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Using research skills to inform the teaching of spirituality
Article
Using research skills to inform the teaching of spirituality Georgina Hawley and Peter Charles Taylor
Spirituality, a basic characteristic of all people, is vital to health (Carson 1989; DeLaune 1998) and therefore knowledge about this phenomenon is important for nurses. Australia’s population has been defined as multicultural with successive Governments encouraging the maintenance of peoples’ cultural heritage. Moreover, the Australian Council of Healthcare Standards (ACHS) state that nurses will meet the spiritual needs of individual patients (ACHS1995,19951997). The difficulty for Australian nurses is that no research has been conducted to ascertain the spiritual needs of patients and/or clients from the differing multicultural groups. In order to gain knowledge and understanding of patients and/or clients’ spiritual needs I utilised the research skills of data collection and analysis. I then used the embodied themes from the data to inform my teaching in order that students would gain applicable knowledge and understanding about spirituality that was inclusive of the various multicultural groups. Although this project was conducted in Western Australia, the method could be adopted by nurses elsewhere in order to understand more about the spirituality of the population in which they practice. c 2003 Elsevier Ltd. All rights reserved.
Introduction Georgina Hawley PhD MSc (Nurs) Dip THEOL, BAppSci (Nursing) Senior Lecturer, School of Health Care, Oxford Brookes University, Oxford, UK. Tel.: +44-1793498653; Fax: +44-1793498423. Peter Charles Taylor PhD, MEd, BSc, DipEd Senior Lecturer, Science Education, Curtin University of Technology, Perth, Australia. (Requests for offprints to GH) Manuscript accepted: 7 November 2002
The aim of this paper is to describe how I (the first author) utilised the research skills of data collection and analysis in order to gain knowledge and understanding of spirituality within the population of Western Australia. This became necessary when I realised there was a discrepancy between the concept of spirituality that students spoke about in the lectures and tutorials that I was conducting and that published in nursing literature (Hawley 1994). When pondering on the problem I realised the importance of finding out more about spirituality from a multicultural perspective. This was because very little research has been conducted into the subject of health care related spirituality; immigration to Australia between 1902 and 1975 was restricted by the ‘White Australia Policy’ and therefore certain cultural and spiritual groups were excluded; since the abolition of this policy various racial and cultural groups have taken up residence in
204 Nurse Education in Practice (2003) 3, 204--211
Australia (e.g., Indian, Chinese, Burmese, African, Indonesian, Laotians, Vietnamese, and those from Middle and Eastern Europe). However, the long period of Anglo-Celtic Judeo-Christian traditions has created a climate of cultural elitism favouring the spiritual needs of this dominant cultural group (Mackay 1993). In addition, the introduction of the Australian Council for Health Services (ACHS) standards require nurses to meet individual patient’s spiritual needs has raised the urgency of identifying the extant spiritual needs of the multicultural Australian population. The importance of teaching nurses about spirituality lies in the fact that it is a dimension within all people and, therefore, all people have potential spiritual needs, whether they are religious or not (Benner Carson 1989). Several nursing and psychology researchers found that spirituality can be a positive internal influence on illness behaviour (Bearon & Koenig 1990; Carroll 1991; Fry 1990; Jalowiec & Powers 1981; King 1985; Leininger & Watson
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Using research skills to inform the teaching of spirituality
1990; Miller 1985; Sodestrom & Martinson 1987; Sutton & Murphy 1989). For example, Muslims regard hardships and suffering in life as tests by God of their faith (Morgan & Lawton 1996). In contrast, some chronic illnesses and the associated treatment may not be accepted in some spiritual communities and churches and, therefore, the patients’ spiritual support network may not be regarded as support or a coping mechanism for patients at that time. For example, an illness, which could be related to sexual activity such as sexually transmitted disease, or HIV/AIDS, may result in a patient and/or client being punished by their spiritual community (Belcher et al. 1989). Similarly, with haematology for Jehovah’s Witness patient and/or client, some forms of haemopoietic stem cell transplantation would not be accepted by their church elders. The first part of this paper discusses the gathering of data about the multiculturalism and spirituality in Western Australia. The second explains what I discovered when analysing the data and the finding of how a conceptual model can represent the relationship between various components or themes of spirituality. The final section describes how I used the findings in teaching. I believe that nurses in other countries could use these same skills of data collection and analysis in order to gain information about the spirituality for those to whom they provide care.
