Four principles for giving spiritual care

Grete Scharfe

What is needed by us as nurses in order to assist the dying patient in his process to live - and die - in peace with himself, others, his future and his God? It does not all depend on what we do, but to a greater extend also on how we are. It is a matter of both "being" and "doing".

1. Be humble

The Danish Philosopher, Soren Kierkegaard, (1813-1855) has written something about true help:

To become a true helper in my understanding I need to acknowledge the patient as the expert in his life and myself as his servant - no matter how great an expert I may be professionally. What does that mean in practical terms? It may mean to:

• to be willing to learn from the patient;
• admit my insecurity to the patient, and of course ask the patient for forgiveness if I have wronged him;
• ask for permission to help a helpless patient before I assist him;
• ask for permission before I ask the patient a personal question;
• let the patient know if there are things I truly admire about him;
• thank the patient for what he gives me e.g. permission to help, his trust, openness, a good conversation or a good laugh (When have I last thanked a patient?).

2. Be promoting

By that I mean: "Take initiative".

Back in the 80'es I made a pilot study on patients' spiritual needs and compared my findings with other studies [2]. Later some of the findings have been confirmed by other writers [3].

I learned that the patients were very attentive to the signals the nurses sent, and that the signals the nurses sent had significance for whether or not the patient would entrust the nurse with his spiritual needs. I found that we as nurses could send three signals: a red, yellow and a green.

Red signalling "Stop!" "Don't talk to me about personal issues". How do we give the patient that impression? By being busy ("I will not bother the busy nurse with that kind of questions" one patient said), or by using a rude language or having an arrogant attitude.

Yellow signalling "Wait!" Here we are waiting for the patient to invite us to talk about spiritual matters. A nurse whom I asked whether she talked with her patients about spiritual issues answered: "I don't want to push the patient. He has to come forward with the issue himself". The funny thing was that when I asked the patients the same question I received a similar answer: "I will only talk with the nurse about such things if she starts". Both were waiting for the other to take the initiative. But in my opinion that is an unreasonable pressure to put on the patient, especially on a dying patient. That leads to the third signal:

Green signalling "Go!" This is the signal many patients are longing for us to send. They want us to take more initiative in giving spiritual care. This is the signal that says: "Here I am. I am interested in what really matters to you. I am willing to listen to your doubts and fears, your anger and despair, your hopes and dreams." How do we send that signal? By:

• sitting down, (showing that we have time, maybe telling the patient how much time we have);
• uninvited inform the patient about the possibilities for spiritual care;
• uninvited ask direct (but tactful) questions. (Don't be afraid of asking questions about spiritual matters. Be more hesitant to give answers!);
• maybe by sharing a little about our own beliefs, so that the patient has an idea of whom he is talking with.

According to the studies the initiative the patients want us to take is not to preach to them or necessarily to share our entire testimonies, but ask them questions, give them offers and information so they can make informed choices [4].

3. Be elastic

Have you ever been in the situation where a patient one moment tells you that he is totally aware of the fact that he only has a few weeks left, and the next moment tells you that he is looking forward to go skiing next month? How do you react to that? In that respect I find the following illustration helpful.

When we hear a patient say something that to us sounds unrealistic a common reaction is to try to get the patient away from his unrealistic thoughts. But in this way we will only push him further towards the unrealistic side. Because the reason why he is unrealistic is that he needs it. It is a defence mechanism because it is too painful for him to face reality.

When he is "dreaming" he is "recharging his batteries" so that he gains strength to be present in the harsh reality. Instead of trying to get the patient away from his unrealistic thoughts we should try to meet the patient where he is e.g. saying "I'd really wish for you that you could go skiing. What does skiing mean to you?" etc.

When the patient has talked about his dream for some time, and when he has experienced that it is legitimate to have those thoughts I have often found that he ends up saying: "But I know I will never experience that again".

4. Be yourself

We have been talking about the importance of the dying patient being allowed to be himself. But it is necessary to point out the importance of us as nurses being ourselves as well. In order for the dying patient to find peace he does not need robots. He needs real flesh and blood. He needs the real you. So "The best thing you can do is to become super at being yourself".

Where do we go if we need help in becoming real persons in our relations with the patient? How do I learn to balance the personal, spiritual and professional aspects of my personality in my nursing practice? I feel privileged because we in the hospice have the possibility to join a group where we reflect upon our professional practice together with a psychologist, our chaplain or a specially trained nurse. Do you have a similar opportunity? Or could something like that be arranged in your workplace?

Bibliography

1. Kierkegaard, S.: (1963) The point of View: Part two. Chapter 1A. The Esthetic Writing, p. 45.
2. Scharfe, G.: (1988) Andelig omsorg - sygeplejerskens rolle? En litteraturanalyse. Dansk Sygeplejerad.
3. Grasaas, K.K. (1997): "De kunne ihvertfall sporre…" ("They could at least ask…" an article about nursing and spiritual needs) Vard i Norden 4/1997 no. 4 p. 32-35.
4. Nielsen, Rita. During a teaching session 22nd Sept. 2005 Rita Nielsen expressed that her study had confirmed the hypothesis proposed by Grete Scharfe 1988 "that green light from the nurse promotes spiritual needs from the patient".