Nurse religiosity and spiritual care

ORIGINAL RESEARCH

Nurse religiosity and spiritual care

Elizabeth Johnston Taylor, Carla Gober Park & Jane Bacon Pfeiffer

Accepted for publication 12 April 2014

Correspondence to E.J. Taylor:

e-mail: [email protected]

Elizabeth Johnston Taylor PhD RN

Professor

School of Nursing, Loma Linda University,

California, USA

Carla Gober Park PhD MPH RN

Director/Assistant Professor

Center for Spiritual Life & Wholeness/

School of Religion, Loma Linda University,

California, USA

Jane Bacon Pfeiffer PhD MS RN

Assistant Professor

School of Nursing, Azusa Pacific University,

San Bernardino, California, USA

TAYLOR E . J . , PARK C .G . & PFE I F FER J . B . ( 2 0 1 4 ) Nurse religiosity and

spiritual care. Journal of Advanced Nursing 70(11), 2612–2621. doi: 10.1111/

jan.12446

AbstractAims. To describe how the religiosity of Christian nurses motivates their practice

and manifests during patient care, especially spiritual care.

Background. Nurses around the world are often religious. This religiosity

inherently affects nursing practice. Ethical codes, however, direct that nurses

ought to never proselytize their religion while caring for patients. Little is known

about how the religion of nurses affects their nursing practice.

Design. Cross-sectional phenomenological study.

Methods. Data were collected during semi-structured interviews in 2009–2011

with 14 Christian nurses in the USA. Data were coded and thematically analysed

after transcription.

Findings. Informants described how they approached patients with religious

conversation or spiritual care interventions that were overtly Christian in nature.

With some awareness of the potential for harm in presenting their Christian

beliefs and practices, these nurses also observed for patient cues before raising

religious discourse and maintained caution so as to respect patient autonomy.

Religiosity also was a personal resource for these nurses as they cared for very ill

patients. The following themes were described: religious determinants and

influences, perceptions of divine promptings and protection, religious approaches

to spiritual care, respecting patient spirituality/religiosity and religious preparation

for daily work.

Conclusion. Understanding these religious motivations and religious spiritual care

practices of Christian nurses provides evidence that can stimulate debate for

policy makers and scholars. It can also inform educators teaching spiritual care

and administrators supervising religious nurses.

Keywords: Christian, ethics, midwives, nurses, nursing, prayer, religion, religios-

ity, spiritual care, spirituality

2612 © 2014 John Wiley & Sons Ltd

Introduction

Many nurses around the world are religious. Indeed, religious

motivations often prompt individuals to be nurses (Ravari

et al. 2009, Taylor & Carr 2009, O’Brien 2010). Nursing

ethics codes admonish, however, that nurses ought to never

proselytize their religion while caring for patients (Taylor

2012). Indeed, the power differential in the nurse–patient

relationship and non-ecclesiastical role of nursing support

the argument that nurses should not introduce religion at the

bedside. Yet most nurses now are taught and expected to

assess and support spiritual well-being (e.g. Australian Nurs-

ing & Midwifery Council 2006, American Association of

Colleges of Nursing 2008, [United Kingdom] Nursing &

Midwifery Council 2010). This creates an internal tension

for the religious nurse who personally finds religious beliefs

and practices promote spiritual well-being. How do religious

nurses bracket their religion at the bedside? Do religious

nurses proselytize behind closed doors? How do religious

nurses manage the tension between believing that their reli-

gious beliefs and practices would be beneficial to patients and

their need to comply with professional standards?

Given the little of research investigating the impact of

nurses’ personal religious or philosophical orientations on

their work, especially spiritual care, it is important to study

this private-professional intersection so that patient and

nurse integrity can be respected. As Fowler (2009) stated:

‘It is critical that religion be removed from nursing’s blind

spot’ (p. 391). Indeed, if nurses fail to recognize how their

religiosity can inappropriately present during patient care,

there is potential for harm to patients. In contrast, if the

positive effects of nurse religiosity are not appreciated, the

religious nurse may not benefit from this source of support.

