Research
Spiritual support interventions in nursing care for patients suffering death anxiety in the final phase of life Helena Kisvetrová, Miloslav Klugar, Ladislav Kabelka
© 2013 MA Healthcare Ltd
C
onfirmation of a life-threatening disease and fear of relapse as a signal of imminent death may induce negative emotions such as anxiety and distress (Hales et al, 2010; Tang et al, 2011). Fear of death and dying is usually connected with a feeling of loss or a threat to one’s dignity, and it can cause a desire for hastened death. Retaining dignity protects against death anxiety and is a priority for patients in end-of-life care (Chochinov, 2006; Shim and Hahm, 2011). Spirituality is a universal human phenomenon. It is an integrating factor in the search for the meaning of life, including existential and religious aspects (Byrne, 2002). Spiritual support offers a perspective on a natural end to life and helps overcome fear of the unknown and death anxiety (Shih et al, 2009). Bulechek et al (2008, p674) defined spiritual support as: ‘Assisting the patient to feel a balance and connection with a greater power’. A compassionate and caring environment brings hope, helps people to deal with the reality of death, and affects spiritual wellbeing in the terminal stage of life (Mok et al, 2010). Nursing activities for spiritual support are connected with active listening, presence with the patient, respect, and support of dignity (Cavendish et al, 2003; van Leeuwen et al, 2006; Doorenbos et al, 2011). Providing spiritual support is also influenced by the way the nurses perceive spirituality (Aubin, 2009; Costello, 2009). In countries with more religious cultures, spiritual support is understood in more religious dimensions (Baldacchino, 2006; Cavendish et al, 2003; Kuuppelomäki, 2001). By contrast, Paley (2009) stated that one would not expect nurses to carry out activities of spiritual care in countries with clearly established secular rational values. Nurses with irreligious (humanist) convictions can and should help patients with their spiritual concerns in the terminal phase. However, it is not considered likely that such assistance would lead to discussion about God or other higher power or the afterlife, because these topics are in contrast with the humanist point of view (Costello, 2009).
International Journal of Palliative Nursing 2013, Vol 19, No 12
Abstract
Purpose: To investigate which activities from the ‘Spiritual Support’ intervention of the Nursing Interventions Classification (NIC) are used in patients with the nursing diagnosis ‘Death Anxiety’ in the Czech Republic, and which activities could feasibly be implemented into practice. Method: The study surveyed 468 Czech nurses using a quantitative questionnaire with Likert scales. Results: The most frequently used activity was ‘Treat individual with dignity and respect’ and the least frequently used was ‘Pray with the individual’. ‘Treat individual with dignity and respect’ was also thought to be the most feasible activity for Czech nursing practice. Significant differences were found between nurses working in hospices and those in other sites and between religious believers and non-believers. Conclusion: Even in the secularised Czech Republic, nurses can make use of the NIC Spiritual Support intervention in end-of-life care. Key words: Death anxiety l Palliative care l Spiritual support l Dignity l Nursing intervention l End-of-life care
The Nursing Interventions Classification (NIC) of the Center for Nursing Classification and Clinical Effectiveness is ‘a comprehensive, standardised language describing treatments that nurses perform in all settings and in all specialties’ (Bulecheck et al, 2008). It is used all over the world and has been translated into the languages of countries with very different cultural traditions and varying degrees of secularisation of society (e.g. Chinese, Japanese, German, Dutch, Spanish, and Italian). In the Czech Republic, activities for official translation of the NIC and Nursing Outcomes Classification systems have begun, which would build on the existing translation of NANDA nursing diagnosis. This work is a prerequisite of implementation of these international classification systems into Czech nursing practice and research. The NIC lists 25 interventions related to the nursing diagnosis ‘Death Anxiety’. The intervention ‘Spiritual Support’ ranks among the priorities and comprises 29 activities with religious and existential dimensions.