Collecting data on spirituality In utilising research skills, I recognised I needed to find data in relation to the incidence of multiculturalism in Western Australia, their nature, location, and spiritual beliefs. To locate the incidence of multiculturalism I consulted the most recent Census (Australian Bureau of Statistics 1996) in Western Australia. The census included such facts as: 32% of the population (all age groups) were not born in Australia but came from other countries. Of the 68% of people born in Australia, 53% were from parents born overseas from the following countries. When the figures of Tables 1 and 2 are added together it is noticeable that a large percentage
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Table 1 Country of birth and number of residents from that country in Western Australia Europe and the Former USSR Asia and Africa America
305,296 57,280 13,728
Table 2 Country of birth of parents whose children were born in Western Australia Parents country of birth UK and Ireland Asian New Zealand Southern European Western Europe Eastern Europe North America Middle East Chile
Population 214,547 62,189 39,613 28,578 21,134 12,899 8834 2358 1162
Percentage (%) 32.52 8.48 5.3 3.71 2.65 1.39 1.06 0.5 1.06
(85%) of Western Australians are relatively new arrivals, that is they were born outside of Australia or their parents were. Moreover, because these figures were collected in 1996, it is likely that the next census will reveal greater diversity in cultures because Australia has, in recent years, accepted more refugees from Vietnam, Burma, Cambodia, Kosova, Iran, Iraq, Afghanistan, and Africa. This would mean that by settling in Australia these newly arrived people would probably want to continue to practice their spiritual beliefs from their home culture and/or country which may well be different from other Australians. Although, the multicultural diversity does not indicate the spirituality groupings of overseas migrants to Western Australia (Mackay 1993), this can be surmised by comparing the different tables in the Census statistics. These were: (1) suburb of residence, (2) with country of birth, and (3) religious group (Australian Bureau of Statistics 1996). Also, it is known that people from many overseas countries will possibly be from a predominant spiritual group. For example, the majority of people who emigrate from Italy to Australia are Roman Catholic, and from Greece, Greek Orthodox (Church Life Survey 1999). The next step in collecting data was to obtain information about the spiritual beliefs of the different multicultural groups in Western Australia. I knew that various religious
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churches and other spiritual groups would be listed in telephone directories, and so I wrote a letter to each group, including churches, spiritual sects, philosophical groups, and multicultural associations. The letter stated that I was university lecturer seeking information about differing spiritual groups for teaching and research purposes. The letter requested material that had been published by the group that would supply me with sufficient information concerning each group’s identity, and questions pertaining to: 1. The origin of the group; 2. Beliefs and rituals; and 3. How these might affect health care should one of their members need treatment. 4. I especially wanted to know which expressions of spirituality would affect: 5. Birth control, termination of pregnancy, pregnancy, child birth, modesty; 6. Blood transfusion, bone marrow transplantation; 7. Medication, pain and suffering; and 8. Death, organ transplantation, and care of the body after death (including specific funeral beliefs). This, I felt, was important information that would enable nurses to respond to their patients and clients in a sensitive manner (Leininger & Watson 1990). Furthermore, because the anticipated responses from the various groups would be voluntary and the information sought from material published by the groups this would meet the ethical standards for both teaching and research. A total of 110 letters was posted in August 1998 and a 50% response rate resulted. Twenty letters were ‘‘returned to sender’’, as the post office had not been able to deliver them to the rightful owner/addressee. Of the remaining 30 letters, I received no response, and assumed that the group did not want to have contact.
Analysing the data collected The material sent to me included letters, pamphlets, books, journals, and invitations to visit the organisation or group came from the following named groups (that is, their official name).
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Aboriginal Bible Fellowship, Anglican, Anglo-Catholic, Assembly of God, Bahai, Baptist, Brethren, Buddhist (four different types), Christian Science, Christian Spiritualism, Church of Christ, Church of Latter Day Saints, Disciples of Christ, Eckanker, Elder Troth, FoGuangShan Temple, Greek Orthodox, Humanist Society, Jewish, Lutheran, Muslim, Naturism, Ninja Society, Pagan Romany, Presbyterian, Reformed Church of Canning, Roman Catholic, Sikh Association, Spiritualist Christian Church, Supreme Master Ching Hi International Assoc., Taoist, Theosophical Society, The Religious Society of Friends, The Revival Fellowship, and Uniting Church. A response from the different spiritual groups, which was repeated on more than one occasion to me, was: Thank you for taking an interest in the spiritual aspect of health care. . .if there is any way in which we (the group) can be of further assistance please do not hesitate to contact us. Six respondents wanted to know why their local hospital and/or medical centre had not requested such information. To them, such information would be utilised more readily at the local level than in my university teaching. Some groups also invited me to meetings and festivities to see firsthand their rituals and activities. These included community meetings with The Society of Friends, Eckanker, meditation and vegetarian cooking classes at the Buddhist temple, a Retreat, New Year celebrations, and a Sikh convention. Letters were sent to all respondents thanking them for the material they had sent and for taking the time to answer my queries. When examining the material from the different groups I developed the following five classiffications or types of groups. Although these five groups are listed as distinct entities, some spiritual groups are a mixture of two or more. 1. Religious groups that had spiritual beliefs not of the Judeo-Christian tradition (Bahai, Buddhist, Eckanker, Muslim, Sikh Assoc., and Taoist).
