Everyone has a worldview—a way of explaining reality—that is in part received and in part self-constructed. This worldview inevitably walks with the nurse to the bedside. This chapter will explore how the worldviews of nurses have an impact on their nursing care. The focus is on those nurses who affiliate with a particular religion, but similar points could well be made about the influence of secular, atheist, or nonreligious spiritual worldviews.
To begin, we will imagine how nurses of diverse religious traditions might possibly draw upon somewhat typical features or approaches of the religion to care for an anxious patient, each in her or his religiously unique way. This will highlight the importance of recognizing a nurse’s religiosity. After reviewing literature that suggests how the religiosity of nurses does influence their practice of nursing, recommendations for how personal religiosity may or may not be appropriately brought to the bedside will be presented.
Lynn is a 48-year-old woman who knows she is dying of breast cancer. Nights are particularly distressing for Lynn, as that is when her friends and family sleep, and she is left to face the angst of her physical pain and mortality alone and without distraction. She queries her nurse, Leslie, one night: “I’m really having a hard time sleeping. What can I do so I’m not so anxious?” What will Lynn’s nurse offer to ameliorate her distress?
If Lynn’s nurse is paralyzed by the idea of dying and unable to be present to Lynn in her suffering, this nurse will likely prescribe a sedative or anti-anxiety drug. And stay out of Lynn’s room. But let us assume that Lynn’s nurse is a well-trained palliative care nurse who is comfortable attending to dying patients. What will this nurse offer?
If nurse Leslie is Buddhist, her repertoire of ways to address stress will likely include meditation techniques. She may suggest to Lynn that it could be helpful if she were to clear her mind of all distracting thoughts and meditate on an object of spiritual or religious significance, or on something from nature (e.g., a flower). Leslie may help Lynn to become aware and grateful for her gentle, regular breathing. She might suggest one of her favorite CDs with chants for focusing. Leslie might also share a written meditation about loving kindness with Lynn, or offer her a mantra on which to focus (e.g., “May I take care of myself with joy”). As Leslie talks with Lynn about her anxiousness and fear of dying, it is possible that in an attempt to comfort, Leslie will project her views about suffering and life after death. That is, she may suggest Lynn’s anxieties reflect her attachments to the present life. By releasing these attachments, she could lessen her suffering. And indeed, doing so will put her in good stead for the rebirth after death—a rebirth that brings her nearer to Enlightenment.
If nurse Leslie, however, is a Seventh-day Adventist (SDA) Christian, her approach to helping Lynn will contrast. The SDA Leslie may offer a colloquial prayer, petitioning God to ease Lynn’s anxieties and fears. If this Leslie converses with Lynn about her anxieties regarding dying, Leslie might share her beliefs about death and the afterlife. That is, death is like sleep; the next thing Lynn will see after “falling asleep in Jesus” will be a resurrection that occurs with the glorious advent of Jesus. Thereafter, all who want to live with God (i.e., those judged righteous, having accepted Jesus’ grace) will go to heaven and enjoy eternal life free of suffering.
To provide a further contrast, consider Leslie, RN as a Roman Catholic. Catholic Leslie may pray colloquially, but may just as well offer a silent prayer or memorized or read form of prayer. She may also encourage Lynn to pray to Archangel Michael, the patron saint for the sick. In lieu of lighting a novena candle (fire regulations), Leslie may have a prayer card to give to Lynn with this angel’s picture on it as a reminder of Michael’s intercession on her behalf. If Lynn and Leslie have any dialogue about what death and afterlife are like, Leslie’s beliefs will likely influence her remarks. For Leslie, death allows the soul to leave the dead body. The soul is evaluated in an initial judgment, which determines whether the life lived worthies it for heaven, purgatory, or hell. Purgatory is a temporary existence that allows suffering to cleanse one of sin, and readies one for heaven. Nurse Leslie will likely wish for Lynn an opportunity to confess her sins (perhaps formally to a priest) before her death.
These vignettes are not meant to essentialize any religious tradition but rather, for the purposes of discussion, to raise the issue that some typical features of a religion, as understood by the layperson nurse may well affect nursing care as well as perspectives on the nursing enterprise itself. Although different “Leslies” even within one religious tradition will have varying interpretations of their religion and approaches to comforting Lynn, this scenario vividly portrays how a nurse’s worldview can influence his or her attempts to care. Even for spiritual nurses who do not formally affiliate with a religion, the religious lens that their family or society gives may have an impact on their care.
But ought a nurse’s religious beliefs and practices be found at the bedside? As an editorial in the British Journal of Nursing stated:
While respecting nurses’ right to faith, I strongly believe that nurses have to—like teachers and the police—divide themselves from their faith in the conduct of their duties. Most do so admirably. To proselytize, or even just share, their faith with patients, many of whom are in a very vulnerable position, not only smacks to me of arrogance, but contradicts the treasured, inclusive, non-judgmental heart of nursing.1
Pollard’s recommendation in this editorial assumes that nurses can divide themselves from their faith. But can they? There also seems to be an assumption that any sharing of faith constitutes proselytizing. But does it?
