Dr. Klelija Štrancar, Andreja Mihelič Zajec Koncept duhovnosti v zdravstveni negi Prejeto 29. 4. 2020 / Sprejeto 16. 11. 2020 Strokovni članek UDK 616-083+2-584 KLJUČNE BESEDE: religija, duhovne potrebe, ce- lostna oskrba, medicinske sestre POVZETEK - Duhovnost, ki se nanaša na mnoge di- menzije človekovega življenja, ima pomembno vlogo v procesu in izidih zdravljenja. Duhovne potrebe so pogosto neenakovredno upoštevane v primerjavi z drugimi človekovimi potrebami. Najpogostejši vzroki za to so: pomanjkanje znanja in usposobljenosti, ne- enotna definicija duhovnosti in nejasnost v razlikova- nju med duhovnostjo in religijo. Ne glede na naštete ovire je v kontekstu holistične obravnave v zdravstve- ni negi potrebno upoštevati duhovno dimenzijo paci- entovega življenja. Naloga medicinske sestre je, da vključi skrb za duhovne potrebe v načrt zdravstvene nege. Za učinkovito vključitev pa je pomembno, da prepozna pacientove duhovne potrebe. Za zagotovi- tev ustrezne podpore mora najprej razumeti, kako naj oceni duhovne potrebe pacienta, uporabi primerne intervencije in se zaveda kompetenc na tem področju. Received 29. 4. 2020 / Accepted 16. 11. 2020 Professional article UDC 616-083+2-584 KEYWORDS: religion, spiritual needs, holistic care, nurse ABSTRACT - Spirituality, which encompasses various aspects of human life, plays a very important role wit- hin the healing process and its outcome. Spiritual ne- eds are often inadequately addressed to in comparison with other human needs. The most frequent reasons are the following: lack of necessary knowledge and qualifications, the need for an unequivocal definition of spirituality as well as the unclear distinction betwe- en the concepts of spirituality and religion. Despite the above-mentioned hindrances, it is necessary to take into consideration the spiritual dimension within the context of holistic treatment in nursing. The task of the nurse is to integrate the care for spiritual needs in the nursing plan. In order to include spirituality in the nur- sing process, it is crucial to perceive and recognize the patients' spiritual needs. To provide the most suitable support, nurses should be able to assess the patients' spiritual needs first, then use appropriate interventions and methods as well as be aware of competences nee- ded in this area. 1 Uvod Duhovnost je pomemben del celostne oskrbe v zdravstveni negi (Harkreader in Hogan, 2004), še zlasti je pomembna za paciente v paliativni oskrbi (Cone in Giske, 2012; Puchalski idr., 2009; Ramezani, Ahmadi, Mohammadi in Kazemnejad, 2014; Tiew in Creedy, 2010) in paciente v kriznih situacijah (van Dierendonck in Mohan, 2006). Kljub temu pa sta duhovnost in duhovna oskrba po mnenju nekaterih avtorjev (Biro, 2012; Chan, 2010; Jones, 2018; Kalish, 2012) še vedno zanemarjena v okviru celostne obravnave pacienta. Med prepoznane ovire spadajo pomanjkanje časa, po- manjkanje znanja (usposabljanja) pomanjkanje zaupanja in osebno nelagodje (Galli- son, Xu, Jurgens in Boyle, 2012; Jones, 2018). Eden od prepoznanih dejavnikov, ki prispeva k tem oviram, je pomanjkljivo znanje o tem, kako sta duhovnost in religija sploh opredeljena. Zato je pomembno, da medicinska sestra pozna razliko med obema (Barber, 2019; Gallison idr., 2012). Koncept duhovnosti v zdravstveni negi 141Dr. Klelija Štrancar, Andreja Mihelič Zajec: Koncept duhovnosti v zdravstveni negi Ko se pacienti soočajo z življenje ogrožajočo boleznijo, se pojavijo vprašanja po- mena in smisla. V ta namen pogosto opravijo pregled svojega življenja, ki se nanaša na vprašanja odnosov in razumevanja lastne vrednosti. Nič nenavadnega ni, da se v tem času pojavi dvom v Boga, pravičnost in pravilnost življenjskih odločitev. Duhovna vprašanja vključujejo doživljanje brezupa, krivde, jeze, zapuščenosti in osamljenosti. Ta vprašanja lahko povzročijo hudo trpljenje, ki je posledica doživljanja odrezanosti od sebe, drugih, Boga ali poslednjega vira smisla (Puchalski in Ferrell, 2010). Frankl (2004) pravi, da človeka ne uniči trpljenje samo, temveč trpljenje brez smisla. Duhov- na oskrba pomaga osmisliti trpljenje in najti upanje. V takšnih trenutkih so lahko skrb, sočutje in odgovornost pomembni dejavniki, ki prinašajo pacientu tolažbo in moč (Puchalski in Ferrell, 2010). Da je duhovnost pomemben del zdravstvene obravnave, kažejo številne raziskave, ki so potrdile želje in potrebe pacientov s hudo boleznijo in pacientov ob koncu življe- nja po vključitvi duhovnosti v njihovo obravnavo (Chan, 2010; Puchalski idr., 2009; Vilalta, Valls, Porta in Viñas, 2014; Wilkinson, 2014). Namen prispevka je pojasniti duhovnost in poudariti njen pomen v okviru celostne zdravstvene nege. Cilji so: □ definirati duhovnost in religijo ter pojasniti razliko med njima; □ predstaviti vpliv duhovnosti na zdravje pacienta; □ seznaniti z osnovnimi pristopi za prepoznavanje duhovnih in/ali religioznih potreb; □ informirati medicinske sestre o načinih in orodjih ocenjevanja duhovnih potreb. 