Dating from as early as the third millennium BCE, Ancient Near Eastern religious texts display a substantial body of prophetic literature. Ugaritic, Phoenician, Aramaic, Urukan, Marian, Assyrian, Ischchalian, and Egyptian prophets all spoke to the people in words of social and religious criticism, of announcements of things to come, and as charismatically authorized messengers from God to the people. Depending on the sociopolitical and religious context of the prophet, in any given example their words may not have reflected all three functions of prophets. In the Jewish Biblical tradition, at times they would speak a word of warning (e.g., preexilic prophets), at times a word of hope (exilic prophets), and at times an announcement of a world to come (postexilic prophets). It seems fitting in a book on religion and nursing to end with a prophetic word—words of warning, hope, encouragement, critique, and of that which may lie ahead.
Nursing’s current neglect of religion as it affects patient care extends to a neglect of religion as it has contributed to modern nursing’s development of nursing schools, education, research, and practice. Both directly and indirectly, religion has played an historical role in shaping modern nursing and in internationalizing nursing in underserved regions, a role that remains largely unexplored though eminently worthy of research. Shunning religion in the service of nursing’s ambition toward social recognition as a science and a profession has not served nursing well in at least two ways. First, patients have not benefited from religiously competent nursing care. Such care could have drawn upon religious understandings of duties toward health and wellness, and in caring for others, and comfort in grief or at the end of life. Our intent is not to erase the ways in which nursing’s focus on spirituality in the last three decades has benefited nursing care, but rather to underscore the incompleteness of approaches that overlook religious understandings. Second, nursing’s longstanding social ethics has never been systematically developed. Some of the healthrelated social policies developed by religious denominations are of exceptional breadth, depth, coherence, and comprehensiveness as models for how nursing might do health policy and social ethics. Contemporary religious policies regarding health and health care often address health disparities and the social determinants of disease. As policies, they demonstrate how the value structure and metaphysics of a tradition might coherently inform and articulate with a social policy. Nursing has much that it could learn if it would permit itself to be informed by the extensive and mature body of social–ethical literature developed over centuries by many religious traditions.
Nursing’s attempt to work in isolation, as it has with spirituality, poses a risk to its study of religion. On the one hand, it runs the risk of essentializing religion, as has been done in any number of Introduction to Nursing textbooks, or reducing it to a set of attributes that reify religion into a static, and largely lifeless entity. On the other hand, religion can be understood so broadly that it fails to provide anything to work with in terms of informing actual patient care. We must not forget that the concern of nursing is religion as it interacts with health; nursing need not define religion per se as much as identify the boundaries of its domain of concern.
A careful reading will indicate that this work is not simply another proreligion source that gives nurses license to discuss religious beliefs with patients or to introduce religious practices into nursing care. Nurses who practice outside of religious hospitals or agencies are not often given ethical guidelines for discussing religion with patients, even though accrediting bodies mandate nurses be taught to assess and care for the spiritual dimension. As integrated, whole persons, nurses inevitably bring their personal religious faith or philosophy to the bedside. As nursing begins to explore the import of religion on nursing and nursing care, attention will need to be given to appropriate moral boundaries for discussing religion in the clinical context. This will also have curricular implications for basic as well as graduate education in nursing.
There is little research data to guide nurses regarding how they might support patients spiritually or religiously. While evidence indicates that religion can create both positive and negative outcomes for patients, nurses are not prepared to assess or intervene appropriately in either case. And while there is some research that incorporates religion, most of it is on religion as a coping strategy or as one of several factors in coping. Yet there is substantially more to religion than coping that is relevant to nursing practice. Additional research is needed to explore the ways in which the metaphysics of a religious tradition influences bioethical and clinical decision making, whether by patients or by nurses. There are, thus, implications for nursing research, instrument development, education, and practice.