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Using research skills to inform the teaching of spirituality
2. Judeo-Christian churches, including Eastern Orthodox (Anglican, Anglo-Catholic, Assembly of God, Baptist, Brethren, Christian Science, Church of Christ, Church of Latter Day Saints (some Christian groups do regard this group as a religion and would have allocated to the above non-Judeo-Christian groups) Disciples of Christ, Greek Orthodox, Jewish, Lutheran, The Religious Society of Friends, The Revival Fellowship, Presbyterian, Quakers, Reformed Church of Canning, Roman Catholic, Uniting Church). 3. Philosophical groups (Humanist Society, Naturism, and Theosophical Society). 4. Mythical spiritual groups (The Dreamtime or Dreaming), and those that had the word ‘pagan and/or heathen’ within their name (Elder Troth, Pagan Romany). These were coupled together as both believe in more that one god or spirit. 5. A group of organisations that declared they were not a religion or a spiritual group per se, but rather an organisation that taught methods for people to gain closer contact with their own god/s for enlightenment (Supreme Master Ching Hi International Assoc., FoGuangShan Temple, Ninja Society). I then used the computer narrative analysis software package ‘‘HyperResearch’’ (HesseBiber et al. 1995) to assist in further analyses of the data. The first task was to identify repeated themes within the data and the possibility of interrelationships (Benner 1994). These major themes were: 1. Focus, or core component, of the group, such as God/s or Higher Power. 2. Truths or beliefs of the group. 3. Manner in which members can access their focus (core component, God or Higher Power). 4. Peoples’ or members’ manifestations and expressions of their spirituality, that is, the expressions people would use in acting out their beliefs or truths. In trying to clarify the relationship between the four identified themes I drew diagrams (Denzin & Lincoln 2000). In portraying visually the inter-relationship between these themes (see Fig. 1), I realised that the diagram
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Fig. 1
‘‘provided a way to visualise reality to simplify thinking’’ (Leddy & Pepper 1993, p. 145), and could be termed a model, or a representation, of the interaction amongst and between concepts, showing patterns. The model includes not only the focus of a patient and/or client’s spirituality, but also the focus of health care -- that is, the person (Madjar & Walton 1999). I realised that inclusion into the schema of the patient and/or client’s spiritual values would allow a nurse to identify possible conflict between proposed treatment and the patient and/or client’s spiritual beliefs. For example, a spiritual group might condemn abortion, but a patient and/or client from that group might feel that abortion would be the right thing to do in given circumstances. I decided that the appropriate place for the patient and/or client’s perspective would be next to the focus of the groups, but opposite the group’s beliefs. I felt comfortable with this model, as I believed it could be used to define the potential content of a patient and/or client’s spirituality. This framework would also enable nurses to develop their understanding of the spiritual, ethical, and religious dimensions of human experiences, including their own. As such, it serves as a map of the knowledge that I believe nurses need if they are to function in an inclusive manner within diverse and pluralist communities.
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The emergent model was checked to see if it fitted the information I received from all of the various spiritual groups. To use the model in clinical practice, a nurse would ask questions to elicit answers from the patient and/or client to procure the necessary information. Once the data are obtained then the nurse would be in a position to facilitate and/or optimise spiritual care. The questions would need to be similar to the following: 1. What is it in your life that gives you meaning and purpose? 2. Is this meaning and purpose associated with a spiritual or religious group? If so what are these beliefs? 3. What is your own perception/perspective of these beliefs? 4. What ways do you use to communicate with the deity, power, focus, or orientation? And/or to understand the beliefs and/or truths? 5. What expressions (behaviours/actions/ rituals) of spirituality do you like to use? 6. What rituals and/or artifacts give you/or would give you comfort and strength? Only when the nurse has data from all six questions would s/he be in a position to facilitate the spiritual health of the patient and/ or client.
Using the findings to inform teaching The findings of this project can be used in several ways. The first, is that other teachers of nursing can undertake a similar project to discern the spiritual needs of their local population. Second, the questions could be used by practicing nurses to discern the spirituality and related needs of patients and/ or clients. The third use of the findings is the utilisation of the emergent model in teaching. The emergent model illustrates a shared experience of humanity, that is, that all people have a spiritual quality, and therefore this is something that we have in common and can share with others. My greatest use of the model has been in teaching, at both undergraduate and postgraduate levels and in continuing education programs that include spirituality. In teaching I
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have found that it helps nurses understand their own spirituality and also that of the patient and/or client they are caring for. That is: • Using the interrelationship of the themes to explain the components of spirituality so that students are more readily able to understand the whole phenomenon of spirituality. • Facilitating the students’ use of the emergent model to help them identify their own spirituality. • Clarifying personal spiritual beliefs and values in relation to the patient and/or client being cared for. • Early identification of possible incompatibility between the patients and/or client’s spiritual beliefs and proposed health care treatment. In teaching I found that these points are similar but at the same time have different uses in helping practicing nurses understand the phenomenon of spirituality. Using each of the points the following section describes my use of the emergent model in teaching.
Using the interrelationship of the themes to explain the components of spirituality In the past I had found that students had difficulty in understanding the concept of spirituality. However, with the use of the model I am able to explain the components or themes of spirituality and how these relate to each other. This is particularly so of the relationship between beliefs, and the acting out those beliefs through behaviours. For example, the patient and/or client who is Orthodox Jew and who has spiritual beliefs about God and food will manifest these through the preparation and eating of certain foods (including the prayers communicated to God prior to eating). By using the model I can explain that beliefs and values can be acted out or manifested as behaviours by the patient and/or client.
Facilitating the students identification of their own spirituality In helping students to understand about their own spirituality I inform them of the components (or themes) that are present in the
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Using research skills to inform the teaching of spirituality
emergent model and the questions that they can ask themselves. They then answer the questions individually and then discuss their answers (if they wish) in small groups. During the group work I hear conversations such as ‘oh I never knew that before’, ‘now that is interesting’, ‘is that why you have two kitchens in your home’, or ‘now you know why I don’t eat lunch at uni at that time’. This sharing of information is done on the understanding that all members abide by the ground rules of group work (e.g., confidentiality, respect for another, being non-judgmental, etc.). It usually is not very long before one of the students realises that there are other people in the geographical area of the hospital or organisation that are not represented by some one in the lecture. The students are concerned by the need to know more about the people for whom they provide care. So they organize themselves to get information about all the spiritual groups in their area.