Helena Kisvetrová is Assistant Professor, Department of Nursing, Faculty of Health Sciences, Palacký University Olomouc, Czech Republic; Miloslav Klugar is Assistant Professor, Department of Social Medicine and Health Policy, Faculty of Medicine and Dentistry, Palacký University Olomouc; Ladislav Kabelka is Medical Director, St Joseph’s Hospice and Pain Centre, Rajhrad u Brna, and President, Czech Society for Palliative Medicine Correspondence to: Miloslav Klugar [email protected]
599
onal Journal of Palliative Nursing. Downloaded from magonlinelibrary.com by 193.061.135.112 on November 13, 2015. For personal use only. No other uses without permission. . All rights r
Research
Aim The aim of this study was to investigate which activities from the Spiritual Support intervention of the NIC are used in patients with the nursing diagnosis Death Anxiety in the Czech Republic, and which activities could feasibly be implemented into practice.
Methods As the nursing activities of the Spiritual Support intervention had not previously been systematically investigated in the Czech Republic, a pilot study using focus groups was conducted (Kisvetrová and Kutnohorská, 2010). The outcomes of the pilot study were used as the basis for setting the main objectives for the study reported in the present paper. Although the international classification NIC was developed in the USA, which has a different culture to the Czech Republic, the pilot study found that some of the Spiritual Support interventions may be valid for the Czech Republic (Kisvetrová and Kutnohorská, 2010).
Sample The population of interest was registered nurses working in health and social care institutions that frequently provide end-of-life care. According to data for 2009 from the Institute of Health Information and Statistics of the Czech Republic (IHISCR, 2012), this population consists of approximately 30 000 nurses. According to Tichácek (1997), an appropriate size for a research sample is 2.5% of the population, i.e. 750 nurses in this case. A total of 750 questionnaires were therefore distributed to 34 health and social care institutions in the Czech Republic that were expected to frequently provide end-of-life care. Eligible participants were registered nurses with at least 1 year’s experience working in a hospice, oncology ward, geriatrics ward, long-term care setting, home for the elderly, or home care. Home care in the Czech Republic is not specialised, but almost 80% of clients are aged over 65 years and about 6% of all clients obtain ‘hospice home care’ (IHISCR, 2012). From the 750 questionnaires distributed, 468 nurses took part (62.4%).
Ethical considerations Ethical approval was obtained from the ethical committee of the Faculty of Health Sciences, Palacký University, Olomouc. The purpose of the study was explained to potential participants and informed consent was obtained.
Procedure A questionnaire was created based on the pilot phenomenological study (Kisvetrová and
600
Kutnohorska, 2010). As well as asking for demographic data, including the respondent’s religiosity, it contained 29 sets of questions that corresponded to each activity defined in the NIC intervention Spiritual Support (Bulechek et al, 2008). It asked participants to rate each item on two 5-point Likert scales—one relating to frequency of use and the other to feasibility of implementing into practice—with values for the first scale ranging from 1=always to 5=never and for the second from 1=always to 5=don’t know. Internal consistency was tested in a pilot study that was attended by 20 nurses from clinical practice, and Cronbach’s alpha was found to be 0.92. Opinions on the importance of each item to caring for patients with death anxiety in the final stage of life were also sought via ‘yes’/‘no’ questions. Furthermore, the questionnaire contained one open question: the nurses were able to describe the circumstances that affect the implementation of the Spiritual Support intervention activities.
Data collection The research was carried out from January to May 2011 as part of a larger research programme focused on the nursing care of death anxiety. The questionnaires were distributed to all nurses in all hospices and oncology and geriatrics wards in the Czech Republic. It was also distributed to nurses from long-term care settings, homes for the elderly and home care who attended the national conference ‘Dying with dignity II in Olomouc’. Administrators of the questionnaire personally visited each site with boxes for questionnaire collection. The researchers were blinded to the names and workplaces of the participants to maintain anonymity.
