Digestión de Cry1Ab

The work reported in this thesis was motivated primarily by a desire to explore how mental health nurses understand and respond to the spiritual needs of service users. Previous work and practice recommendations have indicated that it is important that spirituality is taken into account in the context of mental health nursing (see chapter two), but there is little known about how mental health nurses understand or undertake this care. The rich qualitative data obtained in this study produced detailed findings presented and discussed in chapters four and five.

Some findings supported existing work – for example, the difficulty in defining spirituality is already well documented (see Chapter two - much of the background literature reviewed highlighted this as a major challenge for all practitioners, including mental health nurses). The participants in the present study similarly found defining spirituality difficult, yet they were able to articulate qualities associated with spirituality and how spiritual needs of service users were addressed indicating a type of ‘spiritually competent practice’ described by Rogers and Wattis (2016) (See section 5.8 pages 145-146).

Another finding which emerged from this study was the evident impact of early personal influences on mental health nurses’ understandings of spirituality. As noted in chapter five, although information about current religious affiliation is recorded in some studies (see section 4.6; McSherry et al, 2004; RCN, 2010; McSherry and Jamieson, 2011), there has been little attention paid to how this early personal influence might affect

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nurses’ current approaches to care. The present study makes a novel contribution, drawing attention to early personal development, and the impact this may have on how nurses approach spiritual care. For example, those who have remained committed to an early ‘religious’ upbringing may find it hard to separate spirituality from religion whereas those who have reacted against imposed religion may have a more open view of spirituality. Given that the impact of social development influences in this area has not previously been well covered in the literature, and the clear importance it had to participants in this study, this may be an area that warrants further research. As noted in Chapter 5 (Section 5.6), religious affiliation is often recorded in such work but then not commented on or analysed, and developmental influences on approaches to spirituality are not generally recorded in questionnaire based and quantitative research. This, incidentally, demonstrates one benefit of a qualitative approach. It can draw attention to phenomena the researcher did not know they were looking for. In this study, participants all volunteered early developmental influences without specifically being asked.

Some of the literature specifically categorised different approaches the participants in their studies adopted to address the spiritual needs of service users (Baldacchino and Draper, 2001; Narayanasamy and Owen, 2001). In the present study, I identified participants as describing two broad approaches to the provision of spiritual care for service users which I referred to as ‘Pragmatic’ and ‘Spiritually empathetic’ (see Chapter five, section 5.8). Unlike the categories described in previous literature (Narayansamy and Owen, 2001; RCN, 2010), the two styles in this present study were not mutually exclusive. The spiritually empathetic approach was identified with a sense of ‘knowing’ or ‘connectivity’ (discussed in chapter 5, section 5.8). ‘Spiritual competence’ (Rogers & Wattis, 2015; Jones 2016) embraces the concept of personal connection and of facilitating connection or reconnection with service users’ community contacts, whether secular or religious, and this broad appreciation of where people derive their sense of meaning and purpose from seems to fit well with the spiritually empathetic approach. Person-centred care, derived from the therapeutic theories and practice of Carl Rogers has demonstrable efficacy (Rogers, 1961) and can, at least to a degree, be taught (Pelzang, 2010). The spiritually empathetic approach embraces the concept of a different kind of knowing at a personal level (ideographic knowing or ‘seventh sense’ (as discussed in chapter five) compared to the kind of technical (nomothetic) knowledge

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fostered by the narrow concept of evidence-based practices. This suggests opportunities for education about the spiritually empathetic approach alongside teaching listening skills and Rogerian principles. It also suggests further opportunities for research into this way of approaching knowing.

Much of the literature (see Chapters 2 and 5) suggested that education in spirituality and nursing was lacking and there have been calls on universities to facilitate this (RCN, 2010; McSherry & Jamieson, 2011; Elliott, 2011). This study of mental health nurses also found many felt ill-prepared by their nurse education for addressing spiritual care needs, however it was apparent that spiritual education was being facilitated in both university and practice but with a lack of consistency and not always explicitly (Chapter 4, section 4.3.1). The suggestions above provide one way of addressing this.

I discussed in chapter 5 how it could be difficult to keep participants focused on their own thoughts and experiences through the interviews (participants, especially when they seemed unsure or uncomfortable often talked in terms of ‘we’ [as in ‘the team’ or ‘nurses’] rather than ‘I’). The findings of this study suggest that colleagues and team relationships can have an important impact on how mental health nurses understand and respond to spiritual need – it seems that nurses’ tendency is generally to acquiesce to their perception of what they see as the collective view (described in section 4.3.2). It has been noted in previous research that health and social care professionals are often very aware of the particular professional rhetoric associated with their role, and can tend to resort to ‘official’ or ‘textbook’ explanations rather than an account of their own lived experience in research interviews (Ross et al, 2005; King et al, 2014). Researchers need to be aware of the dangers of accepting an ‘idealised’ account of nursing practice at face value. Using alternative methods to elicit reflection in interviews with participants can usefully disrupt habitual ways of ‘telling a story’ and challenge participants to reflect on their experiences and thoughts in different ways (King et al, 2014). To develop a more detailed and nuanced understanding of ways in which individual nursing professionals think about, experience or respond to particular research phenomena, it may be worth considering how best to break through this habitual professional rhetoric. In the present study the ‘insider status’ afforded me by

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my professional experience seemed useful in this respect (I reflected on this in more detail in Chapter 3, section 3.2).

The present study was undertaken with nurses working in mental health services. Much of the nursing literature considering the notions of ‘spirituality’ and ‘spiritual care’ has been undertaken in the context of (general) adult nursing, but it was evident from the findings of the current study that there are a number of issues in relation to these ideas which are specific to the mental health nursing arena; for example mental health assessments which focus on beliefs and behaviour, secure environments and MHA requirements which are issues that would not normally be seen in adult nursing (see chapter 4; section 4.4.2.3).

The theme ‘fear and anxiety’ was identified as an integrative theme (Section 3.4.1) which often pervaded participants talk in relation to many aspects of spirituality and spiritual care. Earlier research has reported, as was found in this study, that nurses may perceive their professional position as being at risk should they openly express their personal spiritual views (RCN, 2010). McSherry and Jamieson (2011) similarly asserted that, despite attempts by the DH to raise awareness of the benefits of spirituality in health, there was still a gap between personal belief and professional boundaries which was also found in this study (see chapter 4; section, 4.3.1). However, what additionally emerged in this study (undertaken specifically with mental health nurses) were their particular anxieties around misinterpreting spiritual need as mental disorder. Dein et al (2010) also found in their research into religion, spirituality and mental health that some religious communities were reluctant to engage with mental health services for fear of mis-diagnosis. Therefore strategies for engaging with mental health service users who express spiritual and religious beliefs could be a focus for future research.

The key findings from this study also suggest that the context of a mental health care setting has specific issues which may potentially affect the outcome of care for service users: for example; how spiritual care is managed in relation to the security of acute and forensic inpatient services and MHA (2007) requirements described in Chapter 4

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(section 4.4.2.3). Other research (e.g. Narayanasamy & Owen, 2001) highlighted the positive impact spirituality has on health and shows where (general) adult nurses reported that their patients felt comforted as a result of their spiritual care. Some of that care was about enabling people to attend their chosen place of worship or visiting faith leaders. Although it could be argued that some physical debilitating conditions may make such visits difficult, it is rare that patients in general services need to comply with the restrictions described by the mental health nurses in this present work. Given this and the special and unique challenges in relation to care settings described by the mental health nurses in this study, future investigation into how spiritual care is facilitated in mental health services may be warranted with the emphasis on the practical restrictions of care settings and those imposed by the MHA.