Clarifying personal spiritual beliefs and values in relation to the patient Sometimes I give a concrete example of a spiritual behaviour and illustrate how the model can help me to move towards an adequate knowledge and understanding of what is going on, and at the same time clarify my own values. For example, I can show the students a photograph/s of a Muslim woman performing ritualised washing (‘wudu’) before prayer. I then explain that if my understanding is limited to only the knowledge that Muslims are required to perform this ritual as part of their prayer five times a day, then my awareness is only superficial and does not connect with my spirit or spirituality. In order to humanly (and spiritually) connect with this woman, what I need to do is also to explore some of the ways in which this action (and associated beliefs) are related to the experience of being human in which this woman, myself, and all others participate, that is, the shared human experience of spirituality (Watson 1997). From my perspective, I can guess that these actions and the Islamic beliefs that lie behind and are expressed through them focus on the qualities of purity and cleanliness (as major contributors
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to human physical, emotional, and spiritual health). In this way this new understanding and awareness of Muslim purity can help me to understand the Muslim patient and/or client whom I may nurse. At the same time the exercise can help me to articulate my own beliefs and values about spiritual purity and how these may be expressed or not in my own life style. Once the students understand about their own spirituality they are then more capable of providing spiritual care to those patient and/or clients that they nurse.
Early identification of possible incompatibility between beliefs and treatment In teaching the legal and ethical aspects of nursing I recommend that the students use the model and related questions when assessing patients and/or clients. If this is done prior to planning and the discussing proposed treatment plans, the nurse can readily realise the extent of the spiritual beliefs and therefore not be surprised if various aspects of treatment are rejected. In this way, the model helps the nurse to support the patient and/or client in their decision; instead of arguing and trying to get them to agree with treatment they do not want. That is, this model also allows nurses to recognise why some people accept or refuse treatment. For example, a seriously ill patient who needs a blood transfusion to survive may be a Jehovah’s Witness, and therefore it would be wrong in the eyes of their church to accept blood transfusion as treatment. By using the model, the nurse would know of this belief. However, the nurse would still need to clarify this belief with the patient in case there was a disparity between the teaching of the church and the patient’s perception of the beliefs. However, if the Jehovah’s Witnesses’ beliefs corresponded with those of their church then the doctor could follow the legal guidelines of allowing the patient to refuse the treatment (Hawley 1997; Wallace 1995). It also needs to be remembered that spirituality is more personal than religious beliefs (which express the doctrine of the church and are not necessarily the patient’s own spiritual needs). For example, a woman who belongs to a church that condemns
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abortion may not regard the status of her embryo or foetus as sacred, as does her church, and may wish to terminate the pregnancy. Therefore, on asking the woman about her individual spiritual beliefs, these can be documented, and information given about the possibility of terminating the pregnancy.
Summary When teaching the phenomenon of spirituality in relation to nursing practice, I discovered that the literature did not give me a good understanding of the subject nor did it reflect the cultural nuances particular to Western Australians. A project was planned to discover the nature of spirituality for Western Australians. This consisted of identifying and collecting data to support the extent of multiculturalism and also the range of spiritual groups. Once the information was obtained it was analysed to identify common or universal themes. It was discovered that the various spiritual groups had significant truths or beliefs, which were important components of their community member’s lives. The manner in which these beliefs could impact on health care treatment was realised, as well as the ways in which they may want to access the power, deity, or the orientation of spirituality while receiving health care. Questions were developed that would allow nurses to understand their patient’s or client’s spirituality (the basis of these questions is the common themes from the data). These questions were trialled with all the information received from a diverse range of religious and spiritual groups, and it was found compatible with my proposed model. What I had not realised was the ease with which the model and questions helped make sense of the information so that it could be readily understood by nurses. In my experience of using research skills of data collection and analysis to inform my teaching practice, I found not only greater personal knowledge and understanding of the subject in question, but also the importance of finding new knowledge that is appropriate and true for the context in which we nurse.
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References Australian Bureau of Statistics (1996) Census of population and housing: Western Australia. Commonwealth of Australia: Australian Bureau of Statistics Australian Council of Health Services (1995) The ACHS accreditation guide. (13th Ed). Sydney: The Australian Council of Healthcare Standards Ltd Australian Council of Health Services (1997) Equip standards. Sydney: The Australian Council of Healthcare Standards Ltd Bearon LB, Koenig HG 1990 Religious cognitions and use of prayer in health and illness. The Gerontologist 30:249--253 Belcher AE, Dettmore D, Holzmer SP 1989 Spirituality and sense of well being in persons with AIDS. Holistic Nurse Practitioner 3(4):16--25 Benner P (ed.) 1994 Interpretive phenomenology: embodiment, caring, and ethics in health and illness. Sage Publications, California Carroll S 1991 Spirituality and purpose in life in alcoholism recovery. Journal of Studies on Alcohol(May):297--301 Carson VB (ed.) 1989 Spiritual dimensions of nursing practice. WB Saunders, Philadelphia Church Life Survey (1999) Survey of Australian churches. Melbourne Victoria: Church Life Surveys DeLaune SC 1998 The individual, health and wellness. In: DeLaune SC, Ladner PK (eds.) Fundamentals of nursing: standards and practice. International Thompson Publishing, Mexico, chapt 3 Denzin NK, Lincoln YS 2000 Handbook of qualitative research. Sage Publication, London Fry PS 1990 A factor analytic investigation of home bound elderly individuals’ concerns about death and dying and their coping responses. Journal of Clinical Psychology 46(6):737--748 Hawley G (1994) The need for redefinition of spiritual distress in Australian nursing. Conference Proceedings Nursing Diagnosis Conference Perth WA 2nd--4th December Hawley G (ed.) 1997 Ethical workbook for nurses. Issues, problems, and resolutions. Social Science Press, Sydney Hesse-Biber S, Dupuis P R & Kinder T S (1995) HyperResearch 1.55. MA, USA: ResearchWare Inc Jalowiec A, Powers M 1981 Stress and coping in hypertensive and emergency patients. Nursing Research 30(1):10--15 King KB 1985 Measurement of coping strategies, concerns and emotional responses in patients undergoing coronary artery bypass grafting. Heart and Lung 14:579--586 Leddy S, Pepper JM 1993 Conceptual basis for nursing, 3rd ed. Lippincott, Philadelphia Leininger M, Watson J (eds.) 1990 The caring imperative in education. National League for Nursing, New York Mackay H 1993 Reinventing Australia: the mind and mood of Australia in the 90s. Angus and Robertson, Sydney Madjar I, Walton JA 1999 Nursing and the experience of illness: phenomenology in practice. Allen & Unwin, Sydney