To answer these questions, it is helpful to consider how a nonreligious nurse might assist Lynn. Imagine that self-professed atheist and humanist Leslie is Lynn’s nurse. This Leslie might draw from an arsenal of empirical evidence that indicates massage, aromatherapy, music, active listening, and pharmacologic agents can all be used to lessen anxiety. (Of course, the religious Leslies can do the same.) In the conversation that might ensue, Leslie would find comfort in remembering that medical therapeutics often cure disease and possibly project her confident reliance on science to Lynn. Or, if embracing Lynn’s death as imminent, Leslie may have in her nursing care plan for Lynn the goal of making meaning for her life and death—a meaningfulness that does not require a supportive religious framework. Leslie might also interject questions to encourage Lynn to examine the reasons for her anxiety and possibly share skepticism about any ideations regarding an afterlife.
These contrasting “Leslies” all have a system of beliefs—whether a personally collected cluster of values or a codified religious worldview—that have an influence on their responses to patients. Regardless of how aware of these beliefs the nurse is, if the nurse is to behave in a professional context in a manner that is authentic to self—congruent with privately held beliefs, then these beliefs will motivate and shape to some degree the care that is given. Ironically, it is the nurse who is least aware of the influence of private religious (or nonreligious philosophical) beliefs who is most likely to impose these beliefs inappropriately during patient care. This is because the lack of awareness impedes the ability to bracket these beliefs when ethical care may demand it.
Therefore, we argue that it is inappropriate and disrespectful to expect nurses to divide themselves from their religiosity. To do so is to amputate an essential part of their being, and a part of their being that likely prompts their desire to be a nurse. No. The question is not whether nurses should bring their religion to the bedside (they cannot help but do so), but rather the manner in which they should bring their religion to the bedside. It is a question not of ought but how.
There is no study documenting the religiosity of a nurse population. A few studies about how nurses think about and practice spiritual care do superficially inquire about participants’ religiosity. Given the topic for these studies about nursing spiritual care, it is likely that nurses for whom spirituality or religion is rather important comprise these samples.
Claiming a representative sample based on comparison with non-participants, one study of Arizonan nurses in a state university hospital queried them regarding a wide assortment of opinions and practices about spiritual care.2 Of the 299 survey respondents, 42% self-reported that they were “religious” while 41% stated they were “spiritual but not religious.” (Grant and colleagues cite a comparable polling of Americans that showed 30% reported they were “spiritual but not religious.”) What is fascinating is that many of these nurses, in or out of religion, described nursing as a “calling” and were willing to provide the same services of a hospital chaplain if they received time and training. Religious nurses, unsurprisingly, were more agreeable about providing this spiritual care (37% vs. 28%).
Other American studies investigating nurse perspectives on spiritual care that assess study participant religiosity suggest that these nurses who are interested enough to participate are predominantly Christian (roughly 90%), with roughly 40% to 50% being Roman Catholic and the other half Protestant.3–6 When nurses are asked to self-report spirituality and religiosity, their spirituality is found to be higher or similar to religiosity.7,8 A few studies document about half of the nurses attending religious services regularly or viewing them as moderately or very important.9–11
Pesut and Reimer-Kirkham’s ethnographic study describes how the spiritual and religious identities of various health care professionals significantly influence their interactions with patients around spirituality.12 In discussing their findings, these nurse researchers observed that these Canadian clinicians’ religious or spiritual identities were varied, dynamic, and complex. For example, some participants fused aspects of different religious traditions to compose their own identity. Others resonated with the “spiritual but not religious” identity, while still being influenced by earlier religious experience. As these scholars noted, “there were no spiritualities from nowhere.”13
A survey of all Flemish palliative care nurses’ (N = 415) religious and ideological views and practices observed them to be interested in religious issues and likely to believe in a transcendent power.14 These researchers clustered the nurses’ religiosity as follows: church-goers (29%), atheists/agnostics (18%), doubters (18%), religious but not church-goers (18%), and devout church-goers (17%). Combining the three religious groups shows 55% of these nurses to self-report as religious, comparable with Flemish society at large.
A study of Israeli oncology nurses (96% Jewish) measured intrinsic and extrinsic religiosity, spiritual well-being, as well as attitudes toward spiritual care.15 Among the Jewish nurses, 58% self-identified as “secular” while 21% perceived themselves as “traditional” and 21% were “religious.” Although these categories were not used in the subsequent path analysis, the religiosity (especially intrinsic) was observed to contribute indirectly to spiritual care attitude.
Unfortunately, this paltry body of data regarding the religiosity of nurses is too limited in scope and method to provide a base for strong generalization. It is likely that nurses simply reflect the religious diversity of the societies in which they live. As with societal trends, nurses often see themselves more as spiritual than religious. This relatively recent phenomenon suggests individuals desire the essence of religion but without its institutional forms.
Although we know little about the specifics of nurses’ religiosity, it is logical to assume that whatever religiosity shapes a nurse will impact her or his work. Some evidence in this regard suggests that not only does nurses’ religiosity have an impact on the nursing care they deliver, but the experience of giving nursing care can have an impact on nurse religiosity. Theoretical and empirical literature exploring this interrelatedness follows.