Background

Conceptual considerations

However, nurses commonly appear eager to dissociate reli-

gion from spirituality, the overlap between these two con-

cepts is widely accepted. For example, a respected

psychological definition of spirituality cited by some nurse

scholars is that it is the ‘feelings, thoughts, experiences and

behaviours that arise from a search for the sacred’ (Hill

et al. 2000, p. 66). These scholars posit that religion is how

persons search for what is ultimately sacred using pre-

scribed ways recommended by a group. Whether self-identi-

fying as spiritual and/or religious, an individual will possess

(with varying levels of awareness) a worldview that offers

perspective about suffering, mortality, morality and other

fundamental questions of life. Religions then offer codified,

prescribed beliefs or doctrines that address these fundamen-

tal questions. This overlap of spirituality and religiosity

confuses nurses and often is cited as a reason for why

nurses avoid spiritual care (Swift et al. 2007, Carr 2010,

Noble & Jones 2010, Gallison et al. 2013,).

A decade ago, Fawcett and Noble (2004) raised the issue

of how a nurse who believes that patient spiritual needs are

best met by ‘bring[ing] those in their care into a relation-

ship with God, through Jesus’ (p. 140), balances this with

professional prerogatives for not proselytizing. Viewing

such evangelism as a moral imperative for Christian nurses,

they concluded their discussion with the question: ‘. . .does

this moral duty sit comfortably with current imperatives of

professional practice?’ (p. 141). In summing her response to

Fawcett and Noble, Van Loon (2005) offered the adage

attributed to St. Francis of Assissi: ‘Preach the gospel, if

necessary use words’ (p. 267). In essence, van Loon sug-

gested proselytization was unethical if it was overt and

verbal.

Subsequently, Pesut and Thorne (2007) addressed this

issue with more profundity. They asked how nurses can

Why is this research needed?

• Many nurses are religious.

• While nurses are often expected to provide spiritual care,

they are also admonished not to proselytize their own reli-

gious beliefs; this can create difficulty for the religious

nurse.

• Understanding how nurse religiosity impacts nursing care is

essential for ethical care.

What are the key findings?

• These nurses’ care, described by many as ‘ministry,’ was

motivated by a desire to reflect a loving divinity to patients

and to connect patients to God.

• These nurses offered their religious beliefs (e.g. ‘God is in

control’) and practices, especially prayer, to patients.

How should the findings be used to influence policy/practice/research/education?

• Administrators should consider how to support religious

nurses’ religiosity appropriately at work because it is signif-

icant resource that provides comfort and a means for cop-

ing with the stress of work, potentially staving off burnout

and promoting job satisfaction.

• Educators should instil in nursing students an awareness of

how personal religiosity can be a resource and how it can

be ethically and unethically introduced during patient care.

© 2014 John Wiley & Sons Ltd 2613

JAN: ORIGINAL RESEARCH Nurse religiosity

navigate competing identities: ‘. . .there is a profound ten-

sion between our identity as professionals, our identity as

citizens in a liberal society and our identity as persons who

hold specific beliefs and values about spirituality’ (p. 398).

Pesut and Thorne argue that central to this issue is how

nurses view their role in spiritual care: Are they experts or

‘participants in a reciprocal encounter of shared humanity?’

(p. 399). These scholars recognized that the later position

may contribute to nurses omitting spiritual care when it

would be helpful, while the position of expert may contrib-

ute to nurses crossing jurisdictional boundaries and coerc-

ing patients to accept their spiritual beliefs or practices.

Buber’s depiction of an ‘I-You’ relationship, which empha-

sizes reciprocity in a spiritual relationship, is advocated as

an ethical approach to spiritual care. From this stance,

nurses recognize they are not authorities, avoid objectifying

patients and defer to the patient’s spiritual experience

rather than their own.

