“He comforts us in all our afflictions and thus enables us to comfort those who are in trouble, with the same consolation we have received from him” (2 Cor. 1:4 NAB)
By Teresa Durbak Sipos
Moral injury has emerged as one reason that nurses leave the profession, worsening the nursing shortage in the wake of COVID-19. Recent surveys now include the concept of spirituality as a possible resource for nurses, adding support from “those within your community (e.g., through faith-based organizations or other support networks).”
But how can nurses answer research questions about moral injury without first having an understanding of moral theology? And how can nurses provide reliable spiritual care if they lack the knowledge, vocabulary, and experience to integrate spirituality within professional practice?
Prior to COVID-19, I had already developed an introductory nursing lecture which evolved into a nursing spirituality course, “Integrating Spiritual Healthcare Interventions into Nursing Praxis.”
However, I also saw an imminent need to address nurse suffering, specifically depression and suicide – again, even before COVID. Specifically a course was developed to enhance healthcare workers’ personal and professional lives through reflection and application of the fruit and gifts of the Holy Spirit, the theological and cardinal virtues, Catholic healthcare ethics, the Beatitudes, and the corporal and spiritual works of mercy.
Although nurses are present every day, every shift, every hour in healthcare settings, learning to integrate faith into nursing praxis is new information and unfamiliar territory. A part of equipping nurses and healthcare workers to provide spiritual care includes the courage to speak up for the patient’s right to the essential spiritual dimension of healthcare.
New information from my research is summarized in these data points. In the PEER survey (November 2020), 65% of spiritual care providers disagreed or strongly disagreed that nurses know how to provide spiritual care. PEER survey results affirmed unanimously, 100%, that nursing schools should teach spiritual care, and 90% of current professional spiritual care providers responded that they would also benefit from a nursing spirituality course. The PEER data opinion survey also reported unanimously, 100%, that patients want to receive spiritual care.
Baseline research in 2019 reported that 48% of the student nurses at a secular community nursing program would be interested in a course on spiritual care, with 80% of the surveyed student nurses reporting faith/spiritual beliefs. Also, 81% strongly agreed or agreed that faith/spiritual beliefs are related to positive health outcomes, and 89% agreed or strongly agreed that they would not push their spiritual beliefs upon others.
The approved terminology affirming provision of spiritual care by nurses is the nursing diagnosis “spiritual distress.” A similar term that the Ohio Nurses Association has recently adopted for suffering nurses is “moral injury.”
Ethical violations to nurses themselves, overwhelmed with the double burden of both professional and personal suffering during COVID-19, demand a discussion of workplace rights and on treating nurses with dignity and respect. Intense work, long hours and staff shortages have resulted in another serious burden to nurses. (A valuable resource is the NACC Nurse Chaplain Call Group, managed by Ramune Franitza and hosted by Virginia Day.)
St. Pope John Paul II addressed this issue indirectly many years ago referring to the double burden of female healthcare workers. He stated, “It is familiar to doctors and nurses, who spend days and nights at their patients’ bedside. … It is familiar to women, who, sometimes without proper recognition on the part of society and even of their own families, bear the daily burden and responsibility for their homes and the upbringing of their children. … It is familiar to all workers and, since work is a universal calling, it is familiar to everyone.” It is not ethically correct to mandate nurses to work 16-hour shifts repeatedly, without a meal or a place to rest, which may contribute to patient care errors.
However, my investigation of nurses’ meaningful work or vocation also made me aware of nurse suffering, specifically nurses’ depression. In my open-ended and two-step research survey results, 10 out of 30 (33%) student nurses affirmed current or past treatment for depression, and two currently scored at least moderately for depression on the PHQ-9 questionnaire, a standardized depression and suicide clinical tool. It is important to note that these results are before COVID-19. The actual PHQ-9 survey reported 9 out of 61 (14.7%) students nurse scored in the moderate depression range, and one endorsed suicidal thoughts.
Two seminal national nursing research articles also addressed nurse depression. The California HEAR (Healer Education Assessment and Referral) study found that of those self-referred nurses “which includes the Patient Health Questionnaire-9 depression screening tool … an astounding 97 percent of the 184 nurses who answered the survey were found to be at moderate or high risk.” In another study, a JAMA Psychiatry article reported that of over 89,000 nurses surveyed in a longitudinal study, there was a 5- to 7-fold decrease in nurse suicide related to weekly religious service attendance.
A recent webinar by Elizabeth Johnston Taylor has evaluated and promoted nurse-chaplain partnerships. Helpful chaplain interventions to engage nurses include new staff orientations, newsletters, bulletin boards, email blasts, and in-services. She suggests that chaplains invite shadowing, seek new staff out for personal connection, and use “usual care” as opportunities to educate. Before and after patient visits, discuss the visit with the patient’s RN as part of a collaborative health care team (with discretion), participate in regular rounding, participate in team conferences.
Nurses and healthcare workers are suffering both moral injury and spiritual distress. They would benefit from further education with chaplain-encouraged spiritual interventions — and so would patients.
Teresa Durbak Sipos, DMin, RN, is a student chaplain at Appalachian Behavioral Healthcare in Lancaster, OH. This article is adapted from a workshop she will present at the NACC National Conference in Buffalo Aug. 19-22.