The nurses’ role in providing holistic care for a patient should include a spiritual assessment upon hospitalization. The question is, are nurses given the proper training on when to use an assessment tool and if so, how to plan care based on the results for a more holistic healing?
Providing spiritual care for patients becomes more complicated for the nurse as the definition of religion and spirituality seems to blend together. Addressing key nursing strategies, such as educating nurses on how to properly use a spiritual assessment tool, identifying what spiritual therapies are provided or available to patients, and what therapies nurses have found to be beneficial during the healing process are essential in allowing nurses to provide a plan of care that is focused on the overall holistic healing of the patient.
Nurses are in an excellent position to provide spiritual care to patients that can positively impact their healing process. Recognizing the patient’s spirituality may also help to enhance the nurse-patient relationship. Spiritual or holistic nursing is an area that has been neglected within nursing education. Concern over conflicting spiritual values between nurse educators, students, and patients may cause educators and students to avoid these difficult areas of care. (Lovanio & Wallace 2007). When approaching a patient about their spirituality, the nurse must be sensitive and cautious. Spiritual assessment and care should be based on a relationship of trust between patient and nurse. It will involve awareness of the person's culture, social and spiritual preferences, as well as a respect for their beliefs and religious practices. Spirituality is a core component of holistic healing as it provides the foundation for hope and faith that life will continue on through their sickness. When spirituality and emotional needs are not addressed, a patient’s hope can quickly turn to depression, their faith to disbelief, and their will to live can fade. Nurses are in an ideal position to provide spiritual care to patients but many are hesitant to because they lack the experience and education to do so.
Educating nurses on how to properly use a spiritual assessment tool to address patient’s needs is a crucial part of the solution. According to Power (2006), one problem nurses run into in America is that spirituality is often linked to religion. With spirituality being such an important part of the health assessment, nurses are struggling with ways to integrate any assessment tool that is acceptable for everyone. There are several different tools used but the most effective tool is simply using general observation and encouraging patients to talk about their spirituality. Power (2006) states that for nurses to be more sensitive to a patient’s culture and religious practices, a nurse might simply ask what a patients’ belief system is and if there is a pressing concern. Nurses might also consider taking a simple spiritual history. This history should address the patient's spiritual attitudes and value system, spiritual development, and sense of meaning and purpose spirituality may play in the patient's life. The biggest problem found in hospitals is nurses admit they need more education in conducting a spiritual assessment and feel they would be better prepared if there was a way to combine an informal assessment with a more specific assessment tool such as a spiritual history (Power 2006). No matter when, how, or what assessment tool is used, nurses agree that by gaining valuable information about the patients spirituality can be vital to their healing.
While educating nurses is important, another key strategy is identifying what spiritual therapies are available to the patient. Since many nurses feel they are undereducated when it comes to spiritually assessing their patients, Grant (2004) says that nurses are equally unaware of the different interventions and therapies available to their patients. Spiritual interventions should not be limited to services provided by a chaplain or priest but should also include more basic human needs. Some simple therapies that could be given to patients include things such as touch, therapeutic conversation, listening, prayer or meditation, or a referral to other resources inside or outside of the hospital.
Many patients do not think to ask nurses for spiritual support. But if nurses provide simple therapies, then patients develop a bond with their nurse that will make it easier to seek the support they need. Other interventions that patients should be made aware of are alternative therapies such a biofeedback and acupuncture. No matter which therapies or interventions patients choose, nurses should make all options available and encourage patients to seek out what fits their needs and beliefs best.
Knowing what therapies are available is important, but also knowing what therapies and interventions other nurses have found beneficial can greatly impact nurse’s ability to make the biggest difference. Dembner (2005) concludes that many people use prayer as an acceptable belief or tool for healing their loved ones. The difference that prayer makes is to the patient’s spirit and the level of hope they have during their healing process. Other nurses say that their patients do not pray but like to meditate or take quiet moments to reflect on the past and future. Adopting a nursing philosophy that routinely includes therapeutic touch, active listening, appropriate humor, referral to a spiritual counselor and understanding can keep hope alive in patients when physical healing is not taking place. Healing of the soul can give the patient the peace they need to deal with the physical stress of the illness.