Data analysis The data was processed using the statistical software SPSS version 15. Descriptive statistics was used to show demographic data. Differences in the reported frequency of use of the activities and opinions on feasibility by workplace and religiosity were assessed by chi-squared test. If statistical significance was found, the chi-squared test with Bonferroni correction was then used with the level of statistical significance set at P
Spiritual support interventions in nursing care for patients suffering death anxiety in the final phase of life Helena Kisvetrová, Miloslav Klugar, Ladislav Kabelka
© 2013 MA Healthcare Ltd
C
onfirmation of a life-threatening disease and fear of relapse as a signal of imminent death may induce negative emotions such as anxiety and distress (Hales et al, 2010; Tang et al, 2011). Fear of death and dying is usually connected with a feeling of loss or a threat to one’s dignity, and it can cause a desire for hastened death. Retaining dignity protects against death anxiety and is a priority for patients in end-of-life care (Chochinov, 2006; Shim and Hahm, 2011). Spirituality is a universal human phenomenon. It is an integrating factor in the search for the meaning of life, including existential and religious aspects (Byrne, 2002). Spiritual support offers a perspective on a natural end to life and helps overcome fear of the unknown and death anxiety (Shih et al, 2009). Bulechek et al (2008, p674) defined spiritual support as: ‘Assisting the patient to feel a balance and connection with a greater power’. A compassionate and caring environment brings hope, helps people to deal with the reality of death, and affects spiritual wellbeing in the terminal stage of life (Mok et al, 2010). Nursing activities for spiritual support are connected with active listening, presence with the patient, respect, and support of dignity (Cavendish et al, 2003; van Leeuwen et al, 2006; Doorenbos et al, 2011). Providing spiritual support is also influenced by the way the nurses perceive spirituality (Aubin, 2009; Costello, 2009). In countries with more religious cultures, spiritual support is understood in more religious dimensions (Baldacchino, 2006; Cavendish et al, 2003; Kuuppelomäki, 2001). By contrast, Paley (2009) stated that one would not expect nurses to carry out activities of spiritual care in countries with clearly established secular rational values. Nurses with irreligious (humanist) convictions can and should help patients with their spiritual concerns in the terminal phase. However, it is not considered likely that such assistance would lead to discussion about God or other higher power or the afterlife, because these topics are in contrast with the humanist point of view (Costello, 2009).
International Journal of Palliative Nursing 2013, Vol 19, No 12
Abstract
Purpose: To investigate which activities from the ‘Spiritual Support’ intervention of the Nursing Interventions Classification (NIC) are used in patients with the nursing diagnosis ‘Death Anxiety’ in the Czech Republic, and which activities could feasibly be implemented into practice. Method: The study surveyed 468 Czech nurses using a quantitative questionnaire with Likert scales. Results: The most frequently used activity was ‘Treat individual with dignity and respect’ and the least frequently used was ‘Pray with the individual’. ‘Treat individual with dignity and respect’ was also thought to be the most feasible activity for Czech nursing practice. Significant differences were found between nurses working in hospices and those in other sites and between religious believers and non-believers. Conclusion: Even in the secularised Czech Republic, nurses can make use of the NIC Spiritual Support intervention in end-of-life care. Key words: Death anxiety l Palliative care l Spiritual support l Dignity l Nursing intervention l End-of-life care
The Nursing Interventions Classification (NIC) of the Center for Nursing Classification and Clinical Effectiveness is ‘a comprehensive, standardised language describing treatments that nurses perform in all settings and in all specialties’ (Bulecheck et al, 2008). It is used all over the world and has been translated into the languages of countries with very different cultural traditions and varying degrees of secularisation of society (e.g. Chinese, Japanese, German, Dutch, Spanish, and Italian). In the Czech Republic, activities for official translation of the NIC and Nursing Outcomes Classification systems have begun, which would build on the existing translation of NANDA nursing diagnosis. This work is a prerequisite of implementation of these international classification systems into Czech nursing practice and research. The NIC lists 25 interventions related to the nursing diagnosis ‘Death Anxiety’. The intervention ‘Spiritual Support’ ranks among the priorities and comprises 29 activities with religious and existential dimensions.