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Using research skills to inform the teaching of spirituality
Miller JF 1985 Assessment of loneliness and spiritual well being in chronically ill and health adults. Journal of Professional Nursing 1:79--85 Morgan P, Lawton C 1996 Ethical issues in six religious traditions. Edinburgh University Press, Edinburgh Sodestrom KE, Martinson IM 1987 Patients’ spritual coping strategies. Oncology Nursing Forum 14(2):41--46
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Sutton TD, Murphy SP 1989 Stressors and patterns of coping in renal transplant patients. Nursing Research 38(1):46--49 Wallace M 1995 Health care and the law, 2nd ed. Law Book Company, Sydney Watson J 1997 Artistry of caring: heart and soul of nursing. In: Marks-Maran D, Rose P (eds.) Reconstructing nursing: beyond art and science. Bailliere Tindall, London
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Using research skills to inform the teaching of spirituality Georgina Hawley and Peter Charles Taylor
Spirituality, a basic characteristic of all people, is vital to health (Carson 1989; DeLaune 1998) and therefore knowledge about this phenomenon is important for nurses. Australia’s population has been defined as multicultural with successive Governments encouraging the maintenance of peoples’ cultural heritage. Moreover, the Australian Council of Healthcare Standards (ACHS) state that nurses will meet the spiritual needs of individual patients (ACHS1995,19951997). The difficulty for Australian nurses is that no research has been conducted to ascertain the spiritual needs of patients and/or clients from the differing multicultural groups. In order to gain knowledge and understanding of patients and/or clients’ spiritual needs I utilised the research skills of data collection and analysis. I then used the embodied themes from the data to inform my teaching in order that students would gain applicable knowledge and understanding about spirituality that was inclusive of the various multicultural groups. Although this project was conducted in Western Australia, the method could be adopted by nurses elsewhere in order to understand more about the spirituality of the population in which they practice. c 2003 Elsevier Ltd. All rights reserved.
Introduction Georgina Hawley PhD MSc (Nurs) Dip THEOL, BAppSci (Nursing) Senior Lecturer, School of Health Care, Oxford Brookes University, Oxford, UK. Tel.: +44-1793498653; Fax: +44-1793498423. Peter Charles Taylor PhD, MEd, BSc, DipEd Senior Lecturer, Science Education, Curtin University of Technology, Perth, Australia. (Requests for offprints to GH) Manuscript accepted: 7 November 2002
The aim of this paper is to describe how I (the first author) utilised the research skills of data collection and analysis in order to gain knowledge and understanding of spirituality within the population of Western Australia. This became necessary when I realised there was a discrepancy between the concept of spirituality that students spoke about in the lectures and tutorials that I was conducting and that published in nursing literature (Hawley 1994). When pondering on the problem I realised the importance of finding out more about spirituality from a multicultural perspective. This was because very little research has been conducted into the subject of health care related spirituality; immigration to Australia between 1902 and 1975 was restricted by the ‘White Australia Policy’ and therefore certain cultural and spiritual groups were excluded; since the abolition of this policy various racial and cultural groups have taken up residence in
204 Nurse Education in Practice (2003) 3, 204--211
Australia (e.g., Indian, Chinese, Burmese, African, Indonesian, Laotians, Vietnamese, and those from Middle and Eastern Europe). However, the long period of Anglo-Celtic Judeo-Christian traditions has created a climate of cultural elitism favouring the spiritual needs of this dominant cultural group (Mackay 1993). In addition, the introduction of the Australian Council for Health Services (ACHS) standards require nurses to meet individual patient’s spiritual needs has raised the urgency of identifying the extant spiritual needs of the multicultural Australian population. The importance of teaching nurses about spirituality lies in the fact that it is a dimension within all people and, therefore, all people have potential spiritual needs, whether they are religious or not (Benner Carson 1989). Several nursing and psychology researchers found that spirituality can be a positive internal influence on illness behaviour (Bearon & Koenig 1990; Carroll 1991; Fry 1990; Jalowiec & Powers 1981; King 1985; Leininger & Watson
1471-5953/$ - see front matter c 2003 Elsevier Ltd. All rights reserved. doi:10.1016/S1471-5953(03)00003-9
Using research skills to inform the teaching of spirituality
1990; Miller 1985; Sodestrom & Martinson 1987; Sutton & Murphy 1989). For example, Muslims regard hardships and suffering in life as tests by God of their faith (Morgan & Lawton 1996). In contrast, some chronic illnesses and the associated treatment may not be accepted in some spiritual communities and churches and, therefore, the patients’ spiritual support network may not be regarded as support or a coping mechanism for patients at that time. For example, an illness, which could be related to sexual activity such as sexually transmitted disease, or HIV/AIDS, may result in a patient and/or client being punished by their spiritual community (Belcher et al. 1989). Similarly, with haematology for Jehovah’s Witness patient and/or client, some forms of haemopoietic stem cell transplantation would not be accepted by their church elders. The first part of this paper discusses the gathering of data about the multiculturalism and spirituality in Western Australia. The second explains what I discovered when analysing the data and the finding of how a conceptual model can represent the relationship between various components or themes of spirituality. The final section describes how I used the findings in teaching. I believe that nurses in other countries could use these same skills of data collection and analysis in order to gain information about the spirituality for those to whom they provide care.
