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Using the Synergy Model to Provide Spiritual Nursing Care in Critical Care Settings

To purchase electronic or print reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 809-2273 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints{at}aacn.org.

Corresponding author: Amy Rex Smith, DNSc, APRN, BC, Department of Nursing, College of Nursing and Health Sciences, University of Massachusetts Boston, 100 Morrissey Blvd, Boston, MA 02125 (e-mail: amyrex.smith{at}umb.edu).

A consensus is growing that religiosity and spirituality are significantly related to physical and psychological health³ and that the scientific study of spirituality and health is an important focus of nursing research.^4,5 Concerns about the quality of the methods used in research on spirituality and religion are ongoing.³ Despite the resurgence of spirituality as a legitimate focus for nursing research, little data-based information specific to spirituality and critical care nursing practice is available.

In this article, I identify challenges of providing spiritual care in critical care settings, explain how the elements of the American Association of Critical-Care Nurses (AACN) Synergy Model for Patient Care⁶ address spirituality, and recommend nursing interventions based on the Synergy Model that are targeted to critically ill patients’ spiritual needs.

	What Is Spirituality?

Top What Is Spirituality? Spiritual Nursing Care in... Spirituality and the AACN... Patients' Characteristics... Nurses' Characteristics Related... Suggestions for Interventions Conclusions and Summation References

 
Scholars are seeking to clarify spirituality as a concept for use in the health sciences.⁷ Authors^3,5,7–9 generally agree that the concept of spirituality is broader than the concept of religion. Religious beliefs and practices can be expressions of spirituality, but spirituality exists apart from religion.^5,8 The consensus is that spirituality is defined as the manner by which persons seek meaning in their lives and experience transcendence—connectedness to that which is beyond the self—whereas religion is best understood as adherence to an accepted formalized system of belief and practices.^5,8,9 Most nurse authors^8,9 view spirituality as a universal phenomenon, for although all persons do not understand and accept the supernatural, all persons have needs for seeking meaning and acceptance in their lives.

Although spirituality is an abstract and multidimensional concept,^5,8–10 2 components of spirituality are widely described: vertical and horizontal. The vertical component describes that which is transcendent, the connections between a patient (inside the body) and something outside of the patient: God, the divine, or a higher power (upward or out there somewhere).^9–11 The horizontal component addresses the connections between persons. Connections between persons are generally understood as personal and social support that is embedded in the spiritual context and provided by religious settings and spiritual relationships.^9–11

Spiritual care is defined as the provision of interventions in the domain of spirituality and has long been the focus of hospital chaplains.¹² Spiritual care also has been accepted as a legitimate focus of nursing practice. The North American Nursing Diagnosis Association has 2 accepted nursing diagnoses for spirituality: spiritual distress and readiness for enhanced spiritual well-being.^13,14 The Nursing Outcomes Classification includes 20 indicators for spiritual health, and the Nursing Interventions Classification includes 4 specific interventions for spiritual care—religious ritual enhancement, spiritual support, spiritual growth facilitation, and forgiveness facilitation—and 2 more general interventions that are often used in spiritual care: bibliotherapy with sacred texts and presence.^13,14

	Spiritual Nursing Care in Critical Care Settings

Top What Is Spirituality? Spiritual Nursing Care in... Spirituality and the AACN... Patients' Characteristics... Nurses' Characteristics Related... Suggestions for Interventions Conclusions and Summation References

 
Critical care nursing is a demanding specialty that requires advanced knowledge of physiology and highly technological interventions. Nurses care for critically ill patients in intensive care units (ICUs) and progressive care units. Because the acuity of hospitalized patients has increased, some authors¹⁵ claim that all hospital nursing care has become critical care. Patients in critical care units are the most seriously ill and injured among all hospitalized patients.

ICUs house patients who are the sickest and in the most unstable condition, patients whose physiological needs predominate. The culture of critical care units is created by staff interaction around the competing demands of treating multiple life-threatening and complex problems in a fast-paced environment.¹⁶ Fontaine¹⁷ identifies the purpose of ICUs as places to provide monitoring of the sickest patients in the hospital and convincingly describes the difficulties of creating healing environments in ICU settings. The issue of environment is so important that the AACN has identified creating healing humane environments as a research priority.¹⁸ One of the 2 platforms of the new AACN standards on healthy work environments is that work and care environments must be safe, healing, and humane and respectful of the rights, responsibilities, needs, and contributions of patients, patients’ families, nurses, and all health professionals.¹⁹ Although critical care units are a challenging location for spiritual care, such care can be a way to enhance the healing and humanity of the highly technical, physiologically driven ICU environment.

