164 JCN/Volume 30, Number 3 journalofchristiannursing.com
Gail E. Pittroff, PhD, RN, is an Assistant Professor at St. Louis University in St. Louis, Missouri, and a Commissioned Lay Minister in the United Church of Christ. She has experience in ICU, maternal newborn, hospital administration, hospice, and inpatient palliative care.
The author declares no conflict of interest.
Accepted by peer review 1/9/13
By Gail E. Pittroff
Humbled Expert: An Exploration of Spiritual Care Expertise
ABSTRACT: This interpretive phenomenological study explored how inpatient palliative care nurse consultants provide spiritual care and how they acquired these skills. Humbled experts describes the nurses’ personhood and spiritual care practices, offering insight for skilled spiritual care in any setting.
KEY WORDS: chaplaincy, end-of-life, nursing, palliative care, spiritual care
Copyright © 2013 InterVarsity Christian Fellowship. Unauthorized reproduction of this article is prohibited.
journalofchristiannursing.com JCN/July-September 2013 165
component of quality end-of-life care, yet there is a paucity of research on spiritual care in the inpatient setting at the end of life. The purpose of this study was to better understand how inpatient palliative care nurse consultants provide spiritual care and how they acquired these skills. Additional aims included discovering the personhood of nurses providing spiritual care for dying patients.
A purposeful sample of 10 experi- enced palliative care nurse consultants working in inpatient palliative care in the Midwestern United States were recruited for two recorded semi structured interviews to produce 20 transcripts. Institutional review board approval was obtained from the author’s institution, and informed consent was obtained from all partici- pants. A historical self-awareness, nurs- ing process, and expertise in practice interview guide were utilized to obtain narrative data (Benner, Tanner, & Chesla, 2009). Transcripts were decoded, checked for accuracy, and analyzed by the primary investigator (PI). Themes were identified by the PI and verified by a team of experi- enced interpretive phenomenological researchers as well as validated by participants.
Interpretive phenomenology, which seeks holistic understanding and illumination of phenomena, was the methodology used for this study. This is an appropriate research method for examining the everyday practice and skill of providing spiritual care. As nurses presented narratives about caring for patients and families at end of life, they described the lived experience of providing spiritual care in concrete situations where meaning and shared experiences were uncovered and skills and practices explicated.
A CHORUS OF HUMBLED EXPERTS
Ten female nurses actively employed as inpatient palliative nurse consultants participated in this study. They had a median age of 54.5, with 31 median years in nursing and 6.5 median years of palliative care experience. Two of the nurses worked in urban settings, four in suburban, and four in rural settings.
Lord, make me an instrument of your peace. Where there is hatred, let me sow love; where there is injury, pardon; where
there is doubt, faith; where there is despair, hope;
where there is darkness, light; and where there is
sadness, joy. O Divine Master, grant that I may not
so much seek to be consoled as to console; to be
understood as to understand; to be loved as to love.
For it is in giving that we receive; it is in pardon-
ing that we are pardoned; and it is in dying that
we are born to eternal life. Amen
Saint Francis of Assisi
predicated on being humble; humility is essential for providing care and com- fort. “Humbled experts” represents the personhood and spiritual care practices of the palliative care nurse consultants interviewed for the study. Although this study focused on inpatient pallia- tive care, nurses in any setting can learn much about spiritual care from the nurse participants.
Inpatient palliative care is a rapidly exploding field of study. Caregivers in palliative care seek to understand the problems and challenges of end of life through research, which provides evidence for the best care of patients and their families. Spiritual care is a key
EXPLORING SPIRITUAL CARE EXPERTISE
S aint Francis of Assisi, medieval, mystic, and monastic, com- posed this famous prayer of poetic paradox (Tyson, 1999).
The word paradox literally means something contradictory or opposite of what makes sense, yet represents truth. Humbled experts is a paradoxical theme that emerged through a study of pal- liative care nurse consultants and their spiritual care expertise (Pittroff, 2010). Expertise in professional healthcare often is in contradiction with humil- ity. Yet, in the context of spiritual care at the end of life, nursing expertise is
Copyright © 2013 InterVarsity Christian Fellowship. Unauthorized reproduction of this article is prohibited.
166 JCN/Volume 30, Number 3 journalofchristiannursing.com
transcendent meanings and concerns. Through the practice of ordinary acts of nursing care, clients can experience, in their last moments on this earth, the very mystery of our existence. Religious parlance would speak of this as partici- pation with an “experience of the redemptive activity of the Mystery at the heart of things” (Dykstra, 1999, p. xi).