Collecting data on spirituality In utilising research skills, I recognised I needed to find data in relation to the incidence of multiculturalism in Western Australia, their nature, location, and spiritual beliefs. To locate the incidence of multiculturalism I consulted the most recent Census (Australian Bureau of Statistics 1996) in Western Australia. The census included such facts as: 32% of the population (all age groups) were not born in Australia but came from other countries. Of the 68% of people born in Australia, 53% were from parents born overseas from the following countries. When the figures of Tables 1 and 2 are added together it is noticeable that a large percentage
c 2003 Elsevier Ltd. All rights reserved.
Table 1 Country of birth and number of residents from that country in Western Australia Europe and the Former USSR Asia and Africa America
305,296 57,280 13,728
Table 2 Country of birth of parents whose children were born in Western Australia Parents country of birth UK and Ireland Asian New Zealand Southern European Western Europe Eastern Europe North America Middle East Chile
Population 214,547 62,189 39,613 28,578 21,134 12,899 8834 2358 1162
Percentage (%) 32.52 8.48 5.3 3.71 2.65 1.39 1.06 0.5 1.06
(85%) of Western Australians are relatively new arrivals, that is they were born outside of Australia or their parents were. Moreover, because these figures were collected in 1996, it is likely that the next census will reveal greater diversity in cultures because Australia has, in recent years, accepted more refugees from Vietnam, Burma, Cambodia, Kosova, Iran, Iraq, Afghanistan, and Africa. This would mean that by settling in Australia these newly arrived people would probably want to continue to practice their spiritual beliefs from their home culture and/or country which may well be different from other Australians. Although, the multicultural diversity does not indicate the spirituality groupings of overseas migrants to Western Australia (Mackay 1993), this can be surmised by comparing the different tables in the Census statistics. These were: (1) suburb of residence, (2) with country of birth, and (3) religious group (Australian Bureau of Statistics 1996). Also, it is known that people from many overseas countries will possibly be from a predominant spiritual group. For example, the majority of people who emigrate from Italy to Australia are Roman Catholic, and from Greece, Greek Orthodox (Church Life Survey 1999). The next step in collecting data was to obtain information about the spiritual beliefs of the different multicultural groups in Western Australia. I knew that various religious
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churches and other spiritual groups would be listed in telephone directories, and so I wrote a letter to each group, including churches, spiritual sects, philosophical groups, and multicultural associations. The letter stated that I was university lecturer seeking information about differing spiritual groups for teaching and research purposes. The letter requested material that had been published by the group that would supply me with sufficient information concerning each group’s identity, and questions pertaining to: 1. The origin of the group; 2. Beliefs and rituals; and 3. How these might affect health care should one of their members need treatment. 4. I especially wanted to know which expressions of spirituality would affect: 5. Birth control, termination of pregnancy, pregnancy, child birth, modesty; 6. Blood transfusion, bone marrow transplantation; 7. Medication, pain and suffering; and 8. Death, organ transplantation, and care of the body after death (including specific funeral beliefs). This, I felt, was important information that would enable nurses to respond to their patients and clients in a sensitive manner (Leininger & Watson 1990). Furthermore, because the anticipated responses from the various groups would be voluntary and the information sought from material published by the groups this would meet the ethical standards for both teaching and research. A total of 110 letters was posted in August 1998 and a 50% response rate resulted. Twenty letters were ‘‘returned to sender’’, as the post office had not been able to deliver them to the rightful owner/addressee. Of the remaining 30 letters, I received no response, and assumed that the group did not want to have contact.
Analysing the data collected The material sent to me included letters, pamphlets, books, journals, and invitations to visit the organisation or group came from the following named groups (that is, their official name).
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Aboriginal Bible Fellowship, Anglican, Anglo-Catholic, Assembly of God, Bahai, Baptist, Brethren, Buddhist (four different types), Christian Science, Christian Spiritualism, Church of Christ, Church of Latter Day Saints, Disciples of Christ, Eckanker, Elder Troth, FoGuangShan Temple, Greek Orthodox, Humanist Society, Jewish, Lutheran, Muslim, Naturism, Ninja Society, Pagan Romany, Presbyterian, Reformed Church of Canning, Roman Catholic, Sikh Association, Spiritualist Christian Church, Supreme Master Ching Hi International Assoc., Taoist, Theosophical Society, The Religious Society of Friends, The Revival Fellowship, and Uniting Church. A response from the different spiritual groups, which was repeated on more than one occasion to me, was: Thank you for taking an interest in the spiritual aspect of health care. . .if there is any way in which we (the group) can be of further assistance please do not hesitate to contact us. Six respondents wanted to know why their local hospital and/or medical centre had not requested such information. To them, such information would be utilised more readily at the local level than in my university teaching. Some groups also invited me to meetings and festivities to see firsthand their rituals and activities. These included community meetings with The Society of Friends, Eckanker, meditation and vegetarian cooking classes at the Buddhist temple, a Retreat, New Year celebrations, and a Sikh convention. Letters were sent to all respondents thanking them for the material they had sent and for taking the time to answer my queries. When examining the material from the different groups I developed the following five classiffications or types of groups. Although these five groups are listed as distinct entities, some spiritual groups are a mixture of two or more. 1. Religious groups that had spiritual beliefs not of the Judeo-Christian tradition (Bahai, Buddhist, Eckanker, Muslim, Sikh Assoc., and Taoist).
