DISASTERS, SERIOUS ILLNESS, and tragedy prompt many to pray. A preliminary report released by economist Jeanet Sinding Bentzen documented that Google searches for “prayer” reached unprecedented numbers beginning in mid-March 2020, as COVID-19 began to surge around the world.1 Bentzen observed that Google searches about prayer doubled for every 80,000 new cases of COVID-19. This may not surprise most Americans, given 85% of them pray—and nearly 60% do so at least daily.2 Among Americans who pray, 47% pray about their health and illness and 49% pray for help during crisis.3 Presumably, many nurses and patients alike are intensifying their praying during the COVID-19 pandemic.
Prayer is often considered a religious practice. The American Nurses Association Code of Ethics posits that nurses are not to impose their personal religious beliefs or practices on patients.4 Current circumstances, therefore, raise these questions: When a nurse is caring for a scared, possibly mechanically ventilated and dying patient with COVID-19 who is isolated from friends, family, personal clergy, and even hospital chaplains, should a nurse ever initiate an offer of prayer? If so, under what circumstances might a nurse ethically do so? And practically, how could a nurse do this in a therapeutic manner?
After examining the pros and cons of nurses initiating prayer with patients, this discussion will argue that when offered in an ethical, patient-centered manner, prayer can be therapeutic. Suggestions for how to keep prayer ethical are also provided.
Arguments against nurse-initiated prayer
Although it is accepted that nurses can respond to a patient's request for prayer, valid reasons exist for why nurses should not initiate an offer of prayer:5
- Because of the challenges of adapting to illness or disability, patients inherently are physically, emotionally, and spiritually vulnerable.
- This vulnerability is amplified by the reality that the patient is in an asymmetric relationship with the nurse; the power-differential favors the nurse who possesses the health-related knowledge and skills depended upon by the patient. Thus, to avoid any suggestion of unethical coercion, nurses ought to not initiate an offer of prayer. A panel of ethicists discussing the question of whether physicians ought to offer prayer to patients concluded that they should not to avoid even the appearance of coercion.6
- The role of the nurse in 21st century America is not understood to be that of priest/priestess; that role in our culture is given to clergy, chaplains, and other spiritual or religious experts.5 Patients may not want or expect a nurse to function in this priestly role.
- Most Americans who pray do so alone and silently.3 Thus, nurses may not need to copray if patients prefer to pray solo.
- Because nurses typically receive limited education on spiritual care, they may not appreciate how to pray with patients in an ethical and therapeutic manner.7
Each of these arguments undermines the notion that nurses can offer to pray with patients.
Arguments for nurse-initiated prayer
Many examples within nursing literature suggest nurses view prayer with a patient as an appropriate intervention; for example, prayer is included in lists of nursing therapeutics.5,8 Some nurses do pray with patients even though they may perceive it to be uncomfortable and infrequent.9-12 Findings from a survey of 445 religious and mostly Christian nurses revealed that while 25% believed they ought to wait for patients to request prayer, most believed that if circumstances suggested it is warranted, initiating an offer of prayer is appropriate.13 A small minority (12%) felt they could offer to pray with a patient regardless of circumstances.
Although some nurses respond positively to patient requests for prayer, is it appropriate for a nurse to initiate an offer? The following assumptions and evidence build an argument supporting the appropriateness of nurses initiating an offer of prayer.
As the introductory demographic facts presented above imply, and as news stories anecdotally illustrate, many are praying about COVID-19. Patient-centered care is a widely accepted goal for healthcare today. Thus, for patients who desire a shared prayer, should they not be given an opportunity to accept (or refuse) a nurse's offer to pray with them? Prayer is an intimate spiritual experience that is often considered inappropriate in nonreligious social contexts, and it can take a sense of desperation to prompt patients to ask a nurse to pray with them. One study, for example, observed that 39% of 70 Bostonians with incurable cancer would never ask their nurse or physician for prayer.9 Thus, for patients who want prayer, the opportunity to accept or reject it should not be denied. Respect for patient autonomy guides clinicians to engage patients in decision-making about their healthcare and treatment options; this same approach can guide nurses to assess if and how a patient wants prayer.
Other points that support nurse-initiated prayer include the following.
- Whole-person care is an important value within healthcare. This holistic approach to healthcare is not only supported by theory, but also by empirical evidence that indicates that patients with illness benefit psychologically and spiritually from personal prayer. If prayer enhances coping and well-being, then assessing if and how nurses can support prayer is merited.
- In many cases, those who perform the priestly function in America cannot be physically present with those who are hospitalized with COVID-19, even those who are dying. It is the nurse who is present at such times. Just because nurses are not known for serving a priestly role in society should not mean that they should not do so when it would be welcome and beneficial, provided they are willing and able to offer it.
