35.2 Applications of Spirituality to Health Care

Vaccines

Some patients may refuse vaccines, either for themselves or their children, due to their religious beliefs. Religious exemption may be cited by individuals of many denominations, though very few organized religions have specific prohibitions against vaccines. In some cases, people of a certain faith may believe their religion prohibits vaccines, when even their leaders indicate that no such prohibition exists; individual beliefs need to be respected, but this situation creates the need for strong community-based programs. Some smaller groups, such as Dutch Reformed Church and faith-healing denominations, do specifically object to immunizations. However, individuals within the faith may still accept vaccination.

It's also important for the nurse to be aware that patients of certain faiths may have concerns about vaccines due to the ingredients, as they would with medications that may contain ingredients that would be at odds with their dietary practices. However, many religious organizations—such as the Islamic Organization for Medical Sciences—have made statements to those of the faith about the use of certain ingredients in vaccines and take the stance that they are acceptable.

Beliefs Regarding Death and Dying

Although the nurse will want to understand specific religious and spiritual beliefs about death, it’s also important to remember that each patient will have their own ideas and feelings about what happens when they die, as well as what may come after. The nurse should also be aware that a patient’s beliefs may change. A life-changing or life-threatening illness or injury can make people feel more drawn to believing in a higher power when they haven’t before, particularly if they seek the comfort that worship seems to bring to others. But it may also “shake the faith” or instill doubt in a person who has been devout and may even lead to a spiritual crisis. The changes are not always profound; they may be subtle and gradual. Therefore, it’s important for the nurse to monitor a patient’s spiritual well-being as much as their physical and mental well-being. Nurses can and should tailor their approach to each patient, but the following are a few examples of situations they may encounter:

• Judaism
  • Questions about the withholding or withdrawing of life-sustaining therapy are deeply debated within Judaism. Some may be strongly opposed, whereas others may be more open to it. Family members often wish to consult with a rabbi about the specific circumstances and decisions regarding end-of-life care.
  • After a patient has died, Jewish tradition directs that burial happen quickly and that there be no autopsy (unless the autopsy is deemed necessary by a mandate from a medical examiner). The family may request that a member or representative constantly accompany the body in the hospital and even to the morgue (where the person may sit outside any restricted area yet remain relatively close to the body) to say prayers and read psalms.
  • Amputated limbs may be requested for burial. Details should be arranged through the patient’s/family’s funeral home.
• Catholicism, Eastern Orthodox, Lutheran, and some other Christian denominations
  • If a patient is near death, there may be an urgent request for a priest or minister to offer anointing of the sick (or last rites). Last rites are often associated with the Catholic denomination, but others perform similar rituals to support people who are sick or at the end of life. Even if the ritual has already been performed, there may still be a request for a priest to offer prayers and bless the patient.
• Jehovah’s Witness
  • Tradition of Jehovah’s Witness does not teach that people experience an immediate afterlife (what a person believes will happen after death; a place where the spirit goes after the death of the physical body) when they die. For example, the nurse would not hear a patient’s family remark, “He’s in a better place now.”
• Amish
  • Amish funerals are typically modest and held in the home. They may not use elaborate caskets or grave markers. The community comes together to support the grieving family, providing meals and assistance.
• Islam
  • Muslim tradition generally discourages the withholding or withdrawing of life-sustaining therapy. However, because decisions involve the circumstances of the patient and the complexities of medical treatments, family members who are morally conflicted may wish to bring an experienced imam to their discussion with the healthcare team.
  • A family member may request to be present with a dying person so they can whisper a proclamation of faith in the patient’s ear right before death.
  • After a death, the family may request to wash the patient and position the bed to face Mecca. The patient’s head should rest on a pillow.
  • Burial is usually accomplished as soon as possible. Muslim families rarely allow for an autopsy unless there is an order by a medical examiner. Some Muslims may consider organ donation, but the subject is debated within Islamic circles.
  • There may be a request that amputated limbs be made available for burial. Details should be arranged through the patient’s/family’s funeral home.
• Hinduism
  • Hinduism teaches that death is a crucial “transition” with karmic implications.
  • There may be a strong desire for death to occur at home rather than in the hospital.
  • Family may wish to perform predeath rituals (e.g., tying a thread around the person’s neck or wrist).
  • After death, family members may request to wash the patient’s body (by family members of the same sex as the patient).
  • The family may request constant attendance of the deceased’s body. A family member or representative may wish to accompany the body to the morgue or at least remain as close to the body as possible (e.g., sitting outside a restricted area). (Ehman, 2012).
• Buddhism
  • In end-of-life care, Buddhists may be concerned about safeguarding awareness/consciousness. Clarification of the patient’s wishes about the use of analgesics in the days and hours before death is strategically important for developing an ethical pain management plan.
  • As a patient approaches death, medical and nursing staff should minimize actions that might disturb concentration or meditation in preparation for dying. Near the time of death, a Buddhist patient’s family may appear emotionally reserved and even keep their physical distance from the patient’s bed. This can be a custom for the purpose of supporting the patient’s desire to concentrate on the experience of dying without distraction.
  • After the patient has died, staff should try to keep the body as still as possible and avoid jostling during transport. Buddhism teaches that the body is not immediately devoid of the person’s spirit after death, so there is continued concern about disturbing the body. The nurse should also be aware of how these beliefs may factor into discussion of organ donation.
  • Families may request that after a patient has died, the body be kept available to them for several hours for the purpose of religious rites. All requests should be negotiated carefully, maximizing the opportunity for accommodation in recognition of the religious significance (Ehman, 2012).