From a philosophical perspective, Cusveller addresses the question of whether religious nurses should allow religious commitments to influence their nursing care.16 Cusveller raised several pertinent questions: Do nurses’ moral and religious commitments stay in the private realm and never enter health care? Can a nurse really divide commitments? Does nursing “professionalism” really require a neutral moral or religious stance? Is neutrality possible? How is nursing care implemented and evaluated when there are no systems of meaning (philosophy, worldview, or religion) whereby to judge it? After all, science only goes so far in providing answers to what is right, what is well-being, what should be the goal of care, and so forth.
A nurse needs “control beliefs,” beliefs that can guide decisions about what nursing actions to take or not take when universally accepted facts for guiding practice are nonexistent. Cusveller posits that religious beliefs offer religious nurses control beliefs. Cusveller concludes with the following guidance for how the commitments of religious nurses should affect their practice:
Just as scholars cannot rid themselves of their particular points of view, but have to discuss them in order to develop the best possible theories, so nurses have to bring their particular points of view to nursing and [sic] to discuss them in order to provide the best possible care. Moral, philosophical and religious convictions are not just bias, although they may be, but they can also have a positive function. Where there is no universally accepted set of fundamental principles, be it Christian, scientific or professional, nurses may enter the practice of nursing as religious committed nurses.17
Note that Cusveller does not suggest that religious beliefs supersede universally accepted nursing dogma. Thus, rather than sterilizing themselves of religious beliefs while at the bedside, religious nurses can appreciate the control beliefs their religion’s gift to them. Indeed, it is a matter of morality that the nurse maintains integrity, respecting his or her identity and living respectfully with those beliefs.18
Indeed, the notion of value neutrality is an illusion. Ethicist Pellegrino portrays how a clinician’s decision making is inevitably influenced by personal and professional values.19 For example, a nurse teaching a diabetic likely believes that a certain diet and lifestyle is conducive to health, that health should be a high priority for people and society, that teaching the individual is more important than teaching the family, and so forth. Pellegrino disagrees with ethicists who argue the clinician can put aside or alter personal values when a professional role is better filled by doing so (e.g., assist with terminating fetal life when it is against the clinician’s beliefs). To do so would be “moral schizophrenia”; it is impossible and fails to respect the autonomy and dignity of the clinician. Pellegrino suggests that the ethical approach when there is such a clash in values making care impossible should involve: (a) informing the patient of the reasons for why the clinician is removing him or herself from caring, and (b) assisting the patient to find a clinician who will be supportive. The process for informing a patient of a nurse’s removal from care activities, of course, should be respectful and not take advantage of the patient’s vulnerability.
Bjarnason applies physician Daniel Foster’s reasoning for why doctors must consider religion in routine patient care to the work of nurses.20 In addition to accepting that many patients’ responses to illness are influenced by their religious beliefs and that illness often brings to the surface religious issues, Foster recognizes that clinicians’ decisions about how to care for patients is influenced by their own religious beliefs. Although Bjarnason cites a handful of studies about medical doctors’ treatment decisions as being associated with religious beliefs, there is a paucity of research to show how nurses’ caring is influenced by religiosity. A fourth reason for addressing religion among clinicians, according to Foster, is that patients typically place the clinician in the role of secular “priest” (or “priestess” as Bjarnason applies it to nurses). It is not unusual for nurses to receive “confession” from a patient. Such confessions may be of wrongs committed (e.g., sexual indiscretions) or of realizations of the consequences for medical decisions that the patient made while uninformed or under coercion (e.g., to be coded).
Meux and Rooda offer a conceptual model for “religio-specific nursing practice.” 21 This model acknowledges that both the nurse and the patient introduce to the clinical encounter a cultural background that includes religiosity. The model advises that a nurse’s knowledge of differences about religions can help during the actual nurse–patient interaction. The outcome of such interaction should show the nurse’s respect for the patient’s religiosity—hence, religio-specific nursing practice—and the need to educate nurses regarding religions.
A small number of research studies provide insight regarding how nurse religiosity has an impact on nursing care. This research begins to describe how a nurse’s religious affiliation affects attitudes, actual care provided, and how a nurse gives meaning to work. A few studies also describe how religious beliefs help nurses to cope with the stressors of nursing work, as well as how those same beliefs can potentially create dissonance.
Religion Affects Nurses’ Attitudes and Care. Religious nurses often view their work as a “calling”—clearly conferring religious meaning upon their work as nurses.22–24 In Grant’s survey of nurses, a quarter of both those identifying themselves as religious and spiritual (i.e., not religious) acknowledged their work was a calling.25 Indeed, nurses of many other religious traditions likewise view their vocation as a sacred and divinely called—or even as ministry. A Christian nurse participating in a phenomenological study about spiritual care illustrates this point:
We have so many opportunities to share and to witness. I’ve always used nursing as a springboard for ministry. I look at nursing as a ministry, not a job. Maybe that’s why I’ve always enjoyed 32 years and still enjoy it. I still have a passion in working for Christ.26
Whereas some religious nurses view nursing as the end, some (presumably more evangelically oriented) nurses perceive nursing as a means to an end rather than an end in itself. What the “end” is, will vary and reflect the beliefs of the nurse. For example, the ultimate purpose of nursing for some may be to “glorify God” or be a conduit of Love; for others, it may be converting patients to their religious beliefs. These ends raise a vital question for religious nurses: Is the value of my being a nurse in the nursing I do, or in the witnessing I do in the context of nursing? To put this in moral terms, “Is nursing a good in itself, or simply an instrumental good to other ends?”