2 Definicija duhovnosti in religije V zdravstveni literaturi najdemo številne opredelitve duhovnosti. Duhovnost se nanaša na mnoge dimenzije človekovega življenja (McSherry in Jamieson, 2013; Pu- chalski in Ferrel, 2010). Je bistvo človeškosti in se izraža v iskanju smisla o tem, kdo kot ljudje sploh smo, kajti kot pravi Frankl (1994, 13–14, str. 50): »Bivanje ni samo intencionalno, ampak je tudi transcendentno. Preseganje samega sebe je bistvo bivanja. Biti človek, pomeni biti usmerjen k nečemu drugemu kakor k samemu sebi«. Preko duhovnosti posamezniki iščejo in izražajo smisel in namen ter način, s katerim doživljajo svojo povezanost s trenutkom, s sabo, z drugimi, z naravo in s pomembnim ali svetim (Berman in Snyder, 2012; Puchalski idr., 2009; Royal College of Nursing, 2011; Unruh, Versnel in Kerr, 2002). Duhovnost daje pomen in cilj posameznikovemu življenju. Vsak namreč odloča o tem, ali ima njegovo življenje smisel in vrednost, ki sega onkraj sebe, življenja in smrti (Astrow, Puchalski, in Sulmasy, 2001; Puchalski, Dorff in Hendli, 2004). Duhovnost in duhovna oskrba sta bili v preteklosti pretežno pojmovani kot religi- ozna duhovna oskrba. Ne glede na to, da se pojma prepletata, pa nista sinonima (Car- ron in Cumbie, 2011; Dyson, Cobb in Forman, 1997; Jones, 2018; Pike, 2011; Rogers in Wattis, 2015; Sheldon, 2000). Duhovnost je obravnavana v širšem pomenu kot re- ligija, je bistveni način človekovega življenja, ki išče in izkazuje svoj smisel oziroma 142 Revija za zdravstvene vede (7, 2020) razumevanje in ni vezana zgolj na določene obrede ali rituale, ki pripadajo religijam. Religijo določa sistem naukov, norm, vrednot in obredov, s katerimi se izkazuje vera v presežno resničnost. Tako lahko pacient doživlja svojo bolezen kot posledico greha ali božje kazni. V tem primeru je to prepričanje vir stiske, ki potrebuje podporo in pomoč verskega predstavnika ali člana verske skupnosti (Timmins in Caldeira, 2017). Po drugi strani pa lahko oseba izraža globoko potrebo po duhovnosti in živi duhovno, čeprav ni verna. S tega vidika vsebuje vsaka religija dimenzijo duhovnosti, medtem ko duhovnost kot širši pojem ni izenačena z religijo oz. ni sinonim zanjo (Emmons in Paloutzian, 2003; Tanyi, 2002; Unruh idr., 2002). Pomembno je, da medicinska sestra razume pojem duhovnosti ter da se zaveda meja svojih sposobnosti pri izvajanju duhovne oskrbe. V zvezi s tem mora biti sposob- na oceniti, kdaj je primeren čas za pogovor s pacientom o duhovnih zadevah (Timmins in Caldeira, 2017). Komunikacija s pacienti in svojci sega od prepoznavanja duhovnih potreb in vprašanj do formalne ocene stanja, intervencij in vrednotenja izidov. Predpo- goj vsake dobre komunikacije je, da temelji na terapevtskem odnosu. 3 Vpliv duhovnosti na zdravje pacienta Ker se posveča duhovnosti vedno več pozornosti v zdravstveni literaturi, razi- skovalce vse bolj zanima odnos med duhovnostjo in zdravjem v kliničnem okolju (Surbone in Baider, 2010). Dobro duhovno počutje (spiritual well-being) vpliva na pozitivne zdravstvene rezultate, vključno s kakovostjo življenja, zadovoljstvom z živ- ljenjem, odpornostjo, nižjimi stopnjami depresije in tesnobe, duševnim in telesnim zdravjem, večjo socialno podporo in pozitivnimi čustvi, kot sta upanje in optimizem (Kruizinga idr., 2016; McSherry in Jamieson, 2013; Puchalski in Ferrel, 2010). Re- zultati so vidni na psihičnem, socialnem, fizičnem in duhovnem področju (McEwen, 2005; Ramezani idr., 2014; Sun idr., 2016). Raziskava, ki je bila izvedena med muslimani v Jordaniji in je zajela paciente s koronarno arterijsko boleznijo, je pokazala pozitivne učinke religije na sprejemanje in doživljanje bolezni. Vpliv se je pokazal kot povečanje notranje moči in upanja, samoodgovornosti ter kot pomoč pri iskanju in doseganju smisla življenja (Nabolsi in Carson, 2011). Posamezniki, ki so deležni duhovne in verske podpore, imajo manj depresije (ali pa se njeni simptomi prej zmanjšajo), manj je anksioznosti in poskusov samomora. Pri njih je zabeležena tudi manjša zloraba prepovedanih substanc (Bonelli in Koenig, 2013; Koenig, 2009). Raziskave so pokazale vpliv duhovnih intervencij tudi na znižanje stresa, alkoholizma, še zlasti so vidni učinki na manjše občutenje tes- nobe (Forouzi, Tirgari, Safarizadeh in Jahani, 2017; Gonçalves, Lucchetti, Menezes in Vallada, 2015). Pomembni rezultati duhovne in religiozne oskrbe so se pokazali tudi kot pomoč pri samorazumevanju pacienta, njegove bolezni in umiranja (Daaleman, 2012). Duhovnost in religija, ki sta za paciente pomembni, sta povezani z boljšimi rezultati telesnega zdravja kot tudi z boljšimi odnosi s svojci in drugimi (Breitbartidr, 2012; Garlick, Wall, Corwin, in Koopman, 2011; Jim idr., 2015). Pomen duhovnosti 143Dr. Klelija Štrancar, Andreja Mihelič Zajec: Koncept duhovnosti v zdravstveni negi se vse bolj poudarja tudi na področju duševnega zdravja, kjer npr. že samo dejanje »jemanja duhovne anamneze (zgodovine)« lahko izboljša pripravljenost pacientov za sodelovanje in izboljša zadovoljstvo z zdravstveno obravnavo (Moreira - Almeida, Koenig in Lucchetti, 2014; Smith - MacDonald, Norris, Raffin-Bouchal in Sinclair, 2017). Duhovna podpora, ki jo izvaja medicinska sestra, ima pozitivne učinke tudi za njo, kar se odraža s spodbujanjem duhovnega zavedanja in zadovoljstvom pri delu (Ramezani idr., 2014). 