Many of the nurses testified with conviction about a reinforcement of their spirituality, mutuality of care, and mystery of human existence they experience while attending to the spiritual needs of others. Cindy had direct personal and professional experience with loss and the redemptive nature of spiritual care inclusive of God, self, and others. She highlighted the void that exits when spiritual concerns are dismissed and death is denied:
PI: You mentioned feeling excluded from your grandmoth- er’s funeral when you were young. What other experiences had an impact on you?
Cindy: I’m a cancer survivor myself. We’ve had a lot of cancer in our family, so I’ve experienced a lot of death as an adult in our family. I think that’s why I initially was asked to participate in putting our palliative team together here at the hospital. People knew my experiences… they thought I’d be good at it, and my past experiences have helped a bunch.
PI: How would you say it’s helped?
Cindy: Well, I’ve had surgery, chemotherapy, radiation. I understand the side effects, the feelings, the anxieties, and the fears. I think that just helps me relate to patients and the families… My illness also strength- ened my faith, because I had a lot of prayer at that time, I was baptized at that time. So I think I kind of went through a transformation during my cancer treatment that increased my faith and strengthened it.
PI: So you relied on your religious beliefs and the rituals that you’ve learned as a Christian?
Their educational levels included two associate, five bachelors, and three masters degreed nurses. Every nurse reported active participation in a faith tradition; nine Christian and one Unitarian Universalist were repre- sented. Pseudo names were assigned to the nurses to protect anonymity.
None of the participants reported receiving education in spiritual care in their basic nursing education, especially at the end of life. What little knowl- edge they did receive was just the “tip of the iceberg.” Bev, when asked if she had received spiritual care training in nursing school, said, “No absolutely not, oh wait I take that back, we had a lecture on the five stages of grief, one lecture, that was it.” Melissa saw spiritual care as part of the holistic model of caring in all settings and said:
Nurses provide spiritual care all the time, but not formalized like a chaplain would, but they do and sometimes we don’t even realize that were doing it. It’s part of our overall nursing care that isn’t defined as spiritual but it is.
All participants had continuing education in spiritual care through conferences or personal study. How- ever, it was largely through their personal life experience, participation in a faith community, and evolving nursing practice that they learned to recognize and offer an alternative to spiritual suffering. All had experienced loss, some through personal illness and many through family illness and death.
The following excerpts represent the notion of humbled experts. The opportunity to provide care at end of life was described as a “gift” and the role of providing presence, support, and spiritual advocacy as “honor and privilege.” The capacity to provide care of this nature is related to the nurses’ own experience of suffering and loss, growing spiritual awareness, and learned ability not to judge others. The experience of being with people undergoing loss and death creates a context of hospitality, invitation, and mutuality of care. These experiences also have enlarged the nurses’ own perspectives on life:
Jane: People very much invite you into their lives… As I arrived she took her last breaths…this was the end of an ongoing relationship with many difficult decisions being made… I looked upon this as a gift… Her death was very peaceful and I was able to be present…It’s an honor to be part of that.
Melissa: The patient had just died…the daughter was screaming on the floor, so I got on the floor with her and tried to support her. I spent a lot of time with her, not always saying anything, just being present with her, holding her hand. One of the physicians said to me, ‘That’s not your job…’ I’m thinking, it is my job, that’s part of palliative care, to support the family, that’s really what the nurse does, you know, and it is spiritual.
Vicki: I have learned not to be judgmental of people and to accept people for who they are. Before this, I took care of patients in their homes…I saw people with nothing, dirty homes, very sad situations, high illiteracy rates… Gosh, when you started talking to some people, victims of sexual abuse and incest, I wasn’t even aware of that… I was really sheltered. Working in hospice and palliative care was eye-opening for me, because you go home humbled every day from that. You think I’m so grateful for my family and what I have.
Lucy: Looking back on my hospice experiences made me realize that you can’t be judgmental. Every family is very different, there isn’t a right way and a wrong way, it’s just their way. The biggest piece is trying to put yourself in their shoes…and saying to yourself, if this was me, and I were in this situation, what would I want to hear?
Invitation, hospitality, support, presence, nonjudgment, and the recognition of gift and grace represent the etiquette these nurses embody while providing spiritual care. Benner et al. (2009) call this “ethical comportment,” an attribute of agency in expert nursing practice. The manners and humbled relational stances of the nurses engage and permit actualization of spiritual and
Copyright © 2013 InterVarsity Christian Fellowship. Unauthorized reproduction of this article is prohibited.
journalofchristiannursing.com JCN/July-September 2013 167
nurses in this study intentionally work to create and embody a subject-to- subject stance rather than the subject- to- object distancing so prevalent in healthcare. Within this relational stance, study participants described feel- ings of hospitality, privilege, honor, and mutuality. Bev illuminates the personal understandings and professional experiences that engender this stance:
I discharged a patient to hospice today and I thanked him for allowing me to care for him…To be able to help people at this time of life, their most difficult, to take that last step with them is truly an honor… as you become older I think your spirituality develops more, because as you mature, you recognize the meaning of life.
