Professor Stephen G. Wright, FRCN, MBE.
Faculty of Health, St Martin’s College, Lancaster; Editor, Sacred Space and Chairman, Sacred Space Foundation, Renwick, Cumbria
Spirituality and religion are often confused. It can be tempting to stay away from the former due to its association with ‘new age’ flakiness and the latter raises the spectres of fundamentalism, judgementalism and intolerance.
David Stoter (1995), a hospital chaplain working in Nottingham, has suggested that professional wariness of anything associated with religion has led us to consign the issue to a footnote on the patient’s chart. We ask their religion, then promptly pass on any difficulties to the nearest chaplain.
Spirituality touches every aspect of the lives and work of nurses. Even minor health-care problems produce fear and anxiety, provoke questions of what and why we are suffering. We often have to face such questions from patients, and sometimes have to confront their feelings of mortality, their deepest beliefs about who they are and why they are here, how they derive support from their ideas of God and an afterlife. Nurses are not excluded from this terrain. With each nursing moment we may be challenged to face our own sense of mortality, the meaning and purpose of suffering and to draw upon the deepest resources to support ourselves in the often difficult world of nursing.
We are often taught about the religious needs of certain groups (such as those of diet, privacy, time for prayer and so on) and these rituals and practices can usually be observed with nursing help. Meeting spiritual needs, however, can be a little more problematic. Questions about who and what we are, how we deal with distress and suffering, why things happen to us, and so on, can be hard to answer, especially if as nurses we have uncertainties about the answers to such questions ourselves.
Spirituality and religion
It is worth briefly examining the relationship between spirituality and religion. The two should be seen as different but complementary.
Spirituality concerns our beliefs about our place in the world, how we define ourselves as individuals and seek meaning and purpose in and for our lives. It includes how we relate not only to ourselves, but also to others and perhaps our ‘god’.
Religion can be likened to the container, the ritual or liturgy that we use to express and focus those beliefs. Thus, it is possible to argue that while everyone is spiritual - we all seek meaning and purpose in life: ‘Who am I and why am I here?’ - not everyone is religious: channelling those beliefs through specific practices and religious structures.
Spiritual and religious care
A growing body of evidence points to the fundamental difficulties that nurses experience when delivering patients’ spiritual needs, rooted primarily in ignorance of what spirituality is and how to deal with problems when they arise (Nathan, 2001; McSherry, 2001). However, a deep sense of spirituality and/or religion appears to promote a sense of health and well-being. Religious people tend to be healthier and live longer, although, paradoxically, they can suffer more when illness strikes if they view this as punishment from or desertion by God (Pargament et al, 2001; Benn, 2000).
However, as both Nathan (2001) and McSherry (2001) have suggested, nurses remain largely ignorant of the spiritual needs of their patients and how to meet them. It appears that they are fairly good at dealing with the ritualistic aspects of religions (special dietary needs, what to do in the event of death and so on), but very poor at meeting spiritual demands (‘What is happening to me nurse?’ ‘Why is this happening to me?’ ‘How will I cope?’). Perhaps this is not least because nurses have many personal uncertainties about their own spirituality as Snow and Willard (1991) and others have suggested.
There is a growing body of evidence to indicate a failure to attend to the spiritual needs of patients, but this extends to deep ignorance of the spiritual needs of those who care for them as well. This leads to serious difficulties for individuals and the organisations that seek to support them.
Stress and burnout
A number of studies have suggested that there are high levels of stress and burnout among health- care professionals, especially nurses (Health Education Authority, 1996; Borrill et al, 1998; Audit Commission, 1998; Williams et al, 1998). Furthermore, many of these studies point to factors other than just workload and low pay as the only or even the principal causes.
In a world where concerns about pay and conditions for nurses become the modus operandi of our trade unions and professional bodies, and where nurses do indeed experience low morale because of poor pay, it can seem somewhat politically incorrect to suggest that nurses problems lie anywhere else. Getting the pay and conditions right will obviously solve all the health-care system’s difficulties - or so it is often believed. However, in the long term, would the best pay and employment conditions necessarily reduce the exodus from nursing, the high levels of sickness and absenteeism, the regular reports of low morale? While pay is the issue that grabs the headlines, it seems that there may be other powerful forces at work that we have yet to tackle effectively.