While some nurses may perceive their call to ministry via nursing in an understated and general way, others may have an acute awareness of specific circumstances leading them into nursing that they attribute to divine guidance. As another Christian nurse observed:
I look at my job as a calling and as a mission field . . . I do believe that the [way for the] door to be open, way back, to even go to nursing school, was divinely appointed. I was sitting in church. Single mom, divorced, no home, no car. No means other than the job and just to survive and I’ve always wanted to go back to school. And it was just not part of what I could swing. And I got a true word that this was the desire of my heart and shortly thereafter the doors began to open and I was able to do that. . . . The calling got louder. And so it’s always been in my heart to be a minister, for my hands to be trained. And this is just how God trained my hands to deliver that.27
This quote also suggests how when a nurse frames the work of nursing as a response to a divine calling, this meaning inevitably manifests in what the “hands deliver”—that is in how care is given.
Most of the research quantitatively linking a nurses’ religiosity with attitudes that influence nursing practice is research exploring spiritual care attitudes and practice. This research fairly consistently suggests that nurse religiosity is linked with positive attitudes toward providing spiritual care, which is directly related to the frequency of giving spiritual care.28–31 An exception to this trend was found in a study of mostly Israeli Jewish nurses among whom no differences in spiritual care attitudes were found between those who were secular or religious.32 Furthermore, the religious Jewish nurses tended to have possibly less positive attitudes about giving spiritual care, likely reflecting a belief that spiritual needs are the domain of religious professionals. When measuring religiosity as intrinsic or extrinsic, however, religiosity was found to predict attitude toward spiritual care.33
A glimpse of how nurses’ private religiosity influences their spiritual caregiving is also seen in data showing how nurses learn about spiritual caregiving. Although basic and continuing education are primary venues for learning, there is evidence that nurses also take what they have learned from their religious leaders, programs, and personal spiritual or religious experiences and apply it to their practice of nursing.34–36
Several studies have also examined if nurse religiosity is associated with attitudes regarding euthanasia and physician-assisted suicide. A detailed review of the evidence completed by Gielen and colleagues supported the hypothesis that nurse religiosity and worldview does influence attitudes toward euthanasia and physician-assisted suicide.37 Religious affiliation and doctrine, observance of religious practices, and the personal importance of religion were found to be factors influencing attitude. These scholars, however, appreciated the diversity of cultures and religious beliefs represented in the collection of reviewed studies made global conclusions inappropriate. They recommend that future research in this area examine how specific theological beliefs (e.g., about the sanctity of life, afterlife, divine intervention, religious authority) influence nurses’ attitudes and care.
A couple of studies explore how nurse religiosity has an impact on how nurses converse with patients. Christopher explores nurse religiosity in relation to willingness to release control in conversations with patients about end of life care.38 It was theorized that when sensitive and morally ambiguous topics, like dying, are discussed with patients, nurses who are personally disconcerted will manage this distress by exerting more control during the conversation. The study involved an online survey of 115 graduate nursing students; religiosity was measured using an intrinsic/extrinsic religiosity scale. It was found that neither type of religiosity correlated with relational control. A direct relationship, however, was observed between intrinsic religiosity and an additional item “I would want a patient to interrupt if I suggested a treatment contrary to his or her religious beliefs.” Although these study findings failed to fully support the hypotheses, future research with stronger methods can shed further light on the ways in which nurse religiosity does have an impact on interaction with patients. Pesut and Reimer-Kirkham’s ethnographic study describes how nurses sometimes used their religious experience as a connecting point with patients, a way to gain entrée to talk with them about spirituality.39 Conversely, these researchers also observed that sometimes nurses realized their religiosity was something to hold back. Hence, nurses may juggle whether and when to hide or expose their religion. This is illustrated in Geller and colleagues’ survey of genetic nurses.40 Over a quarter of these 59 nurses responded that they occasionally/commonly felt conflicted about disclosing personal beliefs to colleagues or patients.
Although scanty and weak, this evidence does indeed begin to show how nurses’ religiosity influences how they care. The religious beliefs motivating nurses, however, vary. A qualitative study of Iranian Muslim nurses found some nurses viewed the provision of nursing care as an opportunity to worship God.41 Similarly, nurses of other religious traditions may be motivated by an experience of divine love, and wish to reciprocate this through nursing caring.42 Many religions espouse a “Golden Rule” and this may form a foundation that motivates a nurse. As one nurse puts it, “I look to Christ as my example and I look at the patient and [consider] how I would want to be treated in the same manner.” For others, the presumption of a divine judgment and potential retribution may motivate their good deeds. As the first nurse quoted above stated, “I have to answer to Him at the end of the day.”