Nursing urgently needs to wrestle with the implications of including religion in nursing education, research, and practice. More specifically, nursing needs to grapple with what is or is not within its purview with regard to religion and health/illness and to delimit its involvement to religion visàvis health. Even so, there are levels of involvement that may be appropriate to advanced nursing practice that are not appropriate to basic nursing practice that remain to be discussed. In addition, future study and translational research are needed to create processes for improved, effective, and ethical collaboration between nurses and non-nursing experts who can support adaptive patient religiosity.
While the point can be wellargued that the profession of nursing needs to tend to the influence of religion in the lives of their patients and that religious ethics provides guidance to nurses who care for patients affiliated with particular religious traditions, or who are themselves adherents, we would be amiss not to acknowledge the contextual or social constraints that may make this integration difficult. With the development of nursing ethics as distinct from bioethics or medical ethics, attention has been put on the moral climate of the practice environments of nurses. The priorities of the modern health care system of efficiency and cure do not align easily with tending to the sacred. Quality practice environments, such as those found in agnet hospitals, provide the resources, support, and climate required for nurses to enact their moral agency to operationalize ethical principles and values. A question that requires examination is whether the leadership and organizational culture that facilitates quality practice environments would equally support the enactment of religious ethics. It could be anticipated that nurses working in faith-based organizations, or in organizations loosely or historically affiliated with faith traditions (such as hospitals administered by the Catholic Health Association or the Salvation Army) might have more support for the integration of religious ethics. Spiritual care providers (also referred to as chaplains) typically cite spiritual support to staff as an integral aspect of their role, suggesting that spiritual care services in hospitals open dialogic space for tending to matters of the spirit, and departments legitimate the role of religion and spirituality more generally in relation to the illness experience. Health care administrators likewise play a key role in creating a climate where religion and spirituality might be incorporated into care, for all faith perspectives. Undoubtedly, the contextual influences that must be negotiated for the inclusion of religious ethics vary considerably from unit to unit, organization to organization, and society to society. Our work on this volume with contributors from several continents has reminded us of these variations, with the clear message that although numerous health care services, especially those providing public health and community development services, are provided by religious organizations, in many places religion is not always welcomed into the public sphere of health care.
No discussion of the intersections between religions, nursing, and ethics could be complete without acknowledging the contested role of religion in public life, and more specifically in the case of this volume, the role religions should play in the development of public policies and practices in the realm of health care. This question becomes more urgent in pluralistic societies where it is not one religious perspective that is accommodated, but rather multiple voices that may not always agree. Assumptions that secularism provides a neutral space in which to provide health care without the messy interruptions of religion are increasingly challenged, not as obviously in nursing literature to date, but increasingly in the social sciences and humanities. With globalization, religions that do not distinguish between public and private, secular and sacred, are being established in western secular nations to compel an examination of the role of religion in public life.
At the least, nurses and other health care professionals must seek to recognize the influence of religion in patients’ lives and not demean patients on this account. Nursing codes of ethics underscore nurses’ duty to provide safe, competent, compassionate, and ethical care extending to an accommodation of religious, spiritual, and cultural values and practices. Any tendency to relegate religiously informed values and beliefs to the domain of the private and thus as not relevant to health care services and the experience of health and illness risks imposition of the dominant Western cultural worldview (a hegemonic centre) that holds to secular/sacred, public/private binaries. But more than respect for individual values and beliefs, the question of the role of religion in public life extends to the contributions of religious discourse to ethical theories.
The role of religion in public life at the level of the state continues to engage scholars, politicians, and policy makers, and citizens alike in debate, and produces complicated political effects. Sacralization, with the widespread diffusion of the sacred across society, also to what is deemed secular, adds further complexity by its more implicit influences. The challenge is one of achieving a form of responsible pluralism, where multiple religious, spiritual, and nonreligious views are welcomed equally, without relativizing, syncretizing, or homogenizing the underlying belief systems, and without succumbing to the dynamics of power that inevitably shape which of multiple perspectives are foregrounded. Hence, pluralism is qualified with responsible, a term that underlines the need for inclusive dialogic space, but also agreement that there is judgment and negotiation in how one’s own views are enacted in the public realm. At its basis, a responsible pluralism seeks common ground by balancing unity and plurality, recognizing the universality of human experience with detailed engagement with the particularities of various traditions. The challenge—and the opportunity—is that of bringing many perspectives into the realm of professional ethical discourses, including those of religious traditions, rather than confining them to the private realm, and thus enlisting the support of all reliable moral discourses in support of respect, dignity, and equity.