Educating nurses on how to approach a patient with spiritual needs is crucial if a patient’s hope is going to be kept alive. Holistic healing can only take place if the whole body is healing as one. Recognizing a nurses own limitations and knowing when to make a referral, or utilizing other members of the team is as important for spiritual care as it is for other aspects of care. Implementation of key nursing strategies such as educating nurses on how to properly use a spiritual assessment tool to address the patients needs, identifying what spiritual therapies are available, and what therapies nurses have found to be beneficial during the healing process are essential in allowing nurses to provide a plan of care that is focused on the overall holistic healing of the patient.
a. Intervention 1 – Educating nurses on how to properly use a spiritual assessment tool to address patient’s needs is crucial part of healing
i. disadvantage 1 – Nurses do not receive enough education in school to be able to use the spiritual assessment tool correctly
1. Nurses may lack the confidence to broach spiritual issues with patients and their families owing to limited dialogue on spirituality in education and practice.(Cavendish 2005) Most educational experience is limited in assessments practiced in nursing school or during a school’s clinical setting, with spiritual care inconsistently or infrequently addressed.
2.Cavendish, R., DiJoseph, J. (2005 July/Aug). Expanding the Dialogue on Prayer Relevant to Holistic Care. Holistic Nursing Practice. 19(4), 147-154. Retrieved February 4, 2008 from EBSOC Research Database.
ii. disadvantage 2 –Spirituality is difficult to teach to a wide range of people
1. There may be as many different spiritual values and beliefs as there are individuals. Varying spiritual values may make the range of spiritual interventions difficult
for nurses. The lack of emphasis on spiritual assessments and care in nursing school may be because some educators believe that spirituality cannot be taught, but must be modeled by nurse educators in order for students to learn to address the spiritual needs of patients. Nursing educators often lack spiritual education and are consequently ill-prepared to teach spiritual assessment and interventions to students.(Lovanio (2007) Plus, concern for conflicting spiritual values between nurse educators, students and patients, may cause nurse-educators to avoid these difficult areas.
2. Lovanio, K., & Wallace, M. (2007 Jan/Feb). Promoting Spiritual Knowledge and Attitudes: a student nurse education project. Holistic Nursing Practice, 21(1), 42-48. Retrieved January 3, 2007 from Expanded Academic ASAP database.
b. Intervention 2 –Identifying what spiritual therapies & interventions other nurses have found beneficial can greatly impact nurse’s ability to make the biggest difference
i. disadvantage 1 – Spiritual care is not clearly defined
1. Nurses are often not comfortable providing spiritual care and they may not be able to distinguish spiritual needs from religious needs. Cavendish found that spiritual care activities are not clearly defined in the nursing education, and few spiritual care interventions are outlined in nursing care books to guide nurses with their care. The private nature of spirituality may be another reason that spiritual interventions are not initiated.
2. Cavendish, R., Konecny, L., Mitzeloitis, C., Russo, D. (2003 Oct-Dec). Spiritual Care Activities of Nurses Using Nursing Interventions Classification (NIC) Labels. International Journal of Nursing Terminologies and Classifications. Retrieved February 4, 2008 from http://findarticles.com/p/articles/mi_qa4065/is_200310/ai_n9312174/pg_7
ii. disadvantage 2 – Many time spiritual care and interventions are not notated in the patients charts
1. Spiritual care activities (eg, praying with patients or supporting their prayer activities) are rarely found in nursing notes. If nurses are providing spiritual care, many times it is not being documented correctly. In a 2004 study some nurses claim the reason they do not document the type of spiritual care they provided is because they do not know how to document it. Typically, the only reference to spirituality in acute care settings relates to asking if patients would like to visit with a chaplain.
2. Grant, Don. (2004 Jan/Feb). Spiritual interventions: How, when, and why nurses use them. Holistic Nursing Practice, 18 (1), 36 – 42. Retrieved January 3, 2007 from Expanded Academic ASAP database.