Kevern (2012) tackled this issue for nurse managers. He

recognized that many nurses cope with this issue by making a

referral to a chaplain or clergy – in effect avoiding patients’

spiritual concerns – when instead nurses would be more help-

ful if they were able to converse with patients in ways that

appreciate spiritual difference rather than trying to create

similarity. Kevern presented a solution based on an empiri-

cally tested psychological model which identifies four basic

religious positions taken by individuals in a Western, secular

society. Nurses who are literal in their theologies (whether

theistic or non-theistic) place a high value on their own spiri-

tual values and are likely to impose these values on patients;

therefore, they should be limited in their spiritual discourse

with patients to only those with very similar beliefs. Nurses

who accept more symbolic interpretations (whether theist or

non-religious, interpreting truths in metaphorical ways) are

best positioned to converse ethically with patients of differing

theologies or spiritual worldviews. Thus, Kevern concluded

that it is not the specific beliefs of a nurse or patient that con-

tribute to whether nurse-provided spiritual care will be ethi-

cal; rather, it is the flexibility of the nurse to move between

literal and symbolic theological understandings. Literalist ori-

ented nurses should ‘opt out,’ according to Kevern.

Empirical research informing the present study

Studies have documented that some nurses do include reli-

gious support in spiritual caring; typically, this care involves

supporting patients’ religious rituals (Lundberg & Kerdon-

fag 2010, Nixon et al. 2013, Rykkje et al. 2013, Tirgari

et al. 2013). Although most studies describe this support

superficially, Balboni et al. (2011) explored in depth how

clinicians and patients consider prayer at the bedside. They

found that nurses were more apt to think praying with a

patient was appropriate than did oncology patients and

physicians, although all recognized the initiation of prayer

depended on the circumstances.

Studies (mostly qualitative) from several continents

portray how nurses’ religions help them to maintain hope,

find comfort, cope with the stressors of work and provide a

meaningful orientation (Burkhart & Hogan 2008, Duggleby

et al. 2009, Ekedahl & Wengstr€om 2009, Chayu & Kreitler

2011, Rykkje et al. 2013, Udo et al. 2013). For example, a

study of Christian Ugandan nurses who thrived in the

workplace found that they viewed their work as a calling,

service or ministry (Bakibinga et al. 2013). They turned to

God for help to cope, they prayed about their work and

often saw their work as a way to meet religious demands.

Similarly, Iranian Muslim nurses recognized that their reli-

gion gave meaning to their work and helped them to cope

with its stresses (Tirgari et al. 2013). Religiosity was predic-

tive of burnout among Jewish Israeli nurses (Chayu & Krei-

tler 2011). After observing Canadian Sikh nurses’ ‘lived

religion-lived ethics,’ Reimer-Kirkham (2009) recommended

that nursing ethical codes reconsider the role of religion in

the personal morality of nurses. Together, these findings

indicate that for many nurses, religion cannot be disentan-

gled from work.

Religiosity has an impact on patient care also by affecting a

nurse’s beliefs about health and health care. Again, several

studies from around the world indicate thsat religious beliefs

of nurses do influence how they provide patient care. For

instance, the religious beliefs of Jewish nurses contributed to

their beliefs about how to care for women having late term

abortions (Ben Natan &Melitz 2011). Likewise, the religious

beliefs of Spanish nurses affected their thinking about organ

donation (Zambudio et al. 2009). Swiss nurses who were reli-

gious were more likely to make chaplain referrals (Winter-

Pfandler et al. 2011).

In concert, existent evidence indicates nurse religiosity

inherently affects nursing practice. Philosophical enquiries

address how nurse religiosity ought to play out when a nurse

supports patient spiritual well-being. Although there is some

descriptive evidence from around the world about nurse religi-

osity in the context of nursing practice, there is no study that

explicitly explores the religious motivations and religious

spiritual care practices of Christian nurses in the USA.

The study

Understanding how diverse religious orientations influence

nurses’ caring in diverse cultures can inform the discipline


E.J. Taylor et al.

as it shapes ethical codes, practice policies and expectations

for curriculums.

Aim

The aim of this study is to begin to describe how the religi-

osity of Christian nurses motivates and manifests during

patient care. Specific research questions include: (1) How

does religion motivate and influence how a nurse

approaches patient care? (2) What overtly religious prac-

tices and beliefs do religious nurses introduce to patients

during nursing care? This study is an analysis of data col-

lected for a phenomenological investigation about how

Christian nurses conversed with patients to provide spiritual

care.