Helena Kisvetrová is Assistant Professor, Department of Nursing, Faculty of Health Sciences, Palacký University Olomouc, Czech Republic; Miloslav Klugar is Assistant Professor, Department of Social Medicine and Health Policy, Faculty of Medicine and Dentistry, Palacký University Olomouc; Ladislav Kabelka is Medical Director, St Joseph’s Hospice and Pain Centre, Rajhrad u Brna, and President, Czech Society for Palliative Medicine Correspondence to: Miloslav Klugar [email protected]
599
onal Journal of Palliative Nursing. Downloaded from magonlinelibrary.com by 193.061.135.112 on November 13, 2015. For personal use only. No other uses without permission. . All rights r
Research
Aim The aim of this study was to investigate which activities from the Spiritual Support intervention of the NIC are used in patients with the nursing diagnosis Death Anxiety in the Czech Republic, and which activities could feasibly be implemented into practice.
Methods As the nursing activities of the Spiritual Support intervention had not previously been systematically investigated in the Czech Republic, a pilot study using focus groups was conducted (Kisvetrová and Kutnohorská, 2010). The outcomes of the pilot study were used as the basis for setting the main objectives for the study reported in the present paper. Although the international classification NIC was developed in the USA, which has a different culture to the Czech Republic, the pilot study found that some of the Spiritual Support interventions may be valid for the Czech Republic (Kisvetrová and Kutnohorská, 2010).
Sample The population of interest was registered nurses working in health and social care institutions that frequently provide end-of-life care. According to data for 2009 from the Institute of Health Information and Statistics of the Czech Republic (IHISCR, 2012), this population consists of approximately 30 000 nurses. According to Tichácek (1997), an appropriate size for a research sample is 2.5% of the population, i.e. 750 nurses in this case. A total of 750 questionnaires were therefore distributed to 34 health and social care institutions in the Czech Republic that were expected to frequently provide end-of-life care. Eligible participants were registered nurses with at least 1 year’s experience working in a hospice, oncology ward, geriatrics ward, long-term care setting, home for the elderly, or home care. Home care in the Czech Republic is not specialised, but almost 80% of clients are aged over 65 years and about 6% of all clients obtain ‘hospice home care’ (IHISCR, 2012). From the 750 questionnaires distributed, 468 nurses took part (62.4%).
Ethical considerations Ethical approval was obtained from the ethical committee of the Faculty of Health Sciences, Palacký University, Olomouc. The purpose of the study was explained to potential participants and informed consent was obtained.
Procedure A questionnaire was created based on the pilot phenomenological study (Kisvetrová and
600
Kutnohorska, 2010). As well as asking for demographic data, including the respondent’s religiosity, it contained 29 sets of questions that corresponded to each activity defined in the NIC intervention Spiritual Support (Bulechek et al, 2008). It asked participants to rate each item on two 5-point Likert scales—one relating to frequency of use and the other to feasibility of implementing into practice—with values for the first scale ranging from 1=always to 5=never and for the second from 1=always to 5=don’t know. Internal consistency was tested in a pilot study that was attended by 20 nurses from clinical practice, and Cronbach’s alpha was found to be 0.92. Opinions on the importance of each item to caring for patients with death anxiety in the final stage of life were also sought via ‘yes’/‘no’ questions. Furthermore, the questionnaire contained one open question: the nurses were able to describe the circumstances that affect the implementation of the Spiritual Support intervention activities.
Data collection The research was carried out from January to May 2011 as part of a larger research programme focused on the nursing care of death anxiety. The questionnaires were distributed to all nurses in all hospices and oncology and geriatrics wards in the Czech Republic. It was also distributed to nurses from long-term care settings, homes for the elderly and home care who attended the national conference ‘Dying with dignity II in Olomouc’. Administrators of the questionnaire personally visited each site with boxes for questionnaire collection. The researchers were blinded to the names and workplaces of the participants to maintain anonymity.
Data analysis The data was processed using the statistical software SPSS version 15. Descriptive statistics was used to show demographic data. Differences in the reported frequency of use of the activities and opinions on feasibility by workplace and religiosity were assessed by chi-squared test. If statistical significance was found, the chi-squared test with Bonferroni correction was then used with the level of statistical significance set at P