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Using research skills to inform the teaching of spirituality
2. Judeo-Christian churches, including Eastern Orthodox (Anglican, Anglo-Catholic, Assembly of God, Baptist, Brethren, Christian Science, Church of Christ, Church of Latter Day Saints (some Christian groups do regard this group as a religion and would have allocated to the above non-Judeo-Christian groups) Disciples of Christ, Greek Orthodox, Jewish, Lutheran, The Religious Society of Friends, The Revival Fellowship, Presbyterian, Quakers, Reformed Church of Canning, Roman Catholic, Uniting Church). 3. Philosophical groups (Humanist Society, Naturism, and Theosophical Society). 4. Mythical spiritual groups (The Dreamtime or Dreaming), and those that had the word ‘pagan and/or heathen’ within their name (Elder Troth, Pagan Romany). These were coupled together as both believe in more that one god or spirit. 5. A group of organisations that declared they were not a religion or a spiritual group per se, but rather an organisation that taught methods for people to gain closer contact with their own god/s for enlightenment (Supreme Master Ching Hi International Assoc., FoGuangShan Temple, Ninja Society). I then used the computer narrative analysis software package ‘‘HyperResearch’’ (HesseBiber et al. 1995) to assist in further analyses of the data. The first task was to identify repeated themes within the data and the possibility of interrelationships (Benner 1994). These major themes were: 1. Focus, or core component, of the group, such as God/s or Higher Power. 2. Truths or beliefs of the group. 3. Manner in which members can access their focus (core component, God or Higher Power). 4. Peoples’ or members’ manifestations and expressions of their spirituality, that is, the expressions people would use in acting out their beliefs or truths. In trying to clarify the relationship between the four identified themes I drew diagrams (Denzin & Lincoln 2000). In portraying visually the inter-relationship between these themes (see Fig. 1), I realised that the diagram
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Fig. 1
‘‘provided a way to visualise reality to simplify thinking’’ (Leddy & Pepper 1993, p. 145), and could be termed a model, or a representation, of the interaction amongst and between concepts, showing patterns. The model includes not only the focus of a patient and/or client’s spirituality, but also the focus of health care -- that is, the person (Madjar & Walton 1999). I realised that inclusion into the schema of the patient and/or client’s spiritual values would allow a nurse to identify possible conflict between proposed treatment and the patient and/or client’s spiritual beliefs. For example, a spiritual group might condemn abortion, but a patient and/or client from that group might feel that abortion would be the right thing to do in given circumstances. I decided that the appropriate place for the patient and/or client’s perspective would be next to the focus of the groups, but opposite the group’s beliefs. I felt comfortable with this model, as I believed it could be used to define the potential content of a patient and/or client’s spirituality. This framework would also enable nurses to develop their understanding of the spiritual, ethical, and religious dimensions of human experiences, including their own. As such, it serves as a map of the knowledge that I believe nurses need if they are to function in an inclusive manner within diverse and pluralist communities.
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The emergent model was checked to see if it fitted the information I received from all of the various spiritual groups. To use the model in clinical practice, a nurse would ask questions to elicit answers from the patient and/or client to procure the necessary information. Once the data are obtained then the nurse would be in a position to facilitate and/or optimise spiritual care. The questions would need to be similar to the following: 1. What is it in your life that gives you meaning and purpose? 2. Is this meaning and purpose associated with a spiritual or religious group? If so what are these beliefs? 3. What is your own perception/perspective of these beliefs? 4. What ways do you use to communicate with the deity, power, focus, or orientation? And/or to understand the beliefs and/or truths? 5. What expressions (behaviours/actions/ rituals) of spirituality do you like to use? 6. What rituals and/or artifacts give you/or would give you comfort and strength? Only when the nurse has data from all six questions would s/he be in a position to facilitate the spiritual health of the patient and/ or client.
Using the findings to inform teaching The findings of this project can be used in several ways. The first, is that other teachers of nursing can undertake a similar project to discern the spiritual needs of their local population. Second, the questions could be used by practicing nurses to discern the spirituality and related needs of patients and/ or clients. The third use of the findings is the utilisation of the emergent model in teaching. The emergent model illustrates a shared experience of humanity, that is, that all people have a spiritual quality, and therefore this is something that we have in common and can share with others. My greatest use of the model has been in teaching, at both undergraduate and postgraduate levels and in continuing education programs that include spirituality. In teaching I
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have found that it helps nurses understand their own spirituality and also that of the patient and/or client they are caring for. That is: • Using the interrelationship of the themes to explain the components of spirituality so that students are more readily able to understand the whole phenomenon of spirituality. • Facilitating the students’ use of the emergent model to help them identify their own spirituality. • Clarifying personal spiritual beliefs and values in relation to the patient and/or client being cared for. • Early identification of possible incompatibility between the patients and/or client’s spiritual beliefs and proposed health care treatment. In teaching I found that these points are similar but at the same time have different uses in helping practicing nurses understand the phenomenon of spirituality. Using each of the points the following section describes my use of the emergent model in teaching.