	Spirituality and the AACN Synergy Model for Patient Care

Top What Is Spirituality? Spiritual Nursing Care in... Spirituality and the AACN... Patients' Characteristics... Nurses' Characteristics Related... Suggestions for Interventions Conclusions and Summation References

 
The AACN Synergy Model (see Sidebar 1) is emerging as the accepted standard conceptual framework for acute care and critical care nursing.^6(pxi) The first of the 5 assumptions underlying the model is that each patient is a whole person: body, mind, and spirit.^6(p7) This assumption means that each patient is more than the pressing physiological needs that caused hospitalization for the critical illness. Nursing care of the whole person, guided by the Synergy Model, addresses not only physiological care but also care in the psychosocial (care of the mind) and spiritual (care of the spirit) domains. The inclusion of spirit as a central aspect of the AACN Synergy Model makes this nursing model a particularly useful guideline for providing spiritual care in ICUs. Indeed, use of the Synergy Model may help nurses overcome some of the constraints to spiritual care in hospitals identified by Van Dover and Bacon²⁰: priority placed on physical health needs, multiple demands on nurses’ time, and varying expectations of nurses and healthcare institutions concerning the nurses’ role in giving spiritual care.

View larger version (57K): [in this window] [in a new window]   Sidebar 1

	Patients’ Characteristics Related to Spirituality Resiliency

Top What Is Spirituality? Spiritual Nursing Care in... Spirituality and the AACN... Patients' Characteristics... Nurses' Characteristics Related... Suggestions for Interventions Conclusions and Summation References

 
The characteristic of resiliency in patients is defined as the "capacity to return to a restorative level of functioning using compensatory coping mechanisms"^6(p14); the ability to bounce back quickly after an injury. At the lowest level of resiliency (minimally resilient), a patient is unable to mount a response, has "failure of compensatory/coping mechanisms and minimal reserves, and is brittle; ... at the highest level (highly resilient), the patient is able to mount and maintain a response and has intact compensatory/coping mechanisms, strong reserves, and endurance."^6(p14)

Interventions to strengthen a patient’s resiliency can be categorized as belonging to the vertical component of spirituality. Prayer is a communication used to make a connection between human beings and God and is recognized as a coping mechanism.²¹ Prayer is reported to be one of the most frequently used complementary and alternative medicine techniques.^22,23 Studies of spirituality in hospitalized patients often have indicated that prayer is a coping mechanism.^24–27 In a study of 100 patients hospitalized the night before open heart surgery, Saudia et al²⁵ found that 96 of the patients prayed and 2 had others pray for them; only 2 had no prayer. Internal reserves are reserves that are available to be called on in times of need. These reserves can be of great depth, are often beyond rational explanation, and are available in time of need. For example, Arslanian-Engoren and Scott²⁶ conducted a phenomenological study of 7 self-identified spiritual patients who had experienced tracheostomy for prolonged mechanical ventilation (mean length of stay 37 days, SD 14 days). All of the patients found comfort through religion and spent much time in daily prayer. The patients also derived reassurance and support from visions of dead relatives and angels; in these encounters the patients reported that they received guidance and encouragement.

Spirituality also can provide reserves that enhance endurance. In a qualitative research study of men hospitalized with prostate cancer, Walton and Sullivan²⁷ applied the metaphor "men of prayer" because all of the patients identified the use of prayer as vitally important. The patients reported that prayer provided strength, assurance, comfort, and inner strength. Walton and Sullivan²⁷ also identified 2 concepts, trusting and living day by day; meanings ascribed to the 2 concepts indicated endurance through difficult illness, treatments, and unknown outcomes.

Resource Availability
The characteristic of resource availability in patients is influenced by the "extent of resources brought to the situation by the patient, family, and community."^6(p34) Resources are technical, fiscal, personal, psychological, social, or supportive. At the lowest level, resources are few, personal/psychological support is minimal, and access to social systems is minimal. At the highest level, patients have access to many resources. The Synergy Model posits that the more resources, the greater is the potential for a positive outcome; with less resource availability, the potential exists for a more constrained recovery process.^6(p34)

The horizontal component^9–11 of spirituality, the direction symbolizing the connections between persons, contributes directly to a patient’s resource availability. Persons connected to a religious congregation may have the potential for greater resources. Both personal support and social support are often provided by fellow congregants. Personal support for patients who are congregants comes from the patients’ ongoing relationships with clergy, who provide formal pastoral care.¹² Also, many congregations have parish nurses (recently renamed faith community nurses) who provide spiritual and other nursing care to ill congregants.^{28(pp200–202)} Social support comes from congregations that function as de facto social service organizations. The tradition of service found in many faiths, the doing of good works for spiritual gains, can be extended to ill congregants.