References
Cavendish, R., Konecny, L., Naradovy, L., Kraynyak Luise, B., Como, B.,Okumakpeyi, P., Mitzeliotis, C., & Lanza, M. (2006 Jan/Feb). Patients' perceptions of spirituality and the nurse as a spiritual care provider. Holistic Nursing Practice, 20(1), 41-48. Retrieved January 3, 2007 from Expanded Academic ASAP database.
Cavendish, R., DiJoseph, J. (2005 July/Aug). Expanding the Dialogue on Prayer Relevant to Holistic Care. Holistic Nursing Practice. 19(4), 147-154. Retrieved February 4, 2008 from EBSOC Research Database.
Cavendish, R., Konecny, L., Mitzeloitis, C., Russo, D. (2003 Oct-Dec). Spiritual Care Activities of Nurses Using Nursing Interventions Classification (NIC) Labels. International Journal of Nursing Terminologies and Classifications. Retrieved February 4, 2008 from http://findarticles.com/p/articles/mi_qa4065/is_200310/ai_n9312174/pg_7
Dembner, A. (2005, July 25). A Prayer for health. The Boston Globe, Retrieved March 15, 2007.
Grant, Don. (2004 Jan/Feb). Spiritual interventions: How, when, and why nurses use them. Holistic Nursing Practice, 18 (1), 36 – 42. Retrieved January 3, 2007 from Expanded Academic ASAP database.
Lovanio, K., & Wallace, M. (2007 Jan/Feb). Promoting spiritual knowledge and attitudes: a student nurse education project. Holistic Nursing Practice, 21(1), 42-48. Retrieved January 3, 2007 from Expanded Academic ASAP database
Power, Jeanette. (2006 March). Spiritual assessment: developing an assessment tool. Nursing Older People, 18 (2), 16-21. Retrieved January 3, 2007 from Expanded Academic ASAP database.
Ray, Rebecca. (2004 February). The faith connection. Retrieved February 4, 2007 from http://www.nurseweek.com/news/features/04-02/faith_3.asp
Sunday, February 24, 2008
Carl C Ineffective Management of Chronic and Acute Pain
Ineffective management of chronic and acute pain by nursing and other medical staff because of inadequate treatment, education and cultural misconceptions, is a continuing barrier to achieving client wellness. This situation is not a recent development and can be mitigated through the implementation of several strategies of which the nursing cohort is the prime driver.
These strategies include educating nurses to perform adequate and regular pain assessments. These assessments require that the nurse listen to what the client is saying about their pain levels and experience. In addition, the nurse needs to develop awareness in others of cultural and social constructs that create misconceptions surrounding pain and pain treatment therapies. Lastly, the nurse must have the ability to formulate effective strategies to break down these misconceptions of all the involved parties and ultimately, help the client.
Pain is described as;“ A sensation in which person experiences discomfort, distress or suffering due to the provocation of sensory nerves.” (Thomas, 1973) Taber’s then goes on to describe ninety seven different types of pain, demonstrating that pain is a highly complicated subject matter ranging from the metaphorical to sequlae of a specific medical condition. Regardless of the neurological response generated, pain impacts wellness. Acute pain is generally short in duration but severe, such as the pain generated from a surgical procedure or accident. It is expected to abate or at worst convert to chronic pain. Chronic pain is long term and constant, such as the pain of arthritis or cancer. Pain can impact an individual’s ability to lead a participatory life or a patient’s ability to recover from an illness. Pain can impact mental health, acuity and, pain can result in a lifetime of searching for relief (Fine & MacLow, 2006). In her article Managing Chronic Pain (2002), Michelle Meadows relates the story of a woman’s 30 year search for relief from pain resulting from injuries received in a skiing accident. Her search involved multiple surgeries, some of dubious value, therapies, depression and numerous healthcare workers who offered little help or hope.