4 Primeri duhovnih potreb Duhovnost se nanaša na vprašanja o pomenu in namenu življenja in trpljenja, o strahovih in upanju, smrti in posmrtnosti, krivdi, odpuščanju in spravi, odnosu do pre- sežnosti kot tudi o razumevanju življenja. V tem smislu so duhovne potrebe opredelje- ne kot potrebe in pričakovanja, preko katerih ljudje iščejo smisel, pomen in vrednost svojega življenja. Duhovne potrebe pacientov se tako kažejo kot potrebe v poveza- nosti s seboj, z drugimi, z Bogom ali neko višjo silo in kot potrebe znotraj skupnosti (tabela 1). Tabela 1: Primeri duhovnih potreb (Taylor, 2002 v Berman in Snyder, 2012) 144 Revija za zdravstvene vede (7, 2020) 5 Anamneza in ocena duhovnih potreb Anamneza duhovnosti je pomemben korak v procesu zdravstvene nege. Cilji anamneze duhovnosti so: □ prepoznati pacientova prepričanja in vrednote; □ povabiti pacienta, da zaupa duhovne ali religiozne potrebe; □ spodbuditi pacienta, da pove, kaj mu pomeni duhovnost in kaj so njegovi duhovni cilji; □ ostati pozoren na duhovne stiske (nesmiselnost, obup), kakor tudi na njegove vire moči (upanje, smisel in namen, živahnost/odprtost, duhovna skupnost); □ spodbuditi pacienta pri iskanju notranjih virov zdravljenja in sprejemanja; □ prepoznati duhovna in religiozna prepričanja pacienta, ki lahko vplivajo na odlo- čanje glede zdravljenja; □ ugotoviti duhovne prakse pacienta in jih vključiti v načrt zdravstvene obravnave (Puchalski in Ferrell, 2010). Osnovni namen ocene duhovnosti je določiti specifične duhovne potrebe in obli- kovati načrt zdravstvene nege pacienta (Caldeira, Carvalho in Vieira, 2013; Power, 2006). Gre za kontinuiran proces zbiranja informacij na podlagi opazovanja, posluša- nja, postavljanja vprašanj pacientu ter na podlagi uporabe ocenjevalnih orodij. Večina ocenjevalnih orodij vključuje vprašanja o pacientovi osebni duhovnosti in obredih, veri in prepričanjih, virih in pričakovanjih. Zaznane duhovne potrebe je treba vključiti v zdravstvene zapise. Če je duhovna ocena vključena v evidenco zdravstvene nege, obstaja tudi obveza za zagotavljanje intervencij, ki vplivajo na izide, kar pa je mogoče meriti in vrednotiti (Timmins in Caldeira, 2017). Tabela 2: Prikaz pogosto uporabljenih ocenjevalnih orodij (Timmins in Kelly, 2008 v Timmins in Caldeira, 2017) Ocenjevalno orodje Vsebina (komponente) SPIRIT (Maugans, 1996) S – Spiritual belief system (sistem duhovnih prepričanj) P – Personal spirituality (osebna duhovnost) I – Integration with a spiritual community (vključenost v duhovno skupnost) R – Ritualised practices and restrictions (obredne prakse in omejitve) I – Implications for medical care (implikacije za medicinsko oskrbo) T – Terminal events planning (načrtovanje dogodkov v terminalni fazi bolezni) FICA (Puchalski in Romer, 2000) F – Faith or belief (vera, prepričanje, smisel) I – Importance and influence (pomembnost in vpliv) C – Community (skupnost) A – Address: how would you like these issues to be addressed? (na kakšen način želi biti pacient vključen v duhovno oskrbo) HOPE (Anandarajah in Hight, 2001) H – Sources of hope, strength, comfort, meaning, peace, love and connection (viri upanja, moči, tolažbe, smisla, miru, ljubezni in povezanosti) O –The role of organised religion for patients (vloga organizirane religije) P – Personal spirituality and practices (osebna duhovnost in praksa) E – Effects on medical care and end-of-life decisions (učinki na zdravstveno oskrbo in odločitve ob koncu življenja) 145Dr. Klelija Štrancar, Andreja Mihelič Zajec: Koncept duhovnosti v zdravstveni negi Pomembno je, da medicinska sestra ugotovi, ali pacient želi biti vključen v duhov- no obravnavo. V primeru pacientovega strinjanja lahko uporabi ocenjevalna orodja, kot so SPIRIT, FICA in HOPE (tabela 2). Vprašanja pa je mogoče uskladiti in prila- goditi pacientovim potrebam in okoliščinam. Če je npr. pacient obveščen o resnosti diagnoze, bo vprašanje prilagojeno temu stanju: »Imate duhovna prepričanja, ki so vam bila v pomoč v težkih situacijah?« ali »Imate duhovna prepričanja, ki bi vam v tem trenutku pomagala?« (Puchalski in Ferrell, 2010). 6 Aktivnosti zdravstvene nege na področju duhovnosti Na osnovi negovalne ocene medicinska sestra lahko postavi negovalne diagnoze, ki so izhodišče za izbor ustreznih intervencij. Negovalne intervencije vključujejo raz- lične aktivnosti, kot npr. poslušanje pacientove zgodbe, duhovno svetovanje, spodbu- da, da uporablja že uveljavljene duhovne prakse (npr. molitev, meditacije), udeležba v verskih ali duhovnih skupnostih, pisanje dnevnikov, sodelovanje v umetnosti ipd. Namen intervencij na področju duhovnosti je spodbujanje in doseganje dobrega du- hovnega počutja (Timmins in Caldeira, 2017). Če medicinska sestra v času hospitalizacije, ko spremlja in opazuje pacientovo iz- ražanje, ugotovi, da pacient namiguje na občutek brezsmiselnosti, brezupa ipd., lahko spodbudi pacienta k pogovoru. Pacient lahko postavi vprašanja: »Zakaj se to dogaja meni? Kaj bo z menoj?« V takšnem primeru je pomembno odgovoriti. Odgovor naj bo odprt, kot npr. »povejte mi nekaj več o tem«. Z iskanjem odgovorov na vprašanja, ki nimajo odgovora, pa se medicinske sestre zaradi zadrege in doživljanja nemoči pogosto izognejo odgovoru in s tem zamudijo priložnost, da bi slišale stisko pacienta (Puchalski in Ferell, 2010). 7 Razprava V zdravstveni literaturi se že dolgo razpravlja o definiciji duhovnosti. Neenotnost v definiranju razkriva vso širino tega problema in otežuje njegovo razumevanje (John- son idr., 2007; Jones, 2018; Kisvetrová, Klugar in Kabelka, 2013; McSherry in Jami- eson, 2013; Puchalski in Ferrel, 2010). K nerazumevanju prispeva tudi dejstvo, da je bila v preteklosti skrb za duhovne potrebe usmerjena na religijo in njeno prakso (Jo- nes, 2018; Maphosa, 2017). Posledica nerazumevanja duhovnosti pa je, da medicinske sestre pogosto ne prepoznajo in ne dokumentirajo potreb na tem področju. V vsakem primeru pa sta duhovnost in religija pomembna pri zagotavljanju celostne zdravstvene nege za pacienta in se v praksi pogosto prekrivata in prepletata (Jones, 2018). Raziskave so odkrile pozitiven odnos med duhovnostjo ter zdravjem in dobrim po- čutjem pacientov (Carmody, Reed, Kristeller