Design

A cross-sectional, qualitative design shaped by a Husserlian

philosophical orientation and employing empirical methods

congruent with this descriptive phenomenological framing,

guided this study (Porter & Cohen 2013). Specifically,

Colaizzi’s (1978) methodology shaped the approach to the

data analysis. Phenomenological researchers inductively

investigate the ‘lived experience’ in the ‘lifeworld,’ attempt-

ing to unpack the meanings of these experiences (Cohen

et al. 2000). Their intent is to describe and understand

everyday human experience from the viewpoint of the

expert informants who are having that experience. Given

the little of empirical evidence about how nurse religiosity

relates to spiritual care, the sensitive nature of the nurse

religiosity, this method for building descriptive theory was

appropriate. (For more details describing the methods

employed in this study (Pfeiffer et al. submitted).

Participants

Nurse informants were all recruited from two southern Cal-

ifornia, USA hospitals. Nurses identified as spiritual care

experts (i.e. ‘information rich cases’) were recruited to par-

ticipate in this study. Nurses who participated in the study

did so because they were informed by a spiritual care nurse

supervisor about the study, or because a previous study par-

ticipant told them about it. Inclusion criteria included: (a)

being a Registered Nurse with at least 3 years work experi-

ence; (b) current employment as a RN on average at least

ten hours per week; (c) work primarily with adult clients;

and (d) recognition by self or supervisor as a spiritual care

expert. The sample size was determined by the data. That

is, although a phenomenological approach to research

appreciates that there is never an end to gaining new

insights about a phenomenon, it is appropriate to conclude

data collection when a data set appears rich and with varia-

tion.

Data collection

Data were collected from January 2009–May 2011 (except

for one interview in 2006). Demographical and career

information about the informant were collected via a

1-page survey at the start of the interview after informed

consent was obtained. Next, one of the researchers con-

ducted a semi-structured interview (JP 13, EJT 1) that was

digitally voice recorded. Interviews lasted 1–1�75 hours.

Given the original study was designed to explore how

nurses talked about spirituality with patients, the questions

reflected this goal. These questions inquired as to what

prompted such conversation, what the nurse’s goals and

strategies for such discourse were and what a typical spiri-

tual care encounter was like. Although other questions were

asked as well, the question that elicited considerable data

for this article was, ‘Are there any ethical, philosophical or

religious values that might have influenced how you talked

with this client about spirituality?’ However, most of the

data for this analysis was found embedded in responses to

other questions not intended to delve into the area of per-

sonal religiosity and its impact on work.

Data management and analysis

After each interview, the digital voice recording was elec-

tronically sent (securely) to a transcription service that tran-

scribed the interviews verbatim into MS Word documents.

Transcriptions were checked for accuracy and then entered

into NVivo version 8.0 (Doncaster, Victoria, Australia) for

coding.

Colaizzi’s (1978) method proposes that after re-reading

the transcribed data from semi-structured interviews and

becoming intimately familiar with it so as to gain a sense of

its wholeness, significant statements or phrases pertinent to

the research aims were extracted. These pieces of data are

reflected on to formulate meanings and labels, then clustered

thematically. These themes were supported when they were

reviewed in the context of the larger data set to see if any

data were not represented. The result of this process is not

only an exhaustive description, but implications for practice.

The initial analysis for the primary study was conducted

concurrently with data collection. After immersing them-

selves in the data, the investigators coded each significant

idea – whether it was a word, phrase, or paragraph. Each



interview was coded by two investigators (mostly JBP and

CGP), after a process for establishing equivalency was com-

pleted. Discrepancies were always discussed until agreement

was reached. For this analysis, comparison of pertinent

codes about nurse religiosity and religious care was con-

ducted by EJT. Themes were grouped when meanings were

related and validated when no data presented discrepancies.

This analysis was then discussed and validated with JBP

and CGP.

Ethical considerations

Institutional Review Board approval was obtained from the

university where the Principal Investigator was employed. A

process of informed consent was completed with each infor-

mant prior to the collection of any data. All informants’

rights to anonymity and confidentiality were respected.

Transcribed interviews substituted pseudonyms for any

identifiers.

Rigour

Several strategies were employed to promote the rigour of

the study’s findings (Lincoln & Guba 1985). To support

credibility, the interviewers used ‘prolonged engagement’

(of typically approximately 2 hours) with each informant.