One strategy for improving outcomes is educating nurses. A qualitative study conducted in a series of Colorado Long Term Care (LTC) facilities found that 25-33% of the residents experience moderate to severe pain on a daily basis (Clark, Fink, Pennington & Jones 2006). Data from this study indicates that this issue is related to inadequacies of the care staff involving training, basic philosophies and communication among the staff and clients, all correctable factors (Clark, Fink, Pennington & Jones 2006). Education of the nursing and support staff caring for these individuals is critical to improving this situation. Regular and complete assessments for pain must be completed on all clients under care. There are numerous tools available to make these assessments complete and in a common format that all care providers coming in contact with these clients can understand and use to the client’s benefit. The most common tool in use is the very effective 0-10 scale. This tool needs to be augmented with observations made by the managing nurse and include input from support staff who may very well have more contact with the client. Proper communication of the client’s reaction to the multitude of stimuli encountered is as important as the formal assessments and needs to be part of the treatment plan.
Another strategy involves specific cultural issues surrounding how a client may deal with or express pain. Strategies that resolve these issues need to be understood and incorporated into daily care. A known example of this is individuals from some Asian cultures will readily accept pain relief if they are asked several times. They simply feel it is impolite to accept the offering immediately and expect that it will be offered a second time. In this instance, offering pain relief to this client one time and walking away under the assumption they are able to tolerate their pain is an error in care. An adjunct to this is having this specific knowledge and not communicating it to other care staff. In some ways this is no different than ignoring the client’s pain altogether. Key information such as this needs to be available to all the care givers requiring clear and adequate communication are part of the routine of daily care.
A third strategy involves the clarification of misconceptions surrounding pain in general and treatments for pain. In addition to factors elucidated in the LTC study regarding how social constructs impact how pain is treated another issue involves direct treatments for pain. Often times the most effective therapies for pain is the use of opioid drugs or narcotics. While their proper use is known and accepted in much of the medical community, societal controls over these substances places blocks to their proper and effective application. Physicians and practitioners wanting to prescribe these materials are faced with regulations governing their use that are so onerous these professionals physicians often use less effective therapies (Berry & Dahl 2007). Patients and family members often question the use of these therapies based on a fear of addiction and place a self imposed stigma on their use, a situation largely derived from their own ignorance (Mercadante 2007).
The technology and techniques to effectively manage pain already exist. Through the implementation of strategies that include educating nursed in proper assessments, secondly improve social and cultural awareness and lastly that address misconceptions that hinder treatment these techniques can be better utilized. In many instances the barriers to their implementation are created by the very professionals meant to administer these therapies (Berry & Dahl 2007). As primary caregivers the ranks of professional nurses are in an ideal position to make these changes across the entire spectrum of healthcare.
Intervention One
Educate professional care giving staff to adequately assess and treat pain
Disadvantage 1
Currently there are multiple tools in use to measure or attempt to quantify pain. This includes the visual analogue scale (VAS), the numeric rating scale (NRS), the verbal rating scale (VRS), the category ratio (CR-10 scale) and McGill pain questionnaire (Ergun et al, 2005). What is to be taught and how is it to be taught. Are the existing tools up to the task of providing a universal description of pain and quantifying it. Are the existing tools up to the task interpreting across the breadth of cultural and educational diversity that health care professionals are required to address. At this point in time the answers for these questions is not a definitive yes, there are still tools in development that may be more effective. So the question is what is to be taught.
Ergun, U et al, Trial of a New Pain Assessment Tool in Patients With Low Education: The Full Cup Test. International Journal of Clinical Practice 63(3) 2005, Retrieved February 2, 2008 from Medscape Nursing Search. <>
Disadvantage 2
Pain and its assessment is by nature subjective, what is tolerable to one person is not to another. Pain is also a symptom of a condition that may or may not be identified. In this case therapies for pain relief mask the existence of underlying pathology which may go untreated. With these instances in mind, is it even reasonable to assume that effective assessments for pain and the implementation of effective therapies can be adequately taught. A simple 0-10 scale is may not be adequate to the task at hand. (Vallerand et al, 2007).