in Merriam, 2008; Johnstone, Franklin, Yoon, Burris in Shigaki, 2008). Duhovnost daje smisel življenju in je pogosto zelo po- membna za paciente v paliativni obravnavi in v kriznih situacijah. Duhovna in verska 146 Revija za zdravstvene vede (7, 2020) prepričanja vplivajo na to, kako se ljudje spopadajo s težko boleznijo, z življenjskimi stresi in izzivi. Duhovna praksa spodbuja pozitiven odnos do zdravja in okrepi dobro počutje. Po drugi strani pa zanemarjanje in neupoštevanje vpliva duhovnosti v celostni obravnavi lahko povzroča stiske in poveča breme bolezni (Puchalski in Ferrell, 2010). Zato mora medicinska sestra upoštevati vsa področja človekove razsežnosti: fizično, psihično, socialno in duhovno. Z naraščajočim priznanjem vloge duhovnosti v zdravju je pomembno razumevanje duhovne oskrbe, ki je povezana s kakovostno zdravstveno nego (Biro, 2012; Prentis, Rogers, Wattis, Jones in Stephenson, 2014). Ne glede na to, da je duhovnost pomemben del celostne zdravstvene nege, je še vedno zapostavlje- na in pogosto spregledana (Biro, 2012; Chan, 2010; Kalish, 2012; Rogers in Wattis, 2015). Raziskave kažejo, da medicinske sestre nimajo dovolj znanja o duhovnosti v zdravstveni negi (Narayanasamy, 2004). Znanje bi jim pomagalo, da bi se počutile in delovale bolj samozavestno pri izvajanju tovrstne prakse (Jones, 2018; Taylor, 2007). Usposabljanje bi moralo temeljiti na vsebinah, kot so: pomen in namen ocenjevanja duhovnih potreb pacientov; pridobivanje veščin za ustrezne odzive na težka vprašanja in duhovne stiske; seznanjenost z možnimi resursi, kadar je potrebna bolj specializira- na obravnava (preseganje kompetenc medicinske sestre); krepitev (samo)zaupanja v raziskovanju področja pacientove duhovnosti (Jones, 2018). Medicinska sestra z oceno pacientovih duhovnih potreb vstopi v kontinuiran pro- ces zdravstvene nege za obravnavo te življenjske aktivnosti. Kadar prepozna pacien- tove duhovne potrebe in jih dokumentira, mora tudi ustrezno intervenirati (Caldeira in Timmins, 2017). Pri oceni pacientovih duhovnih potreb so ji lahko v pomoč orodja, kot npr.: SPIRIT, FICA in HOPE. Cilj intervencij je ustvariti prijazno in gostoljubno okolje, v katerem lahko pacient brez strahu izrazi svojo ranljivost (Taylor, Lillis, Le- Mone in Lyn, 2011). Intervencije temeljijo na poslušanju, svetovanju, prisotnosti ob pacientu, kar pomeni biti »ob« in »z« pacientom, spodbujanju k izvajanju verske pra- kse, če si pacient to želi ipd. V veliko pomoč za izvajanje intervencij bi bila medicin- skim sestram uporaba standardiziranega jezika, kot je npr. NIC (Nursing Intervention Clasification). Pred osnovna življenjska vprašanja, ki se nanašajo na duhovnost, pa ni postav- ljen samo pacient in njegovi svojci, temveč tudi medicinska sestra. Zato ne gre le za vprašanja, ki si jih zastavlja pacient in njegovi bližnji, temveč tudi za vprašanja, ki si jih mora zastavljati medicinska sestra o tem, kakšen odnos ima do sebe, drugih in do sveta. Pojem smiselnosti, ki ga reflektira v odnosu do drugih, postane osrednje izhodišče spremljanja in duhovne podpore. Izraža se v načelih duhovne oskrbe, ki omogočajo občutenja sprejetosti, ljubeče pozornosti in razumevanja drugačnosti. Prav zato je srečanje z duhovnimi potrebami pacienta ne le velik izziv, temveč tudi velika odgovornost in zavezanost medicinske sestre, da skrbi tudi zase. Od dobre medicinske sestre se pričakuje, da si sama zastavlja vprašanja, nanje išče odgovore in posledično razvija lastno duhovno presežnost. Na ta način razvija potrebne kompetence, ki ob- segajo znanje, veščine, spretnosti, osebnostne in vedenjske značilnosti, prepričanja, motive in vrednote ter samopodobo (Barber, 2019; Caldeira in Timmins, 2017). 147Dr. Klelija Štrancar, Andreja Mihelič Zajec: Koncept duhovnosti v zdravstveni negi 8 Zaključek Duhovna oskrba temelji na predpostavki, da smo ljudje duhovna bitja, ker smo sposobni presegati svojo povezanost s sedanjostjo in postavljati vprašanja, ki zadevajo celoto življenja in bivanja tudi z vprašanji, vezanimi na »onkraj življenja«. V tem je človekova presežnost, njegova transcendenca. Zato nikakor ne smemo prezreti duhov- nih potreb v celostni obravnavi pacienta in tudi njegovih svojcev. Duhovnost in/ali religija sta pomembna dela pacientovega doživljanja bolezni, trpljenja in izgube. Da bi bila medicinska sestra pacientu v času težke bolezni in umiranja v resnično oporo, ga mora spoštovati v njegovi celostnosti. Šele takrat bo lahko prisluhnila njegovemu upanju, strahu, verovanju in vse to vključila v načrt zdravstvene nege. Duhovna oskr- ba je mnogim pacientom in svojcem zadnja življenjsko pomembna opora in pomoč pri soočenju, ovrednotenju in sprejemanju preteklega življenja ter soočenju s sedanjim trenutkom. Klelija Štrancar, PhD, Andreja Mihelič Zajec The Concept of Spirituality in Nursing Spirituality refers to various aspects of human life. It is necessary in the holistic treatment of patients within the process of medical care. Spiritual support plays a ma- jor role both in the healing process and its outcomes. The need for spiritual support can be perceived even more in the period of palliative care. Unfortunately, spiritual needs have often been overlooked or not taken into consideration at all. The most common reasons are the following: lack of knowledge and competences, difficulties to address spirituality and the unclear distinction between spirituality and religion. The definition of the concept of spirituality has been a matter of discussion