Using the interrelationship of the themes to explain the components of spirituality In the past I had found that students had difficulty in understanding the concept of spirituality. However, with the use of the model I am able to explain the components or themes of spirituality and how these relate to each other. This is particularly so of the relationship between beliefs, and the acting out those beliefs through behaviours. For example, the patient and/or client who is Orthodox Jew and who has spiritual beliefs about God and food will manifest these through the preparation and eating of certain foods (including the prayers communicated to God prior to eating). By using the model I can explain that beliefs and values can be acted out or manifested as behaviours by the patient and/or client.
Facilitating the students identification of their own spirituality In helping students to understand about their own spirituality I inform them of the components (or themes) that are present in the
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Using research skills to inform the teaching of spirituality
emergent model and the questions that they can ask themselves. They then answer the questions individually and then discuss their answers (if they wish) in small groups. During the group work I hear conversations such as ‘oh I never knew that before’, ‘now that is interesting’, ‘is that why you have two kitchens in your home’, or ‘now you know why I don’t eat lunch at uni at that time’. This sharing of information is done on the understanding that all members abide by the ground rules of group work (e.g., confidentiality, respect for another, being non-judgmental, etc.). It usually is not very long before one of the students realises that there are other people in the geographical area of the hospital or organisation that are not represented by some one in the lecture. The students are concerned by the need to know more about the people for whom they provide care. So they organize themselves to get information about all the spiritual groups in their area.
Clarifying personal spiritual beliefs and values in relation to the patient Sometimes I give a concrete example of a spiritual behaviour and illustrate how the model can help me to move towards an adequate knowledge and understanding of what is going on, and at the same time clarify my own values. For example, I can show the students a photograph/s of a Muslim woman performing ritualised washing (‘wudu’) before prayer. I then explain that if my understanding is limited to only the knowledge that Muslims are required to perform this ritual as part of their prayer five times a day, then my awareness is only superficial and does not connect with my spirit or spirituality. In order to humanly (and spiritually) connect with this woman, what I need to do is also to explore some of the ways in which this action (and associated beliefs) are related to the experience of being human in which this woman, myself, and all others participate, that is, the shared human experience of spirituality (Watson 1997). From my perspective, I can guess that these actions and the Islamic beliefs that lie behind and are expressed through them focus on the qualities of purity and cleanliness (as major contributors
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to human physical, emotional, and spiritual health). In this way this new understanding and awareness of Muslim purity can help me to understand the Muslim patient and/or client whom I may nurse. At the same time the exercise can help me to articulate my own beliefs and values about spiritual purity and how these may be expressed or not in my own life style. Once the students understand about their own spirituality they are then more capable of providing spiritual care to those patient and/or clients that they nurse.
Early identification of possible incompatibility between beliefs and treatment In teaching the legal and ethical aspects of nursing I recommend that the students use the model and related questions when assessing patients and/or clients. If this is done prior to planning and the discussing proposed treatment plans, the nurse can readily realise the extent of the spiritual beliefs and therefore not be surprised if various aspects of treatment are rejected. In this way, the model helps the nurse to support the patient and/or client in their decision; instead of arguing and trying to get them to agree with treatment they do not want. That is, this model also allows nurses to recognise why some people accept or refuse treatment. For example, a seriously ill patient who needs a blood transfusion to survive may be a Jehovah’s Witness, and therefore it would be wrong in the eyes of their church to accept blood transfusion as treatment. By using the model, the nurse would know of this belief. However, the nurse would still need to clarify this belief with the patient in case there was a disparity between the teaching of the church and the patient’s perception of the beliefs. However, if the Jehovah’s Witnesses’ beliefs corresponded with those of their church then the doctor could follow the legal guidelines of allowing the patient to refuse the treatment (Hawley 1997; Wallace 1995). It also needs to be remembered that spirituality is more personal than religious beliefs (which express the doctrine of the church and are not necessarily the patient’s own spiritual needs). For example, a woman who belongs to a church that condemns
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abortion may not regard the status of her embryo or foetus as sacred, as does her church, and may wish to terminate the pregnancy. Therefore, on asking the woman about her individual spiritual beliefs, these can be documented, and information given about the possibility of terminating the pregnancy.
Summary When teaching the phenomenon of spirituality in relation to nursing practice, I discovered that the literature did not give me a good understanding of the subject nor did it reflect the cultural nuances particular to Western Australians. A project was planned to discover the nature of spirituality for Western Australians. This consisted of identifying and collecting data to support the extent of multiculturalism and also the range of spiritual groups. Once the information was obtained it was analysed to identify common or universal themes. It was discovered that the various spiritual groups had significant truths or beliefs, which were important components of their community member’s lives. The manner in which these beliefs could impact on health care treatment was realised, as well as the ways in which they may want to access the power, deity, or the orientation of spirituality while receiving health care. Questions were developed that would allow nurses to understand their patient’s or client’s spirituality (the basis of these questions is the common themes from the data). These questions were trialled with all the information received from a diverse range of religious and spiritual groups, and it was found compatible with my proposed model. What I had not realised was the ease with which the model and questions helped make sense of the information so that it could be readily understood by nurses. In my experience of using research skills of data collection and analysis to inform my teaching practice, I found not only greater personal knowledge and understanding of the subject in question, but also the importance of finding new knowledge that is appropriate and true for the context in which we nurse.
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