Religious coping among nurses. A handful of studies about nurses begin to show what has been well-established among patients: Religiosity influences coping. Qualitative studies from Canada, Sweden, and the United States briefly portray how nurses’ religious faith help them to maintain hope, find comfort, cope with the stressors of work, and provide a meaningful orientation.43–46 Bunta explores religious coping among emergency department and intensive care unit nurses and found that both state and trait anxiety were predicted in part by religious coping.47 That is, negative religious coping (e.g., endorsing items like feeling abandoned or punished by God, questioning the power of God) explained a significant amount of anxiety. Likewise, positive religious coping was linked with lower anxiety among these nurses in stressful work environments. Another study of Hungarian sister nurses (Roman Catholic nuns) demonstrated an inverse correlation between religiosity and burnout, suggesting that religious beliefs and practices can function to protect nurses against burnout.48
I feel that as a Christian, when the Holy Spirit tells me to pray with that individual even if I’m not supposed to, that the Lord will protect me. And so I don’t care; [laughs] so that’s always been my attitude.49
This nurse’s remark raises questions: Under what circumstances is it ethical for religious nurses to introduce their particular religious practices or beliefs to patients? Is it possible that some religious beliefs, such as interpreting promptings as of the Holy Spirit and the omnipotence of God to protect them from ill-conceived nursing care, could sometimes be detrimental to patient care? How can a religious nurse know whether to follow divine promptings that would have an impact on nursing care? These are difficult questions. Some guidelines for helping the religious nurse to address the above questions will be offered following a discussion to increase an awareness of how nurse religiosity can create negative and positive effects in nurse–patient encounters.
The nurse–patient relationship is inevitably asymmetric in terms of power; a nurse can potentially use his or her religion to harm a patient—albeit unintentionally. Although in theory a patient has the power to refuse a nurse’s care, in reality such a refusal is improbable given the resulting challenges it would pose (e.g., “I need nursing help now, and I don’t want to have to wait for a different nurse—who might be as bad as this one!” “Might the system hold my refusal against me?”). Thus, the patient is in a vulnerable position as the recipient of nursing care. Given this power imbalance, it can be appreciated how the unwelcomed or inappropriate introduction of religion at the bedside could easily become harmful to the patient or detrimental to the nurse–patient relationship and nursing care.
There are more subtle ways, however, in which religious nurses’ beliefs can become hurtful. Taylor identifies ways in which a nurse could speak harmfully, even in an attempt to comfort a patient searching for meaning.50 For example, a very common misquotation from the Christian New Testament is “God doesn’t give you more than you can bear” which may leave the patient confused about a punishing deity and reinforce that they are suffering more than they can bear. Likewise, “Just pray about it” is often unhelpful and may show the patient how the nurse needs to use religion as avoidance coping or for passive decision making. Although a religious nurse likely has the sincerest of intentions, such admonitions can be harmful for patients who are spiritually struggling.
Whereas the potential negative effects of a nurse introducing personal religious beliefs or practices into nursing care can seem to outweigh the potential positive effects, it is important to remember how religion can benefit—and may outweigh the negatives—in the nurse–patient encounter. Because religions offer individuals ways of understanding suffering, explaining life and death, purpose for living, and guidance in clinical moral decisions, religious nurses have a framework for making sense of the tragedies they continually witness at work.51,52 Religions characteristically also provide believers with hope, social support, and practices that promote emotional and physical health.53 If a nurse does find these benefits from a religion, she or he undoubtedly has an important tool for dealing with the stressors of nursing practice.
A common dimensionality applied to religiosity in nursing research is that of intrinsic and extrinsic religiosity. Simply put, intrinsic religiosity is religion that is lived (i.e., religiosity is integrated in all aspects of living), whereas extrinsic religiosity is used to seek an end (e.g., to gain social status, to achieve immortality). The scanty evidence about nurses’ religiosity may mirror that observed among patients: that is, a solid intrinsic religiosity is associated with positive outcomes, whereas extrinsic religiosity may not be helpful.54,55 Furthermore, positive religious beliefs are associated with positive outcomes, and negative religious beliefs are linked to negative outcomes.56 Thus, it is likely that it is the nurse with high intrinsic religiosity and a paucity of negative religious beliefs who is well equipped for the rigors of nursing. We conjecture that such “armor” should allow nurses to be able to be more peacefully present to a patient and offer more wisdom when the patient asks for it.