Bev describes herself as a “cradle Catholic” (Catholic from birth). She holds firm to her belief and faith conviction that as she stated, “I was born to love and serve God and others.” Bev also articulated her journey into palliative care as being influenced by her father’s death and the positive connection and experi- ences her father and entire family encountered with the hospice team prior to his death.
Bev highlighted how personal experience with loss, in addition to providing insight and help for others, also has the potential for interfering with spiritual caring. This occurs when personal self-disclosure supersedes the awareness of client needs. Bev is clear about the importance of humility and this assists her in maintaining an “I and thou” or humbled relational stance:
I see this at times when not so much patients, but families are struggling to do the right thing for their loved one. Someone on the healthcare team, when
beliefs… the power the human spirit has amazes and humbles me a lot. I feel very fortunate… it puts the rest of my life into perspective too.
The chorus of the nurses’ voices revealed that through a humbled relational stance, the client and family experience support, presence, nonjudg- ment, and empathy. The nurses describe the opportunity to provide spiritual care as one of gift, privilege, and honor, taking a relational stance when providing care.
“I AND THOU” RELATIONSHIP Years of experience and learning
engendered responsiveness and empathy from the nurses when dealing with people undergoing, tragedy, loss, and fear of the unknown. They
provide for their clients what theolo- gian Craig Dykstra (1999) metaphori- cally calls “bread instead of stones” (p. 13). They accomplish this largely through a relational stance they maintain with their clients, which Martin Buber (1958) named an “I and Thou” relationship. This is a subject- to-subject rather than a subject-to- object way of relating. It necessitates a humbling of self and reverence to another for full engagement. Pohl- man’s (2009) research on fathers of critically ill preterm infants discussed the technological gaze that persons fall victim to in the healthcare setting, and the objectifying stance this creates in modern institutional care.
Jesus, in the hours before his arrest and crucifixion, taught the disciples the gift of servanthood through the act of washing their feet (John 13:1-17). Jesus embodied through ritual a humbling of self and reverence to another. He honors the disciples and ultimately, through an “I and Thou” relational stance, honors God. The
Cindy: I think for self-support as well as trying to help support others. Certainly I think faith is really important. It’s important to help get you through crisis, and no matter what the outcome, you need that.
Cindy’s dialog highlights the inter- secting relationship inclusive of God, self, and others that is articulated in spiritual care literature (Guido, 2010; Kelly, 2004; Taylor, 2002) and the things that matter to her in terms of spiritual care and practice. Dunne (1997) discusses how practices rely on socially embedded practical knowledge; certainly both shared and tacit background meanings enter into the world of nursing practice in this setting and others. Cindy’s experiences of being excluded from her
grandmother’s funeral, personal illness, and multiple losses of loved ones combine to inform her practice. Her “Being” represents, as Gadamer (1975) described, a “fusion of horizons” (p. 304) with those she cares for. This, simply put, is a shared social reality or under- standing of and participation with others who face similar exclusion, dislocation, illness, fear, anxiety, and death. Cindy’s very “Being” and capacity to respond to suffering is grounded by her personal and professional experience. This “fusion” is affirmed by those who knew and recruited her to start a palliative care program.
The following excerpt from Donna summarizes the honor and mystery of life revealed to her while providing care:
To me it is really an honor to be able to assist people on this journey…People are very honest at the end of their life and you get a glimpse to see into their soul… I see souls, I see spirits, they’re incredible beings, and I know they’re going to go on. It reaffirms my spiritual
Expertise in professional healthcare often
is in contradiction with humility.
168 JCN/Volume 30, Number 3 journalofchristiannursing.com
Sophia: You know it’s interesting because people come with a lot of hope, and we talked about hope in the meeting. The chaplain said sometimes hope changes and goes from hope for a cure, to hope for time, and then a hope for peace. I think because those words came from a chaplain, it was more comforting to the family. Chaplains are faith-driven and there may be a mistrust of the medical at this point… But when the family acknowledges peace, something that people get spiritually from God, I think it opens up a dialogue for me as a nurse practitioner, where I can say, ‘Well, we are not able to cure this, but we can provide comfort…’. The chaplain also promised the wife that someone from their department would see her husband each shift for prayer and support. Nothing can be more valuable to
families when they can’t be here around the clock than a promise that someone will be here to pray and hold the hand of their loved one. That was at the end of the meeting, the family agreed to changing course and the patient is now [receiving] comfort measures only.
