Importancia y aplicaciones del estudio de las tripsinas

The very topic of spirituality seemed to invoke fear and anxiety for many of the mental health nurses interviewed in this study. This may in part have been due to uncertainty surrounding the lack of an agreed authoritative definition (Narayanasamy, 2001; Swinton, 2006; Reinert and Koenig, 2013). Throughout the interviews the participants expressed either implicitly or explicitly their fear and anxiety. Some of the implicit expressions of fear and anxiety were evident in the participant’s body language, facial expression and verbal intonations and this is difficult to discern in the written words of the transcriptions. For example, some of the participants visibly squirmed in their seat and covered their faces with their hands at points which caused discomfort in their interviews. Others used groans, growls and exaggerated facial expressions whenever I asked a question they perceived as difficult. Many of the participants admitted to ‘looking up’ spirituality prior to the interview because of the perceived risk of exposing their lack of knowledge. Their manner showed signs of mild anxiety and they were visibly relieved when I reassured them of my intentions relating to the research. McSherry and Jamieson (2011) found that a lack of education and knowledge was a major concern amongst nurses who felt inadequately prepared to address spiritual need and said that many nurses, like those in the present study, looked for more support from their professional regulatory body the NMC, the Department of Health, or their University training. As a nurse lecturer I have experienced similar concerns and

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reluctance from my nurse lecturer colleagues regarding spirituality. This has resulted in them deliberately avoiding addressing the subject in lectures in favour of workbooks or directed reading where it is less likely to have awkward face to face questions asked.

The findings indicated that many of the mental health nurses described spirituality as ‘intensely personal’ and some used humour to cover up potential embarrassment. Participants described in detail how they feared the responses of their colleagues and indeed their professional body should they openly express their spiritual beliefs. Participants also showed anxiety during the interviews implicitly in their body language which was demonstrated by fidgeting and blushing. Their verbal communication also changed and this was apparent when they were gently interrogated. This often resulted in a tendency for them to drift towards an idealised account of their working practices based on the ideology of their professional discipline as opposed to a genuine account of everyday practice which they really experienced. This type of behaviour has also been noted in previous qualitative research with nurses (see above - King et al, 2013, developed a visual interview tool- the ‘Pictor Technique’ - specifically to overcome such tendencies).

What appeared to be specific to mental health nursing compared to the other nursing fields was participants’ fear and anxiety that they would themselves be labelled or diagnosed as mentally unwell. This was demonstrated by the participants who described how they feared ‘the pink papers’ [MHA section papers] or being ridiculed by their colleagues. Swinton (2006) suggested that some criticism of spirituality in nursing was necessary because this helped to develop further understanding which would lead to engagement and a certain refinement of the subject. However, it is not unreasonable to conclude from evidence offered in this study, that the nurses who work in mental health may find this particularly challenging and may avoid this type of debate because of their fear of ridicule.

Aside from the mental health nurses’ personal ‘fear and anxiety’ in relation to their job, the nurses also expressed professional concerns in relation to service users. One of the foremost concerns was the ‘fear and anxiety of imposition’. The mental health nurses’

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accounts indicated that they were concerned about imposing their beliefs on service users who were already vulnerable. This would be in breach of the nurses’ code of conduct (NMC, 2016). Rogers and Wattis (2015) said that to impose one’s own beliefs and values onto a patient or service user was ethically unacceptable. Swinton (2006) asserted that some care givers (including mental health nurses) avoided addressing spiritual needs because of the fear of imposing their own views on a service user. As a result, they might have avoided questions which they feared might lead them to impose views or negatively influence those who they were trying to care for. This type of avoidance behaviour was described by the mental health nurses in the present study. The ‘fear and anxiety’ the participants experienced concerning imposing their own views on a service user might have led not only to avoidance behaviours identified in the interviews but also to blaming the influence of scientific evidence-based approaches, or lack of education in this area. Much of the literature reviewed (e.g. Swinton, 2006; McSherry and Jamieson, 2011 and Rumbold, 2014) highlighted scientific evidence based approaches as negatively impacting on how nurses perceived the importance of spirituality. However, based on the evidence demonstrated in this integrative theme, there were also other more subtle influences like the fear of ridicule which affected the nurses’ inclination to address spiritual need but these were not as easy to identify as the influence of scientific evidence based approaches. I have already mentioned that my nurse lecturer colleagues avoid addressing spirituality directly and given that they all have nursing backgrounds, like the participants in this study, it is not unreasonable to conclude they experience similar feelings of fear and anxiety for the same reasons. Since starting this project it is not uncommon for my colleagues to ask me to lead on this type of teaching requirements and express the same type of concerns (as the participants) about imposing other beliefs on students. This has led to the development of the spirituality workshop (see implications and suggestion section 6.3 page 179)