Occasionally, a nurse’s personal religious beliefs contradict professional beliefs. Perhaps the most common instance of such a clash is when nurses whose religious beliefs maintain it is morally wrong to abort a fetus are asked to assist with an abortion procedure or counsel couples about it as a therapeutic option. Winslow and Wehtje-Winslow maintain that nurses should provide care that is consonant with their beliefs.57 Pellegrino agrees, and suggests that during initial contact with patients, clinicians should inform patients of their religious perspective if it is likely to influence the subsequent care they deliver.58
Both the American and Canadian Nurses’ Associations codes of ethics contain a “conscientious objection” clause.59,60 Conscientious objection permits a nurse to refuse to participate in a nursing duty on the grounds of moral or religious objection. Conscientious objection can be invoked for categories of activity (e.g., participation in abortion or sexual reassignment) or for particular interventions for particular patients on the grounds of moral inappropriateness for that patient (e.g., not in the patient’s best interests, or the patient did not want it). Both codes state that although patient safety is foremost, the nurse must provide safe, compassionate, and competent care for a patient requiring care the nurse believes to be morally unacceptable until alternative arrangements can be made. The patient is never to be abandoned. Nurses can and should, however, communicate this objection in advance. Conscientious objection to participation in particular treatments ought to be discussed with employers (including patients, if the nurse is in solo practice). For example, a midwife may have a brochure introducing herself, as well as a verbal introduction, that indicates how her religious beliefs could affect her nursing care. A nurse employed by an institution that offers treatments morally objectionable to the nurse should opt out of participation, in writing, at the start of employment. This, of course, would not affect conscientious objection on the grounds that a particular treatment was contrary to the patient’s best interests or wishes. Pellegrino suggests that when clinicians refuse to provide care due to religious reasons, they should assist patients to find a replacement.
Proselytizing, an attempt to convert another to one’s own religion, is the most essential concern about religious nurses sharing their religious beliefs or practices with patients. However, proselytizing should not be confused with openness about one’s religious faith when a patient asks. Proselytizing, or evangelizing, seeks the end of conversion. It is generally considered to be morally objectionable to proselytize in illness settings where that setting is not explicitly and openly religious. There is a power differential between nurse and patient, and patients are generally made more vulnerable by illness. These factors combine to constrain a patient’s freedom in the face of proselytizing.
Thiessen proposes that there is a continuum of persuasion. At a gentle end of this continuum is education.61 While moving toward a more aggressive end of coercion, one passes through advisement and persuasion. This can be schematically presented as:
educate → advise → persuade → coerce
Thiessen posits proselytization can be moral when it is nonaggressive and noncoercive; immoral proselytization, in contrast, is aggressive and coercive. Thiessen argues that proselytizing is ethical or moral when it is done as an expression of care and respect for the other person. It should be done in a way that protects the dignity and worth of the individual. Thus, this philosopher offers a framing for the possibility of an ethical sharing of nurse religiosity with patients.
Fowler disagrees. However soft the attempt at proselytizing, it is intrinsically coercive in a nonreligious setting, and seeks the end of conversion. It also subordinates nursing to evangelization. Fowler would, however, allow that when a patient asks about a nurse’s own faith, the nurse is free to share—as a part of a duty to self to maintain wholeness of person—but it is only permissible if that sharing preserves and affirms the patient’s freedom and autonomy. In these instances, sharing is at the patient’s request, is welcomed by the patient, and aims to support (not convert) the patient. Because such welcome sharing also has the potential to deepen a dialogue with patients that moves them toward greater clarity of the patients ’ own values, or healing, or a relationship that addresses their spiritual needs in the face of illness or trauma, it should not be foreclosed. Sharing one’s faith, then, must be done only with an eye to the health-related concerns, even health-related spiritual concerns, of the patient, and not disconnected from that for some salvific aim.62
Guiding Principles. The ANA and CNA codes of ethics mandate that patients’ “religious beliefs” or “unique values, customs and spiritual beliefs” be respected to preserve their dignity.63,64 The interpretive statements accompanying these codes also provide guidance on this issue of proselytization. The ANA Code of Ethics with Interpretive Statements states:
In situations where the patient requests a personal opinion from the nurse, the nurse is generally free to express an informed personal opinion as long as this preserves the voluntariness of the patient and maintains appropriate professional and moral boundaries. It is essential to be aware of the potential for undue influence attached to the nurse’s professional role. Assisting patients to clarify their own values in reaching informed decisions may be helpful in avoiding unintended persuasion.65
Similarly, the CNA Code of Ethics states:
Nurses maintain appropriate professional boundaries and ensure their relationships are always for the benefit of the persons they serve. They recognize the potential vulnerability of persons and do not exploit their trust and dependency in a way that might compromise the therapeutic relationship. . . .66
These Codes remind nurses of their primary role of supporting patient health (not religious indoctrination) and of the powerful position the nurse holds intrinsically in any nurse–patient relationship. Sharing of a religious “opinion” can threaten this delicate relationship if the patient did not volunteer for it, and if the nurse exploits a patient’s request for it.
Greenway’s fundamental principles for religious evangelism provide further guidance for the nurse whose patient has asked for a religious perspective.67 These principles include:
Reciprocity. This means that the nurse sharing religious beliefs and the patient ought to have equal opportunity to share their ideas. Such a stance requires that the nurse is respectful and not defensive. Guidelines for nurse self-disclosure include not only initially asking “whose needs am I meeting by self-disclosing?” but also following up self-disclosures with a question for the patient that allows them the opportunity to respond so the nurse can gauge the therapeutic value of the disclosure.