Given the three member research team, ‘peer debriefing’

naturally occurred when the team met regularly to discuss

the analysis. ‘Member checks’, or re-interviewing the infor-

mants to clarify significant statements and verify themes

were necessary with four informants during the primary

study. Preliminary findings of early interviews also gener-

ated questions for later interviews, providing a validation

for initial thematic analysis. The transferability of the find-

ings is enhanced by purposive sampling of nurses from var-

ied clinical settings and collecting in-depth or ‘thick’

descriptions of the phenomenon of study. Dependability of

the data was strengthened by having audio-recordings (and

verbatim transcriptions) of each interview. Confirmability

was increased by the investigators practicing ‘bracketing’,

reflecting in a journal on the personal and professional fac-

tors contributing to the research process. In this study,

examining personal religious perspectives and previous

scholarship was observed to potentially influence the inter-

view process and the analyses.

Findings

Informants included 14 RNs, all of whom were Christians

who represented various traditions and eight of whom were

white. Altough most worked in inpatient settings as staff

nurses, a few worked as clinical educators or in an outpa-

tient setting. Except for two, all worked in a Christian uni-

versity healthcare system that overtly sought to include

spiritual support in whole person health care. Although one

informant had worked only 1 year as a nurse, the rest

worked 3–42 (mean = 17) years in nursing. Nurses’ ages

ranged from 26–64 (mean = 47) years. Although the demo-

graphical questionnaire asked with what religion they most

identified, informants typically answered that they were

‘Christian’ or ‘Protestant.’

While discussing how they conversed with patients to

provide spiritual care, these 14 nurse informants inevitably

also described the personal philosophies that motivated and

influenced their spiritual care conversations. These philoso-

phies reflected an evangelical Christian religiosity. At times,

they approached patients with religious conversation or

spiritual care interventions that were overtly Christian in

nature. With some awareness of the potential for harm in

presenting their Christian beliefs and practices, these nurses

often observed for patient cues before raising religious dis-

course and maintained caution so as to respect patient

autonomy. Religiosity also was a personal resource for

these nurses as they cared for very ill patients. Thus, the

following themes will be described: religious motivations

(i.e. determinants and influences, perceptions of divine

promptings and protection, religious preparation for daily

work), religious approaches to spiritual care (i.e. religious

interventions, prayer) and respecting patient spirituality/reli-

giosity.

Religious motivations

Determinants and influences

When discussing what motivated them to give spiritual

care, the language these nurses used often included being a

‘connector,’ a ‘witness,’ and ‘instrument’ for God, so as to

manifest God’s love, joy and peace. As Nurse 6 put it:

‘We’re here on this earth to show God’s love, to be com-

passionate and to exemplify God’s love.’ A couple nurses

referred to their role in this regard as that of ‘sowing seeds.’

Another stated that spiritual care was a nurse’s response to

the ‘call of God for the moment.’ This foundational reli-

gious influence on nursing care is illustrated in Nurse 12’s

comments:

I believe He [God] is the healer of all healers. And if I can connect

people to Him, I will have provided spiritual care because He can

provide that healing I can’t. So I just want to be a connecter. . .. Be

a channel for God to my patients’


E.J. Taylor et al.

It is likely, that all the informants would agree with the

nurse who called nursing care a ‘ministry.’

Although a couple nurses explicitly described how spiri-

tual care was a grateful response to God, three informants

intimated a hint of personal gain in the rationale for their

spiritual caring. Praying privately or with patients (equated

with spiritual care by this nurse) was something that helped

her to cope with the stress of patient care. Two others

referred to an ‘eternal perspective’ that also provided some

prompting for spiritual care. That is, they recognized they

would be judged: ‘meeting Him at the end of the day,’ and

they did not want to ‘feel guilty [laughter].’