Religion has played, and will continue to play, a significant role in the lives of nurses and hence in the profession of nursing. Religion can have numerous benefits for individuals including social support, a sense of significance, and answers for those questions in life that, while common to the human condition, are notoriously hard to answer—what is my purpose, why does suffering exist, and what comes after? Indeed, religion can provide a profound sense of identity whereby one belongs to a special group, with a special purpose, that contributes something good and meaningful to the world.
This sense of identity may be one of the reasons that religion has been so enduringly significant for nursing. The history of nursing appears at times to be one long identity crisis, as the profession has struggled to carve out its niche alongside medicine. Carving out this identity has been attempted through many ideals. Nursing models, the adoption of concepts such as caring to uniquely define nursing, and, more recently, calls for social justice and equity grounded in theoretical perspectives such as feminism, poststructuralism, and postcolonialism have arisen out of a desire to find common ground for a nursing identity. This common ground is moral ground. Within these ideals, nursing is striving to implement change for the betterment of society. Religion too makes an important contribution to nursing as a moral and meaningful practice. What we have sought to reveal in this book is a deeper understanding of how those contributions occur for nurses and patients alike. In contrast to a caricature of religion that superficially deals with belief and ritual, we have sought to illustrate how religions can provide thoughtful and nuanced answers to the complexities of life. Or in some cases, not answers but rather mystery that, while defying answers, may nevertheless contribute profoundly to meaning.
However, inevitably, those things that are most powerful also carry the most risk and such is the case with religion in nursing. As religion becomes more globalized, and the discourse of spirituality becomes more accepted in nursing, there are inherent risks. Professional nursing organizations are consistent in prohibiting proselytizing by nurses. Caution is in order. One of the highest risks is that the same religious identity that provides such a powerful sense of belonging and purpose will ultimately become exclusionary. Paradoxically, the strongest group identities are often built around a sense of owning something special that necessitates the presence of an “other” that does not bear the same privileges. It is this risk that becomes ours as we embrace the idea of religion in nursing. The task then becomes creating a space within which individuals are free to create and enact their sense of religious identity while holding equal space for the religious or nonreligious identities of “others.”
This exclusionary sense is rarely intentional. Rather, it tends to arise when we are passionate about some truth and have the most altruistic sense of wanting to do something right and just with that truth. This happens not only within religion in nursing but in all of those ideals (e.g., caring, equity, social justice) that have informed nursing theory and epistemology over the past decades. They perhaps become most problematic when they are positioned as the lens rather than a lens by which to inform the profession. Spaces for diverse ideals are perhaps better made by anchoring the common ground in the more pragmatic tangibles of practice than in the metaphysical and social claims that by necessity are so complex that they inform one aspect of a more complete picture. We need to be cautious about creating any type of globalizing nursing theory, model, or concept (even that of spirituality) that attempts to reconcile the inherent diversities of religion.
And yet, we can envision a time when nursing must do the difficult task of reconciling diverse religious perspectives. Religions, as this book illustrates, contain sacred and powerful ideas of what is good, and how one should live rightly in relation to that goodness. That is, religion is about morality, but that morality takes on different forms both within religions and across religions. A debate within nursing is where the moral authority comes from that undergirds nursing ethics. Religious nurses have argued that it should be derived from religion. If that is so, in the face of religious diversity, is there a common morality that crosses religions? Others have argued that morality can and should be constructed and negotiated within our shared humanity. In that case, religion is just one aspect that informs that humanity. These approaches may indeed lead to quite different places. As society continues to struggle to accommodate emerging forms of religious and spiritual diversity, we anticipate that these questions will generate significant debate.