Sophia sees a bigger picture and recognizes that agency in expertise involves an interdisciplinary team approach. As a nurse expert, she views the chaplain as a valuable presence not limited to offering spiritual care. Sophia views the chaplain as a source of building trust, assisting with decision making, and creating space for her as a nurse practitioner to continue in a dialog of how best to provide comfort for individuals and their families.
Being with chaplains also enables mentoring, which adds to the nurses’ repertoire of spiritual care skills. The nurses reported learning nuances of spiritual care by listening to and
entire palliative team. She views spiritual care as inclusive of all that gives meaning and value to life, including the religious aspect that, for many patients, articulates the essence of spirituality. She considers the focus of palliative care one in which you utilize the entire team to holistically meet client needs. This team approach highlights what Benner et al. (2009) called expert agency, the ability to work in and through others to meet client needs:
Bev: I always, well I won’t say 100% of the time, but for the most part I have the chaplains come in and discern spiritual needs. They are the experts in that field; they are equipped to respond to patients from an active religious standpoint as well as general support and spiritual
guidance… Enlisting all the experts in the care of patients is really what palliative care is all about.
All of the nurses spoke to the value of their pastoral care departments for meeting spiritual care needs. Many reported a strong team relationship with pastoral care. Sophia, a nurse practitioner, highlighted the impor- tance of chaplain service and the team approach of meeting spiritual care needs and making difficult decisions:
Sophia: I work very closely with chaplains because so many times people are coming in receiving bad news, and they need the support that medication can’t give. So every time we have a family meeting, I will bring the chaplain with me.
PI: So you just had one of those meetings today, what was that like?
we’re having meetings, will all of a sudden start talking about something in their personal life involving a crisis…. It doesn’t help, it’s irrelevant… If the family wants to know more they will ask you about your personal life, but for the most part families don’t…Later families will say to me oh, “I felt so sorry for him [the team member]” and I’m thinking wait a minute, it’s not a about him, it’s about you.
Self-disclosure regarding personal experience and/or beliefs can be beneficial and may enhance the involvement of care. But central to spiritual care is a client-centered therapeutic relationship. Caregivers must continue to examine if their motivation for self-disclosure is meeting their own needs or the needs of their clients. Taylor (2002), when
discussing spiritual self-awareness, suggests nurses ask themselves, “What is the purpose of my self-revelation? For whom is this disclosure? Will my disclosure enhance the therapeutic relationship?” (p. 71). This holds true for the disclosure of personal life experience as well as personal beliefs and values. Bev views her relationship with clients as “invitation” and responds to their hospitality to cojourney with them at the most difficult moments as one of “honor and privilege.” She is aware of the difference between self-serving commentary and commu- nication that meets client needs. Through this awareness she is able to embody a humbled expert relational stance, which includes her ability to enlist other experts.
“ENLISTING OTHER EXPERTS” Bev’s humility assists her in careful
discernment of not only her nursing role but also the expertise of the
Personal experience with loss…has the potential
for interfering… when personal self-disclosure
supersedes the awareness of client needs.
journalofchristiannursing.com JCN/July-September 2013 169
spiritual caring skills can be cultivated at all levels of the nursing skill con- tinuum, from student to novice to expert. Additionally, this study rein- forces the concept that not all scientific nursing knowledge branches from a Cartesian rationalist cause and effect, positivist framework. Nursing relies on both scientific theory-based knowing and the experiential art of tacit knowledge and skills for caring. Together, science and art enhance, inform, and enliven the discipline of nursing to permit agency and expertise in practice. The humbled expert nurses in this study articulated the awareness of the fragility of life, the essence of spirituality and whole persons, the experience of suffering, and the deep human need for connectedness.
Acknowledgment Funding was received for this
research from the Goldfarb School of Nursing and Sigma Theta Tau Interna- tional Tau Iota Chapter.
Benner, P., Tanner, C., & Chesla C. (2009). Expertise in nursing practice: Caring clinical judgment and ethics (2nd ed.). New York, NY: Springer.
Buber, M. (1958). I and thou (Smith Classic Translation). New York, NY: Macmillan.
Dunne, J. (1997). Back to the rough ground. Notre Dame, IN: Notre Dame Press.
Dykstra, C. (1999). Growing in the life of faith. Louisville, KY: Geneva.
Gadamer, H. (1975). Truth and method. (Sheed and Ward Ltd., Trans.). New York, NY: Seabury.
Guido, G. W. (2010). Nursing care at end of life. Upper Saddle River, NJ: Pearson.