- Although an offer of prayer could be coercive, following guidelines can allow nurses to offer to pray with a patient in a manner that is ethical. To not offer to pray because of the desire to avoid the appearance of coercion would also preclude the possibility of introducing a comforting therapeutic. Again, the need for assessment becomes evident.
- Although Americans who pray may do it primarily silently and solo, evidence suggests that the sicker patients become, the more they welcome an offer of prayer from nurses and physicians.14,15 Scanty evidence also indicates that maintaining usual prayer habits is difficult for people who are seriously ill and hospitalized.16 Illness or medications can interfere with their cognitive capacity to pray as they are accustomed. For some, the spiritual distress, manifested as wondering “why?” or doubting preexisting religious beliefs, may make praying difficult. For these patients, having someone else pray with them can be comforting.
- Some research has shown that many, but not all, appreciate a nurse's offer of prayer. Results from one study found that 41% of patients with cancer and 56% of family caregivers agreed they wanted their nurses to “offer to pray with me.” Interestingly, the less intimate “offer to pray privately for me” generated more enthusiasm; 60% of patients and 68% of family caregivers agreed.17 Findings from the Boston study of patients with cancer revealed that 80% endorsed nurse- or physician-initiated prayer as at least mildly supportive.9 Thus, if suggested in a noncoercive manner, a nurse-initiated offer of prayer may be an appropriate part of holistic, patient-centered care—especially if no spiritual care expert is available. Given the potential for coercion, introducing prayer during patient care requires that the nurse use considerable sensitivity.
How can nurses ethically introduce prayer?
Guidelines for nurses to ethically initiate an offer of prayer exist.18,19 Key to these guidelines are assessing that the patient wants prayer and respecting patient preferences. Thus, a few practical suggestions for insuring an ethical and therapeutic prayer experience are provided here.
- Examine your motives. Why would I offer to pray with a patient? Is it a way to meet my own needs, to comfort myself? Do I want to influence the patient to believe the way I do? Or is there a humility about my spiritual journey and an openness and respectfulness for the spirit within the patient? If the need to be a savior, “earn a jewel in a heavenly crown,” or control the patient motivates the nurse, the offer of prayer is likely to be coercive and harm the therapeutic relationship.
- Have at least some relationship with the patient. Before initiating an offer of prayer, establish rapport with the patient. Unsurprisingly, patients prefer prayer from a clinician who they experience as warm, respectful, and kind.9,20 Even if the nurse-patient relationship has existed for only a short time, the nurse's tone of voice, nonverbal signals, kind and competent touch, and other indicators of caring can quickly build rapport.
- Assess if and how the patient wants prayer. Chaplains have coached me to use this screening question: “Would a prayer be helpful?” Notice how this conveys a different message than, “Do you mind if I pray with you?” That question places emphasis on the nurse and makes it difficult for the patient to say no. Of course, assessing in a way that is manipulative would be coercive; for example, telling patients that they will get well faster if they pray or making them feel subtle pressure to please the nurse by accepting the offer. When patients respond affirmatively and circumstances allow for it, inquire as to how and for what they would like to pray. For example, “Is there anything in particular you'd like me to pray about?” and, “Is there a way you prefer that I pray?” Patients' answers often provide rich information about their innermost concerns. In fact, such discourse is the beginning of prayer.
- If a patient declines the offer, respect that decision. The nurse might follow up with a statement such as, “Let me know if there is another way in which I can make this challenge easier for you.”
- Pray in a way that respects patient preferences. Prayer is to “listen to and hear this self who is speaking.”21 There is no right or wrong way to pray. The nurse can simply give voice to the patient's innermost concerns and yearnings. If congruent with the patient and nurse's beliefs, these experiences and desires can be presented to “God,” a label for the divine in which 89% of Americans have some type of belief.22 Although a patient who requests prayer is likely to be comforted by any prayer—regardless of its format or eloquence—nurses ought to express prayers that reflect the patient's preferences. Although most Americans practice a colloquial style of prayer, some take other approaches. For example, supporting prayer practices may involve reading to patients from their prayer book or playing a recorded prayer. Prayers from various faith traditions that can be read to a patient can be found online or obtained from a chaplain. Praying with patients can also involve sharing a moment of silence with shared heartfelt intention. Because time at the bedside is usually limited for patients with COVID-19, a prayer is best kept short.
Note that some may interpret an offer of prayer to mean, “This nurse thinks I am going to die!” A prefatory comment that alleviates this distress may be needed; for example, “I find many patients like to pray with their nurse. Would that be helpful to you?”
There is potential for nurses to unethically impose on patients an offer of prayer and thereby harm the therapeutic milieu. However, given the potential therapeutic value of praying with a patient, it is short-sighted to assume all nurses should never offer prayer to any patient. Avoiding coercion in how the offer is made, assessing if and how a patient desires prayer, and respecting the patient's preferences are essential if a nurse is considering prayer as a comfort measure for a patient.
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