Nursing theories define the foundational concepts of nursing—nursing, person, health, and environment—in ways that identify what nursing is, its phenomena of concern, and its ends. Nurses’ understanding of health, defined in vitro, risk running afoul of patients’ in vivo religiously informed understanding of health and the attendant duties regarding health. It is less likely that there is an outright conflict than that the religious understanding of health in a given tradition is more expansive than that of nursing, set as it is within the broader context of a particular religious worldview. There are, thus, two avenues that nursing might pursue to its own benefit and the benefit of patients. First, nursing might become informed about and by the comprehensive worldview and ethical systems of religious traditions in which health is defined. Beyond health, nursing needs to know more about how these traditions approach concepts such as suffering, compassion, wholeness, striving, equanimity, well-being, justice, illness, and care of the stranger—and the attendant moral issues that arise from them such as quality and value of life, euthanasia, reproductive issues, homosexuality, marriage and family, family breakdown, domestic violence, abortion, vegetarianism, leisure and rest, drug use, the place of elderly persons, conflict, and more. Second, nursing might examine its own theoretical conceptualizations in the light of what religion might offer to enrich, clarify, or critique those conceptualizations. Every day nurses are confronted by human strength and human frailty, wholeness and brokenness, goodness and evilness. These are part and parcel of the human condition and our consanguinity as humans, and the substance of millennia of religious reflection, wisdom, and concern. Nursing’s understanding of itself and of humanity can only be enriched by breaking the taboo against engaging with religion.
For nursing ethics, a renewed attention to religion could mean opening an entire universe of discourse that is as rich and diverse as humanity itself—and from which nursing has largely excluded itself. Religious traditions have much to teach us about how ethical matters are lived out individually and communally in the day-to-day, not necessarily by the application of elegant ethical decision-making frameworks or studied ethical principles, but by reliance on virtues, sacred teachings, and communitarian mores. Examples from religions such as Judaism and Engaged Buddhism can teach us how to apply social justice at once at individual and social levels for human flourishing. Were nursing to open itself to the reflection and wisdom on the human condition, responsibility, and community offered by religious traditions, it would find itself able to think in new and more capacious ways about its identity, theory, practice, and ethics.
Finally, traditional ethics, particularly bioethics, has increasingly been critiqued as “armchair” ethics, debating formal systems of theory (such as the merits of deontological and utilitarian approaches) and prescribing principled solutions and decision-making algorithms for those ethical quandaries that stand out as extraordinary. In contrast, the recent move to “lived ethics” puts forward not a system of formal theory, but rather an approach to ethics that attends to moral assumptions and ideals that shape how individuals and groups live their lives. Lived ethics resonates for nurses who understand the mutual shaping of ideas and real life, where all of one’s professional practice becomes an ethical way of being. Religions too must be understood as lived, not as codified, discrete systems of beliefs and practices. As amply illustrated in this volume, individuals take up religious affiliation, practices, and beliefs in various ways. Other social classifications and phenomena intersect with religion, so that the study of religion in isolation from other social considerations risks reification, conflation, and/or essentialisms. Recurrent in the preparation of this volume is the challenge of teasing out and articulating ethical systems of thought from everyday lived religion. Religious ethics, in particular, are lived in the everyday as an integrative way of life, as individuals and communities take direction from various sources of moral authority that may simultaneously emphasize virtuous living and communal responsibilities for all members of society. Religious ethics—whether indigenous, emergent, Hindu, Jewish, or Sikh—for this reason alone, serves as a remarkable resource for nurses, for it represents a completely different integrative approach to ethics than the bioethical models that dominate Western health care. Too often, nurses align with a particular school of ethics, such as feminist ethics, relational ethics, virtue ethics, contextual ethics, Kantian ethics, or principle based ethics, all of which have their strengths, but which alone do not provide sufficient resource for the complexity of moral practice in today’s diverse societies. Religious ethics, with injunctions for everyday life embedded in strong social networks, can offer many lessons for nursing ethics on the everyday mutual shaping of ideas and practice.