Honesty in both message and methods. Not only must the message given be truthful, but the means whereby it is delivered is not deceptive. Asking a patient, “Do you mind if I ask you a question?” to gain entrée to share religious beliefs is misleading and coercive. Another subtle way some religious nurses may coerce their beliefs is by preaching—sharing beliefs—during a prayer, when a patient has only asked for prayer. “Bait and switch” tactics become unethical in the context of caring for vulnerable people (e.g., having nursing students obtain patients’ permission to survey them about their spirituality, then ending the “survey” with a conversation where their religious beliefs are shared.) This principle should also encourage heart-searching among missionary nurses about methods for health evangelism (e.g., is material assistance or health care used as bait for evangelism among disadvantaged people?)
Humility. The nurse who shares her or his faith must not be arrogant or condescending, and not self-serving or self-glorifying. The nurse who is sharing religious beliefs must not be doing it for personal gain (e.g., to gain her own salvation, or to get “another jewel in my crown”). Rather, sharing must have an authentic desire for the well-being of the other’s health. It is also done to please God, not self or others. Nurses who believe they are responsible for converting others are trusting themselves, not their God.
Respect. The nurse must recognize that patients are not objects to manipulate. Instead of coercion, the religious nurse should respect and support a patient’s freedom to make choices. Of course, this includes the freedom to not discuss religious matters.
Again, Fowler would maintain that proselytizing is impermissible in the nonreligious health care context, that it wounds a patient’s freedom, that it makes nursing subservient to other ends, and that it disconnects faith from health concerns that are the proper purview of the nurse.68 However, she would affirm that Greenway’s principles should be attributes of all nurse–patient relationships: reciprocity, honesty, humility, and respect.
Although there may be times when a religious nurse is asked by a patient to address religious concerns, it is important for nurses to remember that they are the spiritual care generalists.69 Spiritual care experts such as trained chaplains, pastoral counselors, spiritual directors, and clergy are the specialists. Sometimes nurse–patient conversations about religious concerns will inform the nurse that a serious issue exists. At such times, the nurse should ask the patient for permission to make a referral and discuss with the patient which expert is preferred.
Many nurses are religious. The religious dimension of their personhood cannot be extracted and placed in the nurse’s locker while she or he works. Indeed, a small body of evidence indicates nurse religiosity is related to attitudes and practice, especially about spiritual care and end-of-life care. It is important for nurses to reflect on how their personal religiosity does have an impact on their provision of care. Without this bracketing, it is inevitable that the nurse’s religiosity will manifest in disrespectful and harmful ways at the bedside. This chapter provides recommendations for how nurses can ethically bring their religion to the bedside. More clinical guidelines are provided in the companion book Religion: A Clinical Guide for Nurses.70
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2. Grant, Donald, Kathleen M. O’Neil and Laura S. Stephens. “Neosecularization and Craft versus Professional Religious Authority in a Nonreligious Organization.” Journal for the Scientific Study of Religion 42.3 (2003): 479–87.
3. Cavendish, Roberta, Lynda Konecny, Claudia Mitzeliotis, et al. “Spiritual Care Activities of Nurses Using Nursing Interventions Classification (NIC) Labels.” International Journal of Nursing Terminology Classification 14.4 (2003): 113–24.
4. Taylor, Elizabeth J., Martha Highfield, and Madalon Amenta. “Attitudes and Beliefs Regarding Spiritual Care: A Survey of Cancer Nurses.” Cancer Nursing 17.6 (1994): 479–87.
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7. Taylor, Elizabeth J., Martha Highfield, and Madalon Amenta. “Predictors of Oncology and Hospice Nurses Spiritual Care Perspectives and Practices.” Applied Nursing Research 12.1 (1999): 30–37.
8. Grant, et al., op. cit.
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10. Scott, et al., op. cit.
11. Taylor, Elizabeth J., Iris Mamier, Khalid Bahjri, et al. “Efficacy of a Self-Study Programme to Teach Spiritual Care.” Journal of Clinical Nursing 18.8 (2009): 1131–40.
12. Pesut, Barb, and Sheryl Reimer-Kirkham. “Situated Clinical Encounters in the Negotiation of Religious and Spiritual Plurality: A Critical Ethnography.” International Journal of Nursing Studies 47.7 (2010): 85–825.
13. Ibid., 8.
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17. Ibid., 977.
18. Fowler, Marsha. Ed. Guide to the Code of Ethics for Nurses: Interpretation and Application. Silver Spring, MD: American Nurses Association, 2008.
19. Pellegrino, Edmund D. “Commentary: Value Neutrality, Moral Integrity, and the Physician.” Journal of Law, Medicine, & Ethics 28.1 (2000): 78–81.
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21. Meux, Louis, and Linda A. Rooda. (1995). “The Development of a Model for Delivery of Religio-Specific Nursing Care.” Journal of Holistic Nursing 13.2 (1995): 132–41.
22. Edwards, Adrian, N. Pang, V. Shui, et al. “The Understanding of Spirituality and the Potential Role of Spiritual Care in End of Life and Palliative Care: A Meta-Study of Qualitative Research. Palliative Medicine 24.8 (2010): 753–70.