Beliefs Regarding Pregnancy and Birth

Along with having unique perspectives on the end of life, patients also have their own beliefs about the beginning. Religious and spiritual beliefs and practices about pregnancy and childbirth vary, and the nurse should be knowledgeable about how different patients will view this time of life, as well as what concerns they may have about receiving care.

• Christianity
  • All requests for the sacrament of baptism should be relayed to a minister or priest. However, if an infant is likely to die before a priest can arrive, the infant may be baptized by any person with proper intent. The person would say, “[name of infant], I baptize you in the name of the Father, and of the Son, and of the Holy Spirit,” then pour a small amount of water over the infant’s head three times. Emergency baptisms must be reported to the local parish priest.
• Amish
  • Many Amish females prefer to give birth at home with the assistance of midwives. Hospital births are less common but accepted when necessary. Pregnancy and childbirth are community-centered, with significant support from family and neighbors.
• Islam
  • Immediately after the baby is born, the call to prayer (Adhan) is whispered into the baby’s right ear, and the call to begin prayer (Iqamah) is whispered into the left (Al-Islam, 2013).
• Hinduism
  • Jatakarma is when the father chants mantras in the baby’s ear to welcome them into the world (ISKCON Educational Services, 2018).
• East Asian and Chinese religions
  • In some East Asian and Chinese religions, there are various taboos during pregnancy, such as attending funerals, having negative thoughts, and moving heavy objects. It is believed that avoiding these practices protects the mother and baby from harm.
  • After giving birth, the new mother practices “zuo yuezi,” or “sitting the month,” a period of rest and recovery typically lasting about thirty to forty days. During this time, the mother is expected to stay indoors, avoid cold foods, and eat nutrient-rich, warm foods to replenish her energy.
  • The postpartum diet often includes foods believed to promote healing and recovery, such as chicken soup with ginger, eggs, and specially prepared herbal drinks.

Beliefs Regarding Diet

Dietary practices are central to many religious and spiritual groups. Although the nurse should know of and understand the dietary needs of all patients, they should also note those rooted in religious or cultural practices. The nurse must understand that just because a patient follows a particular religion does not mean they strictly follow all its practices, including those about diet. The nurse should not make assumptions but ask patients about their dietary needs and preferences to obtain information and demonstrate cultural sensitivity and respect.