Some of the nurses expressed ‘fear and anxiety’ concerning ‘getting it wrong’ and feeling incompetent in relation to addressing the spiritual needs of service users. Swinton (2006) asserted that spirituality was often presumed by practitioners to be inextricably linked with religion which suggested that spiritual care should fall within the remit of a religious leader. The participants in this present study often discussed how they made referrals to other people who they felt were more qualified at offering the

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specific religious or spiritual support the service user needed. However, the mental health nurses also described how they referred service users to other mental health nurses whom they perceived as more spiritually competent. Koslander and Arvidsson (2006) studied a group of service users in relation to how they felt their spiritual needs were met and the findings indicated that many service users in their study were referred to others or simply had their needs neglected. The findings also showed that the service users turned to each other for spiritual support and the study recommended that nurses should actively seek knowledge about how they could effectively support the spiritual needs of service users.

Rogers and Wattis (2015) suggested there was a clear distinction between religious and spiritual care. Spiritually competent care pays attention to religious needs where they exist but it is broader than religion and does not require the mental health nurse to be ‘expert’ in the service user’s religion. So whilst religious care might be for specialist chaplains or faith leaders, spiritual care was for all practitioners. However, the narratives in the present study suggested that not all nurses felt prepared or indeed inclined to facilitate this aspect of care. Addressing spiritual need as part of religion was described as easier by many of the participants and was particularly evident in the nurses who preferred the ‘pragmatic’ approach. However, it also included the mental health nurses who preferred the spiritually empathetic approach. This may be because of the unease they felt with the concept of spirituality which was compounded by their perception that they lacked the guidance and support they needed. This perception of lack of guidance and support was identified by McSherry and Jamieson (2011).

Participants’ accounts suggested that the mental health nurses in this study could be very creative in finding ways of addressing spiritual need. Despite this, many reported that they felt unprepared to fully recognise and care for the spiritual needs of others. This was also a finding of the RCN (2010) survey on spirituality. However, mental health nurses faced further complexities in terms of the specific mental health needs of the service users, particularly those who experienced psychosis. In the mental health context the spiritually competent nurses described by Rogers and Wattis (2015) clearly had further barriers to navigate in terms of the person’s mental health presentation in order to address spiritual need. Swinton (2006) indicated that the emphasis in mental

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health was on a service user’s psychological distress and the possibility of a spiritual dimension to it might not be considered. During the interviews however, I perceived that there were occasions were the nurse had considered the spiritual dimension but rejected it in favour of a more acceptable theory that the person was experiencing mental ill health. The mental health nurses in the present study described how they feared they had misinterpreted spiritual need as symptoms of mental disorder but even when they were sure that the service user was experiencing spiritual phenomena they still had not felt able to respond to the spiritual need, except in psychiatric terms. Corrigan et al (2003) found that there was a paucity of formal research concerning spirituality and service users with psychosis. Although they believed that spirituality and religion had an essential role in recovery, the participants in present study found that while they appeared to recognise this as an issue, they were apprehensive about challenging the dominance of conventional evidence-based attitudes to mental health care.

5.5 Chapter Summary

This chapter discussed the findings of each theme in turn including the integrative theme ‘fear and anxiety’ which pervaded the others. The following chapter will highlight the key findings of the study before concluding with reflections on the nature and possible limitations of the sample and some suggestions for future research.

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Chapter 6: Summary of key findings and concluding