to explore or identify the spiritual dimension of patients.
The mindset of the nurse at the bedside differs from that of the spiritual care provider. A patient's comment, “Is it strange that people who get cancer want to evaluate their entire life?”, was heard by the nurse as a question to which an answer was expected and by the researcher as an unfolding of what concerned this woman in her illness. In daily nursing practice, where much time and effort go to measuring physical aspects, creating time and space for “the unfolding of the clients' tale” is a challenge.19 Lack of skills pertaining to the spiritual dimension may require an interdisciplinary approach if it is to take a full role in daily practice in the care provided to patients, in addition to the more common focus on the somatic, psychological, and social dimensions.20
Strengths and Weaknesses
Our results are based on observations of daily oncology practice, which provided insights in what takes place. A limitation of the study is that it was conducted in only 1 department of only 1 hospital in the Netherlands. In addition, only a limited number of nurses were observed. Yet, this number was sufficient to reveal multiple opportunities in nursing practice to explore the spiritual dimension. To guarantee anonymity of the nurses, gender was not reported in the results section. This implies that gender-sensitive examination of the data was not possible. That the researcher also worked at that ward as a spiritual care provider may have influenced observing objectively. However, it also made the nurses feel at ease in the presence of the researcher, which made the situation more natural.
Conclusions and Recommendations
Hospitalized patients provide many opportunities to nurses to explore the spiritual dimensions, but because of a diversity of reasons, nurses do not tend to recognize them. To close this gap, nurses should be trained to allow them to naturally, and in a way commensurate with their work, explore the spiritual dimension of patients and to identify a need for specialist counseling or crisis intervention. This certainly applies to the care of patients with cancer, in whom the experience of a life-threatening illness and the uncertainty regarding diagnosis and of facing death can cause spiritual distress.
We are grateful to the employees of this department, and the 4 observed nurses in particular, that they have agreed to the publication of data collected and therefore have made this publication possible.
1. McSherry W, Ross L. Spiritual Assessment in Healthcare Practice
. Keswick, England: M&K Publishing; 2010.
3. van de Geer J, Leget C. How spirituality is integrated system-wide in the Netherlands Palliative Care National Programme. Prog Palliat Care
5. Kalish N. Evidence-based spiritual care: a literature review. Curr Opin Support Palliat Care
6. Balboni MJ, Sullivan A, Enzinger AC, et al. Nurse and physician barriers to spiritual care provision at the end of life. J Pain Symptom Manage
7. Molzahn AE, Sheilds L. Why is it so hard to talk about spirituality? Can Nurse
8. McSherry W, Ross L. Nursing. In: Cobb M, Puchalski C, Rumbold B, eds. Oxford Textbook of Spirituality in Healthcare
. New York, NY: Oxford University Press; 2012:211–217.
9. McSherry W, Ross L. Chapter 30: Nursing. In: Oxford Textbook of Spirituality in Health Care
(paperback version 2014). New York, NY: Oxford University Press; 2012:211–218.
10. Villagomeza LR. Spiritual distress in adult cancer
patients: toward conceptual clarity. Holist Nurs Pract
11. Group SCS. Final Report on Spiritual Support
. Stevenage, England: Mount Vernon Cancer
12. Mulhall A. In the field: notes on observation in qualitative research. J Adv Nurs
13. Van Meurs J, Vissers K. Van geestelijk verzorger naar consulent spirituele zorg. (translation from Dutch: from hospital chaplain to consultant spiritual care). In: Smeets W, ed. Handboek Spiritualiteit in de Palliatieve Zorg
(Handbook Spirituality in Palliative Care). Almere, the Netherlands: Parthenon; 2016:55–64.
14. Nolan S, Saltmarsh P, Leget C. Spiritual care in palliative care: working towards an EAPC Task Force. Eur J Palliat Care
15. van den Brand M, Leget C, van Meurs J. Spirituele vragen herkennen: aanbevelingen voor de praktijk (translation from Dutch: Recognizing spiritual questions: recommendations for practice). Oncologica
16. Pope C, Ziebland S, Mays N. Qualitative research in health care. Analysing qualitative data. BMJ
17. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care
18. Pieper J, Hijweege N, Smeets W. Attentiveness to religious/spiritual coping and meaning questions of patients. A survey among physicians in Dutch Academic Hospitals. J Empiric Theol
19. Pargament K. Spiritually Integrated Psychotherapy. Understanding and Addressing the Sacred
. New York, NY: The Guilford Press; 2007.
20. Dekkers W, Naber S. Suffering, death and palliative care. A European advanced bioethics course. In: Smeets W, ed. Handboek Spiritualiteit in de Palliatieve Zorg
(translation from Dutch: Handbook Spirituality in Palliative Care). Almere, the Netherlands: Parthenon; 2016:306–309.
Keywords:Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved
Cancer; Dutch Spiritual Care Guideline; Ethnographic; Nurses; Observing and exploring spiritual issues; Participant observation