Divine promptings and providence

Several informants described times when they believed they

were divinely guided in how they provided spiritual care to

a patient. Usually, this divine prompt occurred after they

had prayed about the situation. For example, one nurse

was inspired to share a Chicken Soup for the Soul book

with a dying patient’s mother for whom she felt bewildered

as to how to care. Another nurse felt guided to pray and

provide religious information to a patient. This Nurse 4

portrayed the prompting this way: ‘Spiritual care is being

Holy Spirit driven. . .being in tune. . .letting the Word

impress upon me opportunities. . .so when Holy Spirit

impresses on me I need to pray with that individual, I pray

with them.’ Indeed, other nurses specified a sense of being

guided by the Holy Spirit or the Lord in patient care. As

Nurse 11 said, ‘Sometimes I’ll pray and the Lord will tell

me something about this person that I should do. But usu-

ally I have to really concentrate and pray and see which

direction to go.’

Several of these nurses reported sensing a provident and

protective God while at work. Nurses 12 and 14 told sto-

ries of patient healing after their prayers for the patient.

Nurse 2 told a family who inquired as to how she knew to

institute emergency measures for their loved one with a

postoperative internal bleed: ‘It was the Lord, not me.’

Nurse 4 who boldly shared her religious faith with patients,

did so believing she was protected:

‘When the Holy Spirit tells me to pray with that individ-

ual, even if I’m not supposed to, the Lord will protect me.’

Religious preparation for daily work

Nurses’ religious motivations were nourished often by the

personal religious practices, a nurse observed while prepar-

ing for work. Some mentioned personal devotional time

(e.g. reading Bible) before work each day or corporate spiri-

tually nurturing activities they attended on a regular basis

(e.g. women’s fellowship). Praying, however, was the

religious activity that many engaged in while at work, while

driving to work, or while preparing to go to work. This

praying submitted the nurses’ work to God and petitioned

God for wisdom and guidance with patients for whom they

would be caring. This is illustrated by Nurse 3’s prayer:

‘Lord, there is something here that you have for me to do. I

don’t know what it is. And I don’t want it to be just my

observation. It has to be something much deeper. So what-

ever you give me, I’ll go with.’

Religious approaches to spiritual care

Religious interventions

Given the religious foundation guiding these nurses, per-

haps it is natural that they offered overtly religious inter-

ventions as part of their spiritual care. The main religious

offering was prayer. However, a few nurses described using

a few additional interventions. These included offering reli-

gious counsel, literature and information and on rare occa-

sion inviting a patient to attend church. One nurse gave out

hospital-provided cards with spiritual inspirations and his

running medals with his inscription (‘God bless you. Keep

running’) to special patients.

Prayer

All the informants prayed either privately for or openly

with their patients. Nurse 3 stated she prayed privately

before each patient encounter in an outpatient clinic. Nurse

5 described praying privately for patients, especially those

suffering intensely. For example, he described one time

praying, ‘Come on Lord, you’ve got to help me out. This

guy is in pain.’ While many prayed privately unbeknownst

to the patients, some said they would tell patients of this

practice. A story illustrating this came from Nurse 12 who

told the story of offering to pray with a patient. This

patient refused the offer (the only refusal for Nurse 12 in

8 years of nursing). This nurse, however, let the patient

know she would be praying privately for her anyway. The

next morning, Nurse 12’s colleague called her at home to

report that this patient had been having a terrible night, but

that after the patient remembered Nurse 12 was praying for

her, she relaxed and went to sleep.

Many informants also described how they verbally

prayed with patients, after asking patients something like,

‘Would you like me to pray for you?’ Often informants

touched the patient while they prayed. Several stated that

they tried to keep these prayers brief, specific, inclusive of

patient and family and focused on the present circum-

stances. These prayers also typically affirmed a faith in God

and a surrendering of the current concerns to God’s



control. Nurse 14 described her prayers with patients: ‘I

pray with them, either about their faith, their relationship

with God and for their family. . .that [they] will understand

the situation that anything that happens has a reason and

no matter what, God is always in control.’ Indeed, prayer

was a fundamental aspect of spiritual care for all the infor-

mants.