Kelly, J. (2004). Spirituality as a coping mechanism. Dimensions of Critical Care Nursing, 23(4), 162.
Pittroff, G. E. (2010). The cultivation and practice of spiritual care expertise in an inpatient palliative care setting. (Doctoral dissertation). Retrieved from ProQuest LLC. (AAT/ UMI 3432880).
Pohlman, S. (2009). Fathering premature infants and the technological imperative of the neonatal intensive care unit: An interpretive inquiry. Advances in Nursing Science, 32(3), E1–E16.
Prayer of St. Francis of Assisi. (n.d.). Retrieved from www.prayerguide.org/uk/stfrancis.htm
Shulman, L.S. (2010). Forword. In P. Benner, M. Stu- phen, V. Leonard, & L. Day (Eds.). Educating nurses: A call for radical transformation (pp. ix–xii). San Francisco, CA: Jossey-Bass.
Taylor E. J. (2002). Spiritual care: Nursing theory, research and practice. Upper Saddle River, NJ: Prentice Hall.
Tyson, J. R. (1999). Invitation to Christian spirituality: An ecumenical anthology. New York, NY: Oxford.
Young, C., & Koopsen, C. (2011). Spirituality health and healing: An integrative approach (2nd ed.). Toronto: Jones and Bartlett.
care practices. This knowledge is utilized through a team approach as well as in isolation with their clients.
In summary, the astute perceptual skill and tacit knowing of expert nurses providing spiritual care at end of life are hidden in the unassuming posture of humility. Yet, it is humility that permits and actualizes the spiritual aspects of care. The humbled expert nurses in this study embody spiritual skills of caring that include presence, courage, silence, touch, nonjudgment, and empathy for patients and their families. These nurses know when they are beyond the scope of their practice and the interdisciplin- ary team is frequently enlisted. In service to others, the nurses describe a mutuality of care, a reciprocal phenom- enon present in the caring relationship as they get as much as they give and describe their role as one of “gift, privilege, and honor.” Their experiences in life and in practice have enlarged and enlivened their whole perspective of life, informing these nurses with more unique and refined ways to respond to suffering. It is through the humbled expert nurse that patients and families experience grace instead of awkward- ness, comfort instead of suffering, hope instead of despair, and a paradoxical peace. Indeed, “The Lord takes pleasure in his people; he adorns the humble with salvation” (Psalm 149:4, ESV).
IMPLICATIONS FOR PRACTICE AND RESEARCH
This study is unique in that it examined the personhood and spiritual care practices of inpatient palliative care nurses, a relatively new specialty that emerged in the United States within the last decade. This study illuminates expert nurses as possessing astute practical and tacit skills that create a context for a meaningful, peaceful, and dignified death, and acknowledges the practical, ethical, and moral value of nursing care at end of life. The results support the need for structures and policies that will continue and develop inpatient palliative care providers and programs.
The spiritual caring of the nurses in this study was dependent in part on personal life experiences, loss, and faith. Future research should explore how
mimicking the behaviors of chaplains. Lucy discussed how she often is in a situation when someone dies and the chaplain is not available or the family declines chaplain services. However, in the death moment, Lucy is the one left to help with closure before the family leaves the hospital. Lucy mimics the chaplain to help her meet spiritual needs at those times. She carries a small collection of sacred literature and poetry, which she utilizes when appropriate. Lucy is comfortable with prayer, yet modest when discussing her ability to weave thoughtful words carefully together to offer peace at end of life:
I would love to pray as the chaplains do, more spontaneously… I also get too emotional, when [I] say a prayer I almost always tear up, I’d like to get more help with this and be able to do that.
Lucy values the healing presence and carefully crafted words that chaplains provide at the most difficult times in life. Young and Koopsen (2011) point out that only 20% of hospitalized patients in the United States see a chap- lain. Lucy tries to be prepared when called upon hoping to meet patient and family needs while simultaneously experiencing her own grief and loss.
The nurses in this study are clear about their role in spiritual care. Bev, Sophia, and Lucy highlighted their awareness of when they are beyond the scope of their expertise. They operate with a team mentality in meeting client and family spiritual care needs. Yet, they also recognize the overlap of specific disciplinary knowledge and skills inherit of the nursing role. Shulman (2010) names nursing as a hybrid profession, one that is reflective of the attributes of other professions while maintaining a unique identity of its own. The nurses in this study draw insight and knowledge from many disciplines to inform their practice and provide care at end of life. This again points to the Benner et al. (2009) model of expert agency as working in and through others to provide the care their clients need and desire. Pastoral care is highlighted as the discipline that informs much of these nurses spiritual