Connection to a religious congregation is not required, however, for enhancing the availability of spiritual resources. Many spiritual persons are not members of religious groups but do have ongoing, long-term spiritual companions who provide guidance for spiritual growth.²⁹ Spiritual companions is a newer iteration of the traditional "spiritual director," a more mature person who takes on the responsibility for the formation of spirituality. This relationship is a formal one in which the focus is spiritual growth. These spiritual relationships provide excellent sources of personal and social support in times of crisis.

	Nurses’ Characteristics Related to Spirituality Caring Practices

Top What Is Spirituality? Spiritual Nursing Care in... Spirituality and the AACN... Patients' Characteristics... Nurses' Characteristics Related... Suggestions for Interventions Conclusions and Summation References

 
The purpose of caring practices is to promote comfort and healing and prevent unnecessary suffering.^6(p71) Caring cannot occur without respect for each patient as a person who has unique needs. Nursing interventions embedded in caring promote a healing environment. Caring practices acknowledge the give and take between nurses and patients, in which mutuality is part of the relationship.

Caring for the entire patient as a person includes care of the spirit. In a study of 10 critical care nurses, Kociszewski³⁰ identified a "mutual knowing" between patients and the nurses that led to what she called "a bridge" for spiritual assessment. This mutual knowing began with the nurses’ personal spirituality and built on the nurses’ knowledge of spiritual care. Over time, the nurses explored the spiritual needs of the critically ill patients and the patients’ families and looked for overt and covert cues. These cues were often subtle and included photos, artifacts, a visitor praying with a patient, and so on. The connections between the nurses and the patients became bridge building for effective spiritual assessment.

Nowhere in nursing is caring more evident than in end-of-life care, which has emerged as an area of concern in the ICU. In a recent study, the Robert Wood Johnson Foundation convened a critical care end-of-life peer work group and added to the scholarly group 15 physician-nurse teams who worked together in 15 ICUs across the United States. Spiritual support for patients and patients’ families emerged as one of the identified interventions. The working group³¹ identified 3 actions as indicators of the quality of spiritual support:

1. assess and document spiritual needs of patients and patients’ families on an ongoing basis;
   
2. encourage access to spiritual resources; and
   
3. elicit and facilitate spiritual and cultural practices that patients and their families find comforting.
   

These quality indicators were identified specifically for end-of-life care, but they also are appropriate caring practices for all patients in critical care units.

Response to Diversity
The characteristic of response to diversity in nurses is defined as the sensitivity to "recognize, appreciate, and incorporate differences (in patients) into the provision of care."^6(p93) The Synergy Model identifies spiritual beliefs as one of the differences to be addressed. Development of sensitivity among nurses is an important aspect of this characteristic. In 2002, the AACN practice analysis task force expanded the initial 5 assumptions underlying the Synergy Model by adding "the nurse brings his or her background to each situation, including various levels of education/knowledge and skills/experience."^6(p8) This assumption is demonstrated by nurses who bring their own spirituality to the nurse-patient relationship. In an exploration of the attributes of spiritual care in nursing practice, Sawatzky and Pesut^32(p23) provided a definition of spiritual nursing care that simultaneously highlights this assumption and focuses on patients’ diversity: "Spiritual nursing care is the intuitive, interpersonal, altruistic, and integrative expression that rests on the nurse’s awareness of the transcendent dimension yet reflects the patient’s reality."³²

Kociszewski identified the concept of "the spiritual nurse,"^33(p136) a label she gave to nurses who had developed a "spiritual self." These nurses indicated that they were on a spiritual journey or pilgrimage and that "being spiritual was the first step in giving spiritual care."^{31(pp136–137)} The idea that nurses with self-awareness of the spiritual realm are better prepared to provide spiritual care than are nurses without such awareness is well supported.^23,34,35 A spiritual nurse brings the experience and knowledge of the spiritual self into the critical care setting and is particularly adept at meeting patients’ spiritual needs.

It is not expected that every nurse is or should be a spiritual nurse. Studies^35,36 of hospital nurses have identified 2 types of nurses: those who think that it is not within the purview of nursing to provide spiritual care and those who lack education in spirituality. Specialized education in spirituality can help ensure that nurses are aware that spiritual care is within the purview of nursing and can prepare all nurses to deliver an appropriate level of spiritual care to patients. The following suggestions for nursing interventions provide guidelines for appropriate spiritual nursing care.