• Judaism
  • Jewish patients often request a special kosher diet in accordance with religious laws that govern the preparation of certain foods (e.g., beef), the prohibition of certain foods (e.g., pork and gelatin), or the combination of some food (e.g., beef served with dairy products). However, not all Jewish patients keep kosher, so it is important for the nurse to be aware of their dietary practices. Prescribed nutrition therapy for patients must align with their cultural and spiritual traditions.
  • Hand washing before eating may also have a religious significance.
• Catholicism
  • Patients may request nonmeat meals, especially during the time of Lent (the forty days before Easter) (United States Conference of Catholic Bishops, 2024).
• Amish
  • Amish patients typically avoid processed foods and prefer homegrown and home-cooked foods, including meats, vegetables, grains, and dairy.
• Islam
  • Muslims may specifically request a diet in accordance with religious laws for halal food, though many Muslims choose a vegetarian diet as a simple way to avoid religious prohibitions against pork products or gelatin. Forbidden foods are referred to as haram.
  • Muslim dietary regulation can affect patients’ use of medications, especially drugs that have pork origins or contain gelatin or alcohol. The dietary prohibition against alcohol has occasionally raised questions about Muslims’ use of alcohol-based sanitizers in the hospital. Concerns should be addressed thoroughly and sensitively, and perhaps with the input of an imam (a person who leads prayers in a mosque).
  • During the thirty-day month of Ramadan, Muslims refrain from food and drink from dawn until sundown. Providers should consider whether it is medically appropriate for patients to fast while in the hospital. If so, they will need to look at the options for predawn meals, provide patients with dates and spring water in the late afternoon (a traditional way to break the daily fast), and delay dinner until after sunset (Ehman, 2012).
• Hinduism
  • Hindus are often strictly vegetarian and do not consume meat or animal by-products. For such patients, even medications produced using animals would not be allowed. Some Hindus refrain from eating certain vegetables, such as onions or garlic.
  • Fasting is a common practice in Hinduism, and patients may wish to discuss the possibility within the context of their medical/dietary care plan.
• Buddhism
  • Some Buddhists are strictly vegetarian and refuse to consume any meat or animal by-products. For such patients, even medications produced using animals would not be allowed.
• African religions
  • Some African religions have taboos against consuming certain types of meat, such as pork or shellfish, which may be seen as unclean or spiritually impure.
• Indigenous Americans
  • Preferred diets come from locally sourced and seasonal foods (rather than processed food) such as wild game, fish, fruits, vegetables, and grains that are harvested or gathered from the surrounding environments.
• East Asian and Chinese religions
  • Food is often seen in terms of its energetic properties (hot, cold, neutral) and its effects on the body. Balancing these properties is believed to promote health.
  • Some East Asian religions, such as Buddhism, promote vegetarianism to adhere to the principle of ahimsa (nonviolence). Taoism may advocate for specific dietary practices that align with natural and seasonal cycles.

Beliefs Regarding Rituals or Holy Tenets

The unique and specific beliefs of each religion and spiritual culture come with their own set of practices or traditions that help people feel connected to them, as well as contribute to the broader sense of connectedness to the world. Patients may partake in some, but not all, of these practices and rituals, whereas others may strictly follow them. Meeting a patient’s spiritual needs means understanding the practices that are important to them and finding ways to integrate them into care.

• Judaism
  • Some Jewish patients strictly observe the rule of not working on the Sabbath (from sundown on Friday until sundown on Saturday) or on religious holidays. If so, this religious injunction against work, including prohibitions against using certain tools or engaging in tasks that initiate electricity use, can prevent tasks such as writing, using a cell phone, flipping a light switch, pushing buttons to call a nurse, adjusting a motorized bed, or operating a patient-controlled analgesia (PCA) pump. The tearing of paper can be considered work, so roll toilet paper may need to be replaced with an opened box of individual sheets.
  • Medical procedures should not be scheduled during the Sabbath or religious holidays (unless they are lifesaving), nor should hospital discharges be planned during such times without the patient's consent. Although these restrictions on work are generally associated with Orthodox Judaism, they may be important for any Jewish patient.
  • Jewish holidays are usually highly significant for patients, especially Passover in the spring and Rosh Hashanah and Yom Kippur in the fall. These holidays may affect the scheduling of medical procedures and may involve dietary changes (related to a need for special food or a desire to fast). All Jewish holidays run from sundown to sundown.
  • It is common for male Jewish patients to wear a yarmulke or kippah (skull cap) during prayer, and some Jews may wish to keep them on at all times (Figure 35.10). Patients or family members may wear prayer shawls and use phylacteries (two small boxes containing scriptural verses and having leather straps worn on the forehead and forearm during prayer). There may be a request that at least 10 people (called a minyan) be allowed in the patient’s room for prayer.
• Catholicism
  • Some patients may keep religious objects with them, such as a rosary (a loop of beads with a crucifix used for prayer), a scapula (a small cloth devotional pendant), or a religious medal. If patients request that an object remain with them during medical procedures, one option may be placing it in a sealed bag that can be kept on or near the patient. If an object is metal and the patient is having a radiological procedure or test (such as an MRI scan), explain why metal cannot be brought into the room for the exam and ask the patient or family if they can bring in a nonmetal substitute.
  • Interruption of religious practices, such as regular attendance at Mass or special observance of special holy days, may be highly stressful to Catholic patients. It can be helpful to connect them with local clergy and/or a hospital chaplain.
  • Sacraments, the consecrated elements of the Eucharist (e.g., the bread or Host), and blessings by a Catholic priest can be viewed as highly important, especially before surgery or when there is a perceived risk of death.
  • Patients may request Holy Communion (Eucharist) prior to surgery. Although a Catholic priest or Eucharistic minister would typically offer only a tiny portion of a wafer, patients who are NPO (to have nothing by mouth) should have this request approved by the healthcare team as medically safe before proceeding.