Respecting patient spirituality/religiosity

These informants were keenly aware that initiating spiri-

tual/religious discourse or interventions with patients was

something that must be done with sensitivity and respect

for the patient. Because of this, these nurses were careful

to continually assess patient responses. Nurse 13 stated

she read patient body language and facial expressions;

Nurse 5 said he thought it was essential to: ‘tread soft-

ly. . .listen and pick up cues.’ These nurses frequently spoke

of the importance of establishing rapport and relationship

first with a patient before spiritual/religious discourse or

intervention (e.g. offering to pray). Nurse 7 learnt from

experience that if she offered to pray before knowing the

patient to some extent: ‘they weren’t as receptive and

could get upset or offended.’ Nurse 13 articulated the rea-

son well:

Spiritual care isn’t right away. Until you’ve got a feel for that

patient, established trust, then you feel like you can. It would be

disingenuous to just have met a patient, you’re hooking them up to

monitors. . .and you say, ‘Would you like me to pray with you?’. . .I

see it as part of everything else we do. I think it just isn’t probably

right in the beginning. . .. [Regarding spiritual care potentially being

‘disingenuous’: It would be] as if you’re throwing them a bone-

. . .just talk, it’s not so good

Indeed, most of these informants recognized they needed

to follow the patient’s lead in this regard. Many of these

nurses held that they should ‘always put the patient’s need

and wants first before your own’ (Nurse 3). Although this

stance was respectful, Nurse 2 also found it expedient:

‘You have to go with the patient, because otherwise it’s like

pushing to a child a plate of food when they don’t want to

eat. . .. They have to feel thirsty to drink.’ When a nurse

perceived cues that such discourse or intervention was not

welcome, the nurse quickly backed off and maintained

respect and care for the patient.

Nurse 10’s response to a patient who rejected her offer

of prayer is typical: ‘‘Okay’ – and you just move on; don’t

make a big deal. I’m giving them the option.’ Various inter-

pretations were ascribed by these nurses to the infrequent

refusals they received. Some attributed refusals to their own

poor approach, while others believed refusals were because

of the patient’s circumstances (e.g. not a Christian, angry

with God). Uniformly, these nurses reported it was extre-

mely rare to be refused by a patient.

These nurses also talked about how they related to

patients whose religious experience differed from theirs.

Although one nurse described a time when she ‘freaked out’

because a patient said he did not believe in God, these

informants generally accepted that they were ‘not going in

there to push God. . ..because their value system might be

completely different’ (Nurse 12). Indeed, some recognized

the potential for harm: ‘Just be sensitive, because a lot of

people have been hurt in that area. So you don’t want to

go in and do more damage. . .by going somewhere where

the patient doesn’t want to go, pushing them. . .’ (Nurse

10). A few nurses, however, did appear to promote their

religious thinking to some degree and this was expressed in

varying ways. For extreme examples, Nurses 4 and 14 each

told of an occasion when they overtly encouraged a patient

to attend church (albeit whatever church nurtured them).

Nurse 3 used non-religious language with non-religious

patients when engaging them in conversations about spiritu-

ality, trying to help these patients come to understand this

spirituality when they did not (e.g. teaching a patient that

his mountaintop moment of awe was a reflection of his

spirituality).

Discussion

These richly descriptive data portray nurses whose sense of

vocation is that of ministry to reflect a loving divinity to

patients. Their religiosity is not left in a nursing locker;

rather, religious motivations permeate these nurse infor-

mants’ work. Because of this personal-professional merger,

these nurses offered their religious beliefs and practices to

patients. These results, although potentially unique to a

Christian healthcare environment in a rather religiously tol-

erant American culture, nevertheless highlight the potential

benefits and harms of nurse religiosity for patient care.

Data show how religious beliefs and practices (especially

prayer) provided these nurses with a means for coping with

the stress of their work, comfort while being in the presence

of suffering and a sense of protection and guidance during

their work. With such a viewpoint, it would not be surpris-

ing to find such nurses are less apt to burnout and more

apt to have job satisfaction, as others have observed (Chayu

& Kreitler 2011, Ravari et al. 2012). Given these data and

that from numerous other studies documenting the positive

impact of religiosity on nurses’ ability to attribute meaning

and cope with the stressors of patient care (see


E.J. Taylor et al.

Background), it would behove nurse leaders to support

healthful religiosity in the nursing workforce. How this

could be accomplished should reflect the clinical and socio-

cultural environment of the nurse. In this study, some

nurses found such support by praying with similarly minded

nurses before or during their nursing shift.