in scientific studies and literature for a long time. The complexity and the wide dimensions of the concept have only contributed to making it more difficult to understand. Consequently, nurses and other healthcare professionals are often not able to perceive, recognize and document the needs in this area. Idespite of the above-mentioned obstacles, the spiritual dimension of the patient's life should be taken into account in the context of holistic treatment in nursing. The task of a nurse is to include the spiritual needs in the nursing plan. In order to effici- ently integrate spirituality in the nursing process, the nurse should be able to identify the patients' spiritual needs. To provide adequate support the nurse has to understand how to assess their needs, implement suitable interventions and be aware of her own competences in this field. Spiritual questions can comprise feelings of hopelessness, guilt, anger, aban- donment and loneliness. These questions can cause anxiety and serious suffering beca- use they are excluded and separated from themselves, from others, from God or from 148 Revija za zdravstvene vede (7, 2020) the ultimate source of meaning. Spiritual care can help give meaning to suffering, as well as find hope in despair. In moments like these, showing care, compassion and responsibility can help patients regain their hope, consolation and strength. Numerous studies and research have emphasized the importance of spirituality as part of the he- althcare treatment by showing the need and desire of those patients undergoing severe illness or the ones whose death is imminent to integrate spirituality in their treatment. The purpose of this article is to explain the concept of spirituality and to emphasi- ze its importance within the holistic healthcare, especially during palliative care. The aim is to define spirituality and religion and to destringuish clearly between them, to show the influence of spirituality on health, to present the basic approaches to iden- tifying spiritual and/or religious needs and to inform about the ways and instruments for their assessment. Although spirituality and religion are interwoven concepts, they are not synony- mous. Spirituality has been dealt with in a broader perspective than religion, as it is an essential way of human life, of person’s searching for and manifesting its meaning and understanding. It is not only related to specific rituals or rites, which belong to different religions. Religion is determined by a system of doctrine, norms, values and rituals that enable people to express their faith in transcendence. In this case patients perceive their illness as a consequence of a sin or God's punishment. Spirituality can undoubtedly have a positive impact on people's health. Spiritual well-being can contribute to positive effects and outcomes of medical care, including the quality of life, life satisfaction, resilience, decrease in depression and anxiety, men- tal and physical health, stronger social support and positive feelings such as hope and optimism. The positive effects of spiritual and religious care have shown the impor- tance of this kind of support during the patient's process of self-understanding when being ill or dying. Those individuals who are given spiritual and religious support usually experience lower levels of depression (or the symptoms disappear earlier), less anxiety and fewer suicidal attempts, as well as less drug abuse. On the other hand, neglecting or not including spirituality into the holistic treatment might not only cause psychological distress but also increase the burden of the illness. For that reason, a nurse must take into account all dimensions of human life: physical, mental, social and spiritual. Spiritual support provided by the nurse can also be beneficial for her, which reflects in the enhanced spiritual awareness and work satisfaction. In order to ensure the positive influence of spirituality on the health of patients, the nurse has to identify their spiritual needs first. These are definedas needs and expecta- tions through which the individuals seek the meaning, purpose and value of his or her life. They are also related to issues such as the meaning of suffering, fears and hope, death and life afterwards, guilt, forgiveness and reconciliation, the attitude towards transcendence and the understanding of life. According to Taylor (2002, quoted by Berman and Snyder, 2012) spiritual needs can be divided into four main categories: needs for being connected to oneself, to others, to God and to the needs within the community. 149Dr. Klelija Štrancar, Andreja Mihelič Zajec: Koncept duhovnosti v zdravstveni negi It is important that the nurse not only understands the term of spirituality but is also aware of the limits of her ability in practicing spiritual care. She has to be able to determine the right time to talk about spiritual issues with the patient. The communi- cation with patients and their relatives ranges from the stage of identification of these needs and issues to the formal assessment of the conditions, approaches and the final evaluation of the outcomes. The prerequisite for successful communication is to be based on a therapeutic relationship. To assess spiritual needs, it is necessary to have an insight into the conditions as well as to determine the care anamnesis. The main purpose of spiritual assessment is to specify the spiritual needs and prepare a plan of medical care. The