Figure 35.10 Yarmulkes or kippahs are often worn by Jewish men during worship. Some men keep them on at all times. (credit: “Casamento judeu1” by David Berkowitz/Wikipedia, CC BY 2.0)

• Jehovah’s Witness
  • Jehovah’s Witnesses do not celebrate birthdays or Christian holidays (Ehman, 2012).
  • Contrary to popular misconceptions, faith healing is not a part of Jehovah’s Witness tradition. Prayers are often said for comfort and endurance.
• Islam
  • Muslim prayers are conducted five times a day. Patients may desire to pray by kneeling and bending to the floor, but Islamic tradition recognizes circumstances when this is not medically advisable (Figure 35.11). If patients are disturbed by their inability to pray on the floor, advice should be encouraged from an imam.
• Buddhism
  • Buddhism places a strong emphasis on mindfulness, so patients may request peace and quiet for the purpose of meditation, especially during crises.
  • Patients or families may pray or chant out loud repetitiously. This is often performed quietly, and any noise concerns in a hospital can usually be negotiated easily. Families may sometimes wish to place a picture of the Buddha in the patient’s room.

Figure 35.11 Muslim prayers are done five times daily. When possible, patients may prefer to kneel on the floor for prayer. (credit: “Damascus, Umayyad Mosque, prayers” by Arian Zwegers/Flickr, CC BY 2.0)

Objective Assessment

In addition to asking open-ended questions, nurses must observe patients for cues indicating difficulties in finding meaning, purpose, or hope in life. It is also important to determine if a patient has supportive relationships (Ackley et al., 2020).

Patients experiencing chronic or serious illness may make statements that suggest spiritual distress, and their words should cue the nurse that spiritual care is needed. Examples of these statements/concepts are (Puchalski et al., 2014):

• Lack of meaning: “I am not the person I used to be.”
• Loss of hope: “I have nothing left to hope for.”
• Mystery: “Why did this happen to me?”
• Isolation: “All my family and friends are gone.”
• Helplessness: “I have no control over my life anymore.”

Readiness for Enhanced Spiritual Well-Being

A readiness for enhanced spiritual well-being can be defined as a pattern of experiencing and integrating meaning and purpose in life through connectedness with self, others, art, music, literature, nature, and/or a power greater than oneself, which can be strengthened. For example, many people experienced feelings of isolation as they sheltered at home during the COVID-19 pandemic; someone with a readiness for enhanced spiritual well-being would be encouraged to spend more time outdoors. In this situation, the nurse could encourage patients to visit local parks and walk outdoors while wearing a mask and maintaining social distancing.

Impaired Religiosity

Impaired religiosity is when a patient has difficulty exercising their beliefs and/or participating in rituals of their particular faith tradition. Hospitalized patients may be unable to attend religious services as usual. In this situation, the nurse could help the patient overcome environmental barriers to practicing their religion by contacting the patient’s pastor to arrange a visit or determine if services can be viewed online.

Spiritual Distress

Spiritual distress is defined as a state of suffering related to the impaired ability to experience meaning in life through connections with self, others, the world, or a superior being. Events that place patient populations at risk for developing spiritual distress include the birth of a child, the death of a significant other, exposure to death, a significant life transition, severe illness or injury, exposure to natural disaster, racial conflict, or an unexpected life event (Herdman & Kamitsuru, 2018). Conditions that place a person at risk for developing spiritual distress include actively dying, chronic illness, illness, loss of a body part, loss of function of a body part, or a treatment regimen (Herdman & Kamitsuru, 2018). For example, a patient diagnosed with life-threatening medical diagnoses such as cancer may experience spiritual distress as they move through the typical stages of loss. In this case, the nurse would implement interventions to enhance coping.

Outcome Identification

Goals and outcomes should be customized for each patient. When a patient has the nursing diagnosis of readiness for enhanced spiritual well-being, a sample goal statement might be, “The patient will demonstrate hope as evidenced by the following indicators: expressed expectation of a positive future, faith, optimism, belief in self, sense of meaning in life, belief in others, and inner peace” (Ackley et al., 2020). An example of a related outcome is, “The patient will express a sense of meaning and purpose in life by discharge” (Ackley et al., 2020).

When a patient has the nursing diagnosis of spiritual distress, a sample goal statement might be, “The patient will demonstrate improved spiritual health as evidenced by one of the following indicators: feelings of faith, hope, meaning, and purpose in life with connectedness with self and others to share thoughts, feelings, and beliefs” (Ackley et al., 2020). A sample outcome is, “The patient will express a purpose in life by discharge” (Ackley et al., 2020).