	Suggestions for Interventions

Top What Is Spirituality? Spiritual Nursing Care in... Spirituality and the AACN... Patients' Characteristics... Nurses' Characteristics Related... Suggestions for Interventions Conclusions and Summation References

 
The Synergy Model can be used to organize and guide 5 nursing interventions.

Caring Practices: Accurately Identify Spiritual Needs
Being listened to and cared for are basic needs of all patients and their families in the environment of the ICU. When performing nursing assessments, nurses should identify cues specific to the spiritual realm and should collect data to identify spiritual needs. Ongoing assessment is essential, because spiritual concerns can arise during hospitalization. In-service training or continuing education and support are needed if staff nurses are to develop expertise in spiritual assessment. The Joint Commission on Accreditation of Healthcare Organizations³⁷ has established that as a minimum, each hospitalized patient’s denomination, beliefs, and spiritual practices should be assessed and has made suggestions for additional questions to be used in a spiritual assessment (see Sidebar 2). Two especially detailed and comprehensive nursing guides for spiritual assessment are offered in spiritual care texts by O’Brien²⁸ and Taylor.³⁹ Assessing spiritual needs includes identifying patients who do not want any spiritual care, a step that is important inasmuch as studies of hospitalized patients indicate that one third of patients do not desire spiritual care while hospitalized.⁴⁰

View larger version (60K): [in this window] [in a new window]   Sidebar 2

Support Resiliency: Make Appropriate Referrals
For critical care nurses, the pressing priority is physiological care; spiritual care often happens in-between and while delivering other nursing care. Consultation and referral to the hospital chaplain and/or a patient’s own clergy or spiritual companion and making space and time for the patient and the chaplain, clergyperson, or companion to be together privately helps support the vertical component of the patient’s spirituality.

Support Resiliency: Make Space and Time for Group and Individual Religious Rituals and Spiritual Practices
An appreciation for the practices of a patient’s faith is actualized by prioritizing time and providing space for sacred ritual in the hospital environment. A patient may need to have uninterrupted time for spiritual reading or prayer; a church group may need to offer a sacred song or a blessing. In some faiths, a patient may need a connection with nature, such as being able to look out a window or see the sun rise or set. This nursing intervention is a simple but important one that cannot be overemphasized.

Support Resource Availability: Make Connections Between Patients and Their Spiritual Support Systems
If appropriate, critical care visitation can be extended to the members of a patient’s congregation. When fellow congregants cannot visit patients, the congregants can often visit the patients’ families in the waiting room and support the families. Many congregations have videotapes of worship services; opportunities and equipment for patients to watch tapes can be provided. Flower delivery by congregants is the traditional mark of religious visitation; when flowers are not permitted, small symbolic religious gifts may be brought. Other ways to make connections can be individualized to meet patients’ needs.

Specific spiritual nursing interventions are presented in the 2 case studies. Case 1 focuses on supporting resiliency by making space and time. Case 2 focuses on caring practices when a spiritual nurse is able to accurately identify a spiritual need.

View larger version (113K): [in this window] [in a new window]   Case 1: Supporting Resiliency by Collaborating With a Chaplain and Making Time and Space for Religious Ritual

	Conclusions and Summation

Top What Is Spirituality? Spiritual Nursing Care in... Spirituality and the AACN... Patients' Characteristics... Nurses' Characteristics Related... Suggestions for Interventions Conclusions and Summation References

Using the Synergy Model as a basis for research on spiritual care in the critical care setting is needed, especially monitoring the frequency and quality of spiritual assessments. Synergy can be studied by examining assignments of patients to nurses and patients’ outcomes. Referrals can be tracked, as can presence or absence of rituals in the setting. In addition, studies of spiritual care education for staff nurses, documented with pretesting and posttesting, would be a valuable contribution. Sources of spiritual care education include formal courses offered by faith-based universities and online resources provided by nursing specialty organizations such as the Oncology Nursing Society and Association of Nurses in AIDS Care.

Creating a humane healing environment in the hospital is a challenge; creating the environment for healing is especially difficult in the ICU. Spiritual care, within the context of the Synergy Model, can make important contributions to a healing environment and theory-based nursing care.

View larger version (159K): [in this window] [in a new window]   Case 2: Caring Practices, or an Intensive Care Unit Patient Needs a "Spiritual Nurse"

	References

Top What Is Spirituality? Spiritual Nursing Care in... Spirituality and the AACN... Patients' Characteristics... Nurses' Characteristics Related... Suggestions for Interventions Conclusions and Summation References

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