anamnesis of spirituality is as important as other aspects in the process of medical care. The aim of spiritual anamnesis is to identify the patients' values and beliefs. The nurse should en- courage patients to express their spiritual/religious needs, she also inquires about the meaning of spirituality and its goals. She should be very attentive to their discomfort and worries (despair, meaninglessness…) as well as to the patient's inner sources of strength (hope, meaning and purpose, liveliness/ open-mindedness, spiritual commu- nity). Patients should be encouraged to find inner sources of healing and accept their complaints. The nurse should identify the spiritual and religious beliefs that might in- fluence her decisions regarding treatment and should inform herself about the patient’s spiritual practices in order to integrate them into the plan of medical care. The nurse should also be aware of whether the patient is willing to participate in the spiritual treatment. In case the patient agrees, she can use assessment tools such as SPIRIT (Spiritual belief system-Personal Spirituality-Integration with a spiritual com- munity-Ritualised practices and restrictions-Implications for medical care-Terminal events planning) (Maugans, 1996), FICA (Faith or belief-Importance and influence -Community-Address: how would you like these issues to be addressed? (Puchalski and Romer, 2000) and HOPE (Sources of hope, strength, comfort, meaning, peace, love and connection-The role of organised religion for patients-Personal spirituali- ty and practices-Effects on medical care and end-of-life decisions (Anandarajah and Hight, 2001). However, the questions can be tailored to patients' needs and adapted to the circumstances. After assessing the spiritual needs of the patient, the nurse decides on the necessa- ry care measures. They may include various activities such as listening to the patient's story, spiritual counselling, encouraging the patient to use well-established spiritual practices (prayers, meditation), participation in religious or spiritual communities, writing a journal, art performances etc. The main purpose of these interventions is to stimulate, encourage and ultimatively achieve spiritual well-being. During hospita- lization, the nurse, while observing and monitoring the patient's ways of expressing, should encourage the patient to talk about feelings, especially when the patient expres- ses feelings of hopelessness and despair. It is pointless to look for answers to questions that cannot be answered. Nurses often avoid giving answers because they feel asha- med and weak themselves, thus missing the opportunity to understand the patient’s discomfort and pain. 150 Revija za zdravstvene vede (7, 2020) Spiritual care is based on the assumption that people are spiritual beings who are able to transcend their connection with the present and to ask questions about the wholeness of life and existence in relation to the »life beyond«, which is the human capacity for transcendence. Therefore, spiritual needs must not be overlooked in the holistic treatment of patients and their families. Spirituality and/or religion are of cru- cial importance in patients who experience and go through illness, suffering and loss. In order to provide appropriate support to dying patients,, the nurse must respect them in their entirety. Only then will she be able to listen to their hopes, fears and beliefs and integrate them into the medical care plan. For many patients and their relatives, spiri- tual care represents the last refuge and ahelp when it comes to confronting, evaluating and accepting their past life and facing the present moment. LITERATURA 1. Anandarajah, G. and Hight, E. (2001). Spirituality and medical practice: using the HOPE questions as a practical tool for spiritual assessment. American Family Physician, 63, št. 1, str. 81–89. 2. Astrow, A. B., Puchalski, C. M. and Sulmasy, D. P. (2001). Religion, spirituality and healthcare: social, ethical and practical considerations. American Journal of Medicine, 110, št. 4, str. 283–287. 3. Barber, C (2019). Working within a spiritual framework. British Journal of Nursing, 28, št. 4, str. 229. 4. Berman, A. and Snyder, S. J. (2012). Kozier & Erb's fundamental of nursing. 9th ed. Upper Saddle River: Pearson Education. 5. Bonelli, R. M. and Koenig, H. G. (2013). Mental disorders, religion and spirituality 1990 to 2010: a systematic evidence-based review. Journal of Religion and Health, 52, št. 2, str. 657–673. https:// doi.org/10.1007/s10943-013-9691-4 6. Biro, A L., (2012). Creating conditions for good nursing by attending to the spiritual. Journal of Nursing Management, 20, št. 8, str. 1002–1011. https://doi.org/10.1111/j.1365-2834.2012.01444.x 7. Breitbart, W., Poppito, S., Rosenfeld, B., Vickers A. J., Li, Y., Abbey, J. idr. (2012). Pilot randomized controlled trial of individual meaning-centered psychotherapy for patients with advanced cancer. Journal of Clinical Oncology, 30, št. 12, str. 1304–1309. https://doi.org/10.1200/jco.2011.36.2517 8. Caldeira, S., Carvalho, E. C. and Vieira, M. (2013). Spiritual distress – proposing a new definition and defining characteristics. International Journal of Nursing Knowledge, 24, št. 2, str. 77–84. https://doi.org/10.1111/j.2047-3095.2013.01234.x 9. Caldeira, S. and Timmins, F. (2017). Implementing spiritual care interventions in nursing. Nursing Standard, 31, št. 22, str. 50–57. https://doi.org/10.7748/ns.2017.e10313 