Spirituality and nurses
On this basis, it is possible to argue that the crisis, which continues to affect so many nurses, is a spiritual one (Snow and Willard, 1991; Wright and Sayre-Adams, 2000). In other words, the roots of the problems lie not just in ‘structural’ matters (the way health services are organised and do or do not reward their staff), but also in ‘relational matters’ (how nurses feel connected to the organisation and their colleagues, how they feel about themselves and their place in the wider scheme of things, what meaning and purpose they find in their work). These factors relate to spirituality. The studies cited above, and those who have undertaken research on the nature of helping relationships, such as Dass and Gorman (1990), point to some specific difficulties that health-care workers such as nurses experience:
- Nurses identify themselves so closely with their role (‘I am a nurse’) that they find it difficult to let go. Constantly playing the part, like an actor in a soap opera, it is possible to lose the sense of who you really are. And, like actors condemned to always playing the same part, it is possible to burn out
- Trapped in the role of helping others, it is easy to neglect your own needs (it is easy to feel guilty if you don’t always put the patient first: ‘Are you sure you need that break/to go off on time/that holiday nurse; we are busy you know’)
- Many organisations are like dysfunctional families, energised by issues of power, control, threat and anger, rather than positive nurturing relationships. Professionals spend as much time in power struggles with each other or shoring up traditional roles and boundaries as they do caring for each other. Professionals and patients can exhibit similar power struggles
- Lost in others’ definitions of who you are and how you should behave, thousands of carers endure fundamentally unhappy relationships with colleagues and patients. Snow and Willard (1991) and Williams et al (1998) found 50% and 80% of nurses, respectively, were struggling in relationships at work and showed higher levels of stress than comparable groups. They had literally lost faith in their work, being caught up in hospitable cultures and the feeling that they should always be giving of themselves. Under such circumstances they became indifferent, sick or felt the need to ‘medicate the pain of their disease with alcohol, drugs, food, sex, spending, serial unhappy relationships and more’ (Snow and Willard, 1991).
A spiritual crisis - and spiritual solutions
Many nurses can find nursing a trap, not a liberating force to express compassion and who they really are. Nurses are more likely than many other groups to lose our sense of self in our work, to find meaning and purpose in a world where we deal with the suffering of others without attention to our own (Wright and Sayre-Adams, 2000). The situation is compounded by hostile working conditions: not just pay, but organisations that are fundamentally abusive, blaming and shaming; not just workload, but uncaring cultures and relationships with colleagues.
The crisis for nursing and nurses is therefore bigger than the simplistic view permeated in the media. For many nurses, it is a crisis of relationships; with others, with organisations and with ourselves. It is a crisis of meaning in our work where so many values seem to be turned on their heads; such as throughput and cost-effectiveness overtaking caring and compassion. It is a crisis where who you really are is lost in your surrender to others’ definitions of who you are.
Some might argue that stress and burnout problems could be resolved by giving nurses huge increases in pay and reducing workloads. Unfortunately, the problems are unlikely to be reduced by such a simple and seductive answer. Complex problems require complex solutions. Evidence from units where workloads and expectations are higher, yet with lower attrition rates, sickness, burnout and higher morale supports the view that other factors may be operating (Black, 1992; Salvage and Wright, 1995; Goleman, 1999). Stress and burnout are not only the products of workplace stress factors, but of domestic ones as well. Extra holidays might seem like a good idea, but seem to be unproductive in the long term; unless significant change takes place in the nurse and/or the workplace the same person returns to the same environment - and the problem recurs.
The Sacred Space Foundation has been set up to help nurses (Box 1; Box 2), but we are only dealing with the tip of the iceberg. If the problem is to be dealt with effectively, it is going to need to receive as much attention from the Government, unions, employers and professionals as is currently focused on nurses’ salary scales.
If the spiritual problems and crisis in nursing faced by staff cannot be tackled from a moral standpoint, that human beings deserve to be treated well in the workplace, then perhaps it can at least be approached from an economic one. Caring for staff by attending to spiritual needs, for example through programmes of meditation, team support, developing a sense of meaning and purpose in the workplace, connectedness and good relationships among colleagues, seem to be instrumental not only in making work a ‘great place to be’ (Hatfield, 1999), but is also a cost-effective option.
A recent large-scale study (Hatfield, 1999) found that organisations that paid attention to these issues were not only happier places to work, they were also more effective and profitable as well. Perhaps the message will someday percolate throughout our health services.
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