Hazard Vallerand et al, Knowledge of and Barriers to Pain Management in Caregivers of Cancer Patients Receiving Homecare. Cancer Nursing, 2007, 30(1):31-37, Retrieved February 2, 2008 from Medscape Nursing Search. <>
Intervention 2
Removal of barriers to effective pain control
Disadvantage 1
Many of the most effective therapies for pain relief involve the use of opiates, the ability to use these medications more freely would improve pain control. The vast majority of the governments in the world place heavy regulation on the use and distribution of these dangerous chemicals for good reason. Reducing the control mechanisms already in place over these materials would reduce the responsibilities associated with their prescription and dispensing(Mercadante 2007). Given the potential for abuse and danger here facilitating their use is unwise.
Mercadante, S. (2007). Why are our patients still suffering pain? National Clinical Practice Oncology 4(3) pp 138-139. Retrieved April 19, 2007 from Medscape Today Search. <>
Disadvantage 2
Fear of addiction is a very legitimate fear and a distinct possibility where the regular use of strong pain medications is involved. A patient’s or their family’s concern over this matter is well placed. In many instances the populations of not only inner city but urban hospitals display drug seeking behaviors (McCaffery et al, 2007). Are these individuals in pain or are they seeking an alternate source to better serve their additions. Is it the job of the medical community and the population of those responsibly insured to support these actions. Can a medical system that is not capable of providing services to the population as a whole afford to support addictive behavior (Levine et al, 2007).
McCaffery et al, On the Meaning of "Drug Seeking" Pain Management Nursing 8(3) 2007, Retrieved February 2, 2008 from Medscape Nursing Search. <>
Levine et al, Improving Access to Health Care: A Consensus Ethical Framework to Guide Proposals for Reform. The Hasting Center Report, 2007;37(5):14-19. Retrieved February 2, 2008 from Medscape Nursing Search. <>
Bibliography
Berry, P.; Dahl, J., Advanced Practice Nurse Controlled Substances Prescriptive Authority: A Review of the Regulations and Implications for Effective Pain Management at End-of-Life. Medscape Nurses. Released October 30, 2007. Retreived November 6, 2007 from Medscape Nursing Search.
Clark, L, Fink, R, Pennington, K & Jones, K, (2006) Nurses' reflections on pain management in a nursing home setting. Pain Management Nursing 7(2) pp 71-77, Retrieved April 13, 2007 from Medscape Today Database.
Ergun, U et al, Trial of a New Pain Assessment Tool in Patients With Low Education: The Full Cup Test. International Journal of Clinical Practice 63(3) 2005, Retrieved February 2, 2008 from Medscape Nursing Search. <>
Fine, P. & MacLow, C., (2006). Principles of effective pain management at the end of life. Medscape CME/CE Activity. Released October 5, 2006. Retrieved April 19, 2007 from Medscape Today Search. <>
Hazard Vallerand et al, Knowledge of and Barriers to Pain Management in Caregivers of Cancer Patients Receiving Homecare. Cancer Nursing, 2007, 30(1):31-37, Retrieved February 2, 2008 from Medscape Nursing Search. <>
Levine et al, Improving Access to Health Care: A Consensus Ethical Framework to Guide Proposals for Reform. The Hasting Center Report, 2007;37(5):14-19. Retrieved February 2, 2008 from Medscape Nursing Search. <>
McCaffery et al, On the Meaning of "Drug Seeking" Pain Management Nursing 8(3) 2007, Retrieved February 2, 2008 from Medscape Nursing Search. <>
Meadows, M. (2004, March-April ). Managing chronic pain. FDA Consumer Magazine. Retrieved April 13, 2007. <>
Mercadante, S. (2007). Why are our patients still suffering pain? National Clinical Practice Oncology 4(3) pp 138-139. Retrieved April 19, 2007 from Medscape Today Search. <>
Thomas, C. L. (Ed.). (1973). Taber’s cyclopedic medical dictionary (12th ed.) p-4. Philadelphia, PA: Davis.