10. Carmody, J., Reed, G., Kristeller, J. and Merriam P. (2008). Mindfulness, spirituality, and health-related symptoms. Journal of Psychosomatic Research, 64, št. 4, str. 393–403. https://doi. org/10.1016/j.jpsychores.2007.06.015 11. Carron, R. and Cumbie, S. A. (2011). Development of a conceptual nursing model for the implementation of spiritual care in adult primary healthcare settings by nurse practitioners. Journal of the American Academy of Nurse Practitioners, 23, str. 552–560. https://doi.org/10.1111/j.1745- 7599.2011.00633.x 12. Chan, M. F. (2010). Factors affecting nursing staff in practising spiritual care. Journal of Clinical Nursing, 19, št. 15–16, str. 2128–2136. https://doi.org/10.1111/j.1365-2702.2008.02690.x 13. Cone, P. H. and Giske, T. (2012). Teaching spiritual care – a grounded theory study among undergraduate nursing educators. Journal of Clinical Nursing, 22, št. 13–14, str. 1951–1960. 14. Daaleman, T. P. (2012). A health services framework of spiritual care. Journal of Nursing Management, 20, št. 8, str. 1021–1028. https://doi.org/10.1111/j.1365-2834.2012.01482.x 151Dr. Klelija Štrancar, Andreja Mihelič Zajec: Koncept duhovnosti v zdravstveni negi 15. Dyson, J., Cobb, M. and Forman, D. (1997). The meaning of spirituality: a literature review. Journal of Advanced Nursing, 26, št. 6, str. 1183–1188. https://doi.org/10.1046/j.1365-2648.1997.00446.x 16. Emmons, R. A. and Paloutzian, R. F. (2003). The psychology of religion. Annual Review of Psychology, 54, št. 1, str. 377–402. 17. Frankl, V. E. (1994). Volja do smisla. Celje: Mohorjeva družba. 18. Frankl, V. E. (2004). Man's search for meaning. London, Sydney, Auckland, Johannesburg: Rider. 19. Forouzi, M. A., Tirgari, B., Safarizadeh, M. H and Jahani, Y. ( 2017). Spiritual needs and quality of life of patients with cancer. Indian Journal of Palliative Care, 23, št. 4, str. 437–444.https://dx.doi. org/10.4103%2FIJPC.IJPC_53_17 20. Gallison, B. S., Xu, Y., Jurgens, C. Y. and Boyle, S. M. (2012). Acute care nurses' spiritual care practices. Journal of Holistic Nursing, 31, št. 2, str. 95–103. https://doi.org/10.1177%2F0898010112464121 21. Garlick, M., Wall, K., Corwin, D. and Koopman, C. (2011). Psycho-spiritual integrative therapy for women with primary breast cancer. Journal of Clinical Psychology in Medical Settings,18, št. 1, str. 78–90. 22. Gonçalves, J. P. B., Lucchetti, G., Menezes, P. R. and Vallada, H. (2015). Religious and spiritual interventions in mental health care: a systematic review and meta-analysis of randomized controlled clinical trials. Psychological Medicine, 45, št. 1, str. 2937–2949. https://doi.org/10.1017/ S0033291715001166 23. Harkreader, H. and Hogan, M. A. (2004). Fundamentals of nursing: caring and clinical judgment. 2nd ed. St. Louis: Saunders. 24. Jim, H. S .L., Pustejovsky, J. E., Park, C. L., Danhauer, S. C., Sherman, A. C., Fitchett, G. idr. (2015). Religion, spirituality, and physical health in cancer patients: a meta-analysis. Cancer, 121, št. 21, str. 3760–3768. https://doi.org/10.1002/cncr.29353 25. Johnson, M. E., Piderman, K. M., Sloan, J. A., Huschka, M., Atherton, P. J., Hanson, J. M. idr. (2007). Measuring spiritual quality of life in patients with cancer. The Journal of Supportive Oncology, 5, št. 9, str. 437–442. 26. Johnstone, B., Franklin, K. L., Yoon, D. P., Burris, J. and Shigaki, C. (2008). Relationships among religiousness, spirituality, and health for individuals with stroke. Journal of Clinical Psychology in Medical Settings, 15, št. 4, str. 308–313. https://doi.org/10.1007/s10880-008-9128-5 27. Jones, K. F. (2018). Spirituality: more than just religion. Journal of the Australasian Rehabilitation Nurses' Association, 21, št. 2, str. 12–14. 28. Kalish, N. (2012). Evidence-based spiritual care: a literature review. Current Opinion in Supportive and Palliative Care, 6, št. 2, str. 242–246. doi: 10.1097/SPC.0b013e328353811c 29. Kisvetrová, H., Klugar, M. and Kabelka, L. (2013). Spiritual support interventions in nursing care for patients suffering death anxiety in the final phase of life. International Journal of Palliative Nursing 19, št. 12, str. 599–605. https://doi.org/10.12968/ijpn.2013.19.12.599 30. Koenig, H. G. (2009). Research on religion, spirituality, and mental health: a review. The Canadian Journal of Psychiatry, 54, št. 5, str. 283–291. https://doi.org/10.1177/070674370905400502 31. Kruizinga, R., Hartog, I. D., Jacobs, M., Daams, J. G., Scherer - Rath, M., Schilderman, J. B. A. M. idr. (2016). The effect of spiritual interventions addressing existential themes using a narrative approach on quality of life of cancer patients: a systematic review and meta-analysis. Psycho- Oncology, 25, št. 3, str. 253–265. https://doi.org/10.1002/pon.3910 32. Maphosa, S. (2017). The role of spirituality in nursing Part 2. Nursing Update, str. 40–41. 33. Maugans, T. A. (1996). The SPIRITual history. Archives of Family Medicine, 5, št. 1, str. 11–16. 34. McSherry, W. and Jamieson, S. (2013). The qualitative findings from an online survey investigating nurses'perceptions of spirituality and spiritual care. Journal of Clinical Nursing, 22, št. 21–22, str. 3170–3182. https://doi.org/10.1111/jocn.12411 35. McEwen, M. (2005). Spiritual nursing care: state of the art. Holistic Nursing Practice,19, št. 4, str. 161 –168. 