Although the positive impact of religion on religious nurses

may appear obvious to some, the more difficult discussion

these data direct us to is that of how this religiosity may

potentially harm patients. Given this was a study of nurses’

perspectives, it is unknown how patients received their reli-

gious care. All the informants perceived nearly all patients to

respond positively. It is possible, however, that patients rec-

ognize a power differential in the nurse-patient relationship

and choose to go along with whatever the nurse offers so as

to not upset the ‘hand that feeds them.’ Did these nurse-pro-

vided religious interventions ever function to disempower the

patients? How was the nurse religiosity, held by the majority

in their society, received by those of minority faith traditions?

Did the patients appreciate the religious care simply because

they were starved for compassionate care? Did the nurses fil-

ter out patient resistance and interpret patient politeness for

patient interest? These possibilities are recognized by astute

chaplains (Personal Communication, Chaplain John Ehman,

8 August 2013).

These informants recognized the import of establishing

relationship prior to offers of religious care. Furthermore, if

they perceived their religious care (e.g. prayer) had threa-

tened the nurse-patient relationship, they took care to mend

it. Yet there were variations in these nurses’ intentions and

initiation of religious care. For example, whereas one nurse

may have been content to pray privately for a patient,

another made a point of telling patients that she was pri-

vately praying for them. Although some occasionally

offered to pray with a patient when circumstances made it

seem appropriate, others made it a habit to offer prayer to

nearly all clients. When a patient did not view their circum-

stances with the same theological lens, some nurses

appeared to encourage the patient to adopt their viewpoint

(e.g. Nurse 3 insisting on a there being a spiritual reality

with a patient who otherwise was unaware, nurses who

shared specific religious beliefs with patients in attempts to

comfort and help them make sense of their tragedy).

While these nurses recognized to some degree the impor-

tance of not imposing their religion, they also relied on

seemingly valid rationale for unwittingly doing so. Some

relied on The Joint Commission requirement that spiritual

assessment and support be provided to all clients in accred-

ited institutions. Others cited nursing’s goal of providing

holistic care. These rationales illustrate the professional

cloak that Pesut and Thorne (2007) recognized nurses could

wear to legitimize hegemonic spiritual care. Most novel,

however, was the identification of how several of these

nurses’ believed they were following the guidance of the

Holy Spirit. This raises fascinating questions. For instance,

could the Holy Spirit guide a nurse to practise in ways that

are incompatible with ethical practice? Taylor (2012)

addresses this issue and cautions Christian nurses that the

‘Holy Spirit’ may sometimes actually be the nurse’s ‘gut’ or

personal needs.

Limitations

This analysis of data collected from a phenomenological

study does have limitations. More exhaustive direct ques-

tioning of informants about their religiosity may have pro-

duced even richer data. These data are from evangelical

Christians, so it is unknown how other Christian or non-

Christian nurses would respond to the same questions. Sim-

ilarly, most of the informants worked in clinical settings

that valued spiritual care, so it is unknown how these

nurses would have implemented their commitment to spiri-

tual care in another setting or complied with (non)religious

mores of another workplace.

Conclusion

Religious nurses rely on their beliefs and practices while

endeavouring to provide spiritual care. Existent nursing

knowledge, including findings from this study, suggests nurse

researchers, educators, policy makers and administrators

need to further explore and teach how this religiosity –

which is inevitably a part of who the nurse is, can be ethi-

cally and effectively present during patient care. As Taylor

and Fowler (2011) posit: ‘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’ (p. 342). Rather than dissociate from this powerful

resource for religious nurses and patients, the discipline must

further examine how to appropriately incorporate religiosity

in nursing practice.

Acknowledgements

The authors are enormously grateful to the nurse informants

who volunteered to participate in this research, to Kathy

McMillan who assisted with participant recruitment.



Funding

Loma Linda University School of Nursing Seed Grant to

Elizabeth Johnston Taylor.

Conflict of interest

No conflict of interest has been declared by the authors.

Author contributions

All authors have agreed on the final version and meet at

least one of the following criteria [recommended by the

ICMJE (http://www.icmje.org/ethical_1author.html)]:

• substantial contributions to conception and design,

acquisition of data, or analysis and interpretation of

data;

• drafting the article or revising it critically for important

intellectual content.

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Nurse religiosity and spiritual care