23. Grant, et al., op. cit.
24. Taylor, Elizabeth J. and Mark Carr. “Nursing Ethics in the Seventh-Day Adventist Religious Tradition.” Nursing Ethics 16.6 (2009): 707–18.
25. Grant, et al., op. cit.
26. Unpublished data from a phenomenological study of Christian nurses identified as spiritual care “experts” being conducted by Taylor, Elizabeth J., Jane Pfeiffer, and Carla Gober. Loma Linda, CA: Loma Linda University School of Nursing.
27. Ibid.
28. Grant, et al., op. cit.
29. O’Shea, Eileen R., M. Wallace, Margaret Q. Griffin, et al. “The Effect of an Educational Session on Pediatric Nurses’ Perspectives toward Providing Spiritual Care.” Journal of Pediatric Nursing 26.1 (2011): 34–43.
30. Taylor, Elizabeth J. “Spiritual Care Nursing Research: The State of the Science.” Journal of Christian Nursing 22.1 (2005): 22–28.
31. Chan, Moon Fai. “Factors Affecting Nursing Staff in Practicing Spiritual Care.” Journal of Clinical Nursing 19.15–16 (2010): 2128–36.
32. Musgrave, Catherine and Elizabeth McFarlane. “Israeli Oncology Nurses’ Religiosity, Spiritual Well-Being, and Attitudes toward Spiritual Care: A Path Analysis.” Oncology Nursing Forum 31.2 (2004): 321–27.
33. Musgrave & McFarlane, 2004, op. cit.
34. Sellers, Sandra C. and Barbara Haag. “Spiritual Nursing Interventions.” Journal of Holistic Nursing 16.3 (1998): 338–54.
35. Highfield, Martha, Elizabeth J. Taylor, and Madalon Amenta. “Preparation to Care: The Spiritual Care Education of Oncology and Hospice Nurses.” Journal of Hospice and Palliative Nursing 2.2 (2000): 53–63.
36. Taylor, Elizabeth J., Iris Mamier, Khalid Bahjri, Triin Anton, and Floyd Petersen. “Efficacy of a Self-Study Programme to Teach Spiritual Care.” Journal of Clinical Nursing 18.8 (2009): 1131–40.
37. Gielen, et al., op. cit.
38. Christopher, op. cit.
39. Pesut & Reimer-Kirkham, op. cit.
40. Geller, et al., op. cit.
41. Ravari, Ali, Zohreh Vanaki, Hydarali Houmann, et al. “Spiritual Job Satisfaction in an Iranian Nursing Context.” Nursing Ethics 16.1 (2009): 19–30.
42. For example, see: Taylor & Carr, op. cit.
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46. Geller, et al., op. cit.
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49. Taylor, Pfeiffer, & Gober, op. cit.
50. Taylor, Elizabeth J. Spiritual Care: Nursing Theory, Research, and Practice. Upper Saddle River, NJ: Prentice Hall, 2002.
51. Cavendish, Roberta, Lynda Konecny, B. K. Luise, et al. Nurses Enhance Performance through Prayer. Holistic Nursing Practice 18.1 (2004): 26–31.
52. Gerow, Lisa, Patricia Conejo, Amanda Alonzo, et al. “Creating a Curtain of Protection: Nurses’ Experiences of Grief Following a Death.” Journal of Nursing Scholarship 42.2 (2010): 122–29.
53. Levin, Jeff. God, Faith, and Health: Exploring the Spirituality-Healing Connection. New York: Wiley, 2001.
54. Christopher, op. cit.
55. Musgrave & McFarlane, 2004, op. cit.
56. Bunta, op. cit.
57. Winslow, Gerald R. and Betty Wehtje-Winslow. Ethical Boundaries of Spiritual Care. Medical Journal of Australia 186.10 Supplement (2007): S63–65.
58. Pellegrino, op. cit.
59. American Nurses Association. Code of Ethics with Interpretative Statements. Silver Spring, MD: Author, 2008. Web. 20 March 2011, from http://nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/EthicsStandards/CodeofEthics.aspx.
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61. Thiessen, Elmer J. “The Problems and Possibilities of Defining Precise Criteria to Distinguish between Ethical and Unethical Proselytizing/Evangelism.” Cultic Studies Review 5.3 (2006): 374–87.
62. Perspective of Dr. Marsha D. M. Fowler, noted nurse ethicist and ordained Presbyterian clergy, in personal communication with the author April 7, 2011.
63. American Nurses Association, op. cit.
64. Canadian Nurses Association, op. cit.
65. American Nurses Association, op. cit., Provision 5.3.
66. Canadian Nurses Association, op. cit. ANA Provision D.7.
67. Greenway, Roger S. “The Ethics of Evangelism.” Calvin Theological Journal 28 (1993): 147–54.
68. Fowler, op. cit.
69. Taylor, Elizabeth J. “ Spiritual Care: Nursing Theory, Research, and Practice.” Upper Saddle River, NJ: Prentice Hall, 2002.
70. Taylor, Elizabeth J. “ Religion: A Clinical Guide for Nurses.” New York: Springer, in press.