36. Moreira - Almeida, A., Koenig, H. G. and Lucchetti, G. (2014). Clinical implications of spirituality to mental health: review of evidence and practical guidelines. Revista Brasileira de Psiquiatria, 36, št. 2, str. 176–182. http://dx.doi.org/10.1590/1516-4446-2013-1255 152 Revija za zdravstvene vede (7, 2020) 37. Nabolsi, M. M. and Carson, A. M. (2011). Spirituality, illness and personal responsibility: the experience of Jordanian muslim men with coronary artery disease. Scandinavian Journal of Caring Sciences, 25, št. 4, str. 716–724.doi: 10.1111/j.1471-6712.2011.00882.x 38. Narayanasamy, A. (2004). The puzzle of spirituality for nursing: a guide to practical assessment. British Journal of Nursing, 13, št. 19, str. 1140–1144. https://doi.org/10.12968/ bjon.2004.13.19.16322 39. Pike, J. (2011). Spirituality in nursing: a systematic review of the literature from 2006-10. British Journal of Nursing, 20, št. 12, str. 743–749.doi: 10.12968/bjon.2011.20.12.743 40. Power, J. (2006). Spiritual assessment: developing an assessment tool. Nursing Older People,18, št. 2, str. 16–18. https://doi.org/10.7748/nop2006.03.18.2.16.c2413 41. Prentis, S., Rogers. M., Wattis, J., Jones, J. in Stephenson, J. (2014). Healthcare lecturers' perceptions of spirituality in education. Nursing Standard, 29, št. 3, str. 44–52. https://doi. org/10.7748/ns.29.3.44.e8584 42. Puchalski, C. M., Dorff, R. E. in Hendli, I. J. (2004). Spirituality, religion and healing in palliative care. Clinics in Geriatric Medicine, 20, št. 4, str. 689–714. https://doi.org/10.1016/j. cger.2004.07.004 43. Puchalski, C. M. in Ferrell, B., 2010. Making health care whole: integrating spirituality into patient care. West Conshohocken: Templeton Press. 44. Puchalski, C., Ferrell, B., Virani, R., Otis - Green, S., Baird, P., Bull, J. idr. (2009). Improving the quality of spiritual care as a dimension of palliative care: the report of the consensus conference. Journal of Palliative Medicine, 12, št. 10, str. 885–904. https://doi.org/10.1089/jpm.2009.0142 45. Puchalski, C. and Romer, A. L. (2000). Taking a spiritual history allows clinicians to understand patients more fully. Journal of Palliative Medicine, 3, št. 1, str. 129–137. https://doi.org/10.1089/ jpm.2000.3.129 46. Ramezani, M., Ahmadi, F., Mohammadi, E. and Kazemnejad, A. (2014). Spiritual care in nursing: a concept analysis. International Nursing Review, 61, št. 2, str. 211–219. https://doi.org/10.1111/ inr.12099 47. Rogers, M. and Wattis, J. (2015). Spirituality in nursing practice. Nursing Standard, 29, št. 39, str. 51–57. https://doi.org/10.7748/ns.29.39.51.e9726 48. Royal Collage of Nursing (2011). Spirituality in nursing care: a pocket guide. Royal Collage of Nursing: London. Pridobljeno dne 27. 7. 2019 s svetovnega spleta: www.rcn.org.uk. 49. Sheldon, J. E. (2000). Spirituality as a part of nursing. Journal of Hospice and Palliative Nursing, 2, št. 3, str. 101–108. 50. Smith - MacDonald, L., Norris, J. M., Raffin - Bouchal, S. and Sinclair, S. (2017). Spirituality and mental well-being in combat veterans: a systematic review. Military Medicine, 182, št. 11–12, str. e1920–e1940. https://doi.org/10.7205/MILMED-D-17-00099 51. Sun, V., Kim, J. Y., Irish, T. L., Borneman T., Sidhu, R. K., Klein, L. and Ferrell, B. (2016). Palliative care and spiritual well-being in lung cancer patients and family caregivers. Psycho- oncolog, 25, št. 12, str. 1448–1455. https://doi.org/10.1002/pon.3987 52. Surbone, A. and Baider, L. (2010). The spiritual dimension of cancer care. Critical reviews in oncology/hematology, 73, št. 3, str. 228–235. https://doi.org/10.1016/j.critrevonc.2009.03.011 53. Tanyi, R. A. (2002). Towards clarification of the meaning of spirituality. Journal of Advanced Nursing, 39, št. 5, str. 500–509. https://doi.org/10.1046/j.1365-2648.2002.02315.x 54. Taylor, E. J. (2007). What do i say? Talking with patients about spirituality. Philadelphia: Templeton Foundation Press. 55. Taylor, C. R., Lillis, C., LeMone, P. and Lyn, P. (2011). Fundamental of nursing: the art and science og nursing care, 7th ed. Philadelphia, Baltimore, New York, London, Buenos Aires, Hong Kong, Sydney, Tokyo: Walters Kluwer, Lippinicott Williams & Wilkins. 56. Tiew, L. H. and Creedy, D. K. (2010). Integration of spirituality in nursing practice: a literature review. Singapore Nursing Journal, 37, št. 1, str. 15–22. 57. Timmins, F. and Caldeira, S. (2017). Assessing the spiritual needs of patients. Nursing Standard, 31, št. 29, str. 47–53. 153Dr. Klelija Štrancar, Andreja Mihelič Zajec: Koncept duhovnosti v zdravstveni negi 58. Unruh, A. M., Versnel, J. and Kerr, N. (2002). Spirituality unplugged: a review of commonalities and contentions and resolution. The Canadian Journal of Occupational Therapy, 69, št. 1, str. 15– 19. https://doi.org/10.1177/000841740206900101 59. 59. van Dierendonck, D. in Mohan, K.(2006). Some thoughts on spirituality and eudaimonic wellbeing. Mental Health, Religion and Culture, 9, št. 3, str. 227–238. https://doi. org/10.1080/13694670600615383 60. Vilalta, A., Valls, J., Porta, J. and Viñas J. (2014). Evaluation of spiritual needs of patients with advanced cancer in a palliative care unit. Journal of Palliative Medicine, 17, št. 5, str. 592–600. https://doi.org/10.1089/jpm.2013.0569 61. Wilkinson, S. (2014). Spiritual recognition within palliative care. International Journal of Palliative Nursing, 6, št. 1, str. 4. https://doi.org/10.12968/ijpn.2000.6.1.4 Dr. Klelija Štrancar, univerzitetna diplomirana teologinja E-naslov: klelija.strancar@siol.net Andreja Mihelič Zajec, predavateljica na Zdravstveni fakulteti Univerze v Ljubljani E-naslov: andreja.mihelic@zf.uni-lj.si