CUADRO CONSOLIDADO DEL ÍNDICE DE SATISFACCIÓN
3.3 MARCO PROPOSITIVO
Analysis identified five key emergent themes within interview 1:
1. Participants definitions of spirituality
2. Participants views of spirituality and Religion
3. Participants understanding and experiences of spirituality in the consultation and openness to spirituality
4. Participants views of boundaries and emotional connection within the consultation
5. Participants conceptualisation of Availability and Vulnerability
A number of powerful stories were shared by the participants and add depth to the findings; one of these will be considered as a model case in chapter 8.
7.3.1 Defining Spirituality:
Some of the participants had no personal definition of spirituality and were confused about what spirituality actually was. Other participants appeared to have a deep understanding of spirituality and were able to offer a clear definition of what it meant to them. Within the first interviews there was some association made between spirituality and religion with participants asking whether or not these were the same, interlinked or separate.
The varying definitions of spirituality offered by the participants included broad definitions with commonalities about our innateness, our humanness and our way of living.
156 For example, Polly defined Spirituality as:
“everything that that person believes, almost their way of life…..What is
important to them and how they would want to live their life and how they want
to impact others around them…..it’s how a person likes to live their life”
(Polly1)
A metaphor for spirituality, acknowledging its uniqueness, was made by Lucy. She
described it as a “fingerprint”. She was able to recognise the breadth of spirituality which allowed for individual differences to be included. She suggested that:
“Spirituality for me is about the essence of a person…..it’s about your
essence, it’s about your make-up, some of the things you are born with, some
things you develop because of your environment and how you are brought up.
I think it’s probably like a fingerprint really, it’s different for everybody….You have to know it’s about being who you are” (Lucy1).
Jane also talked of the innateness of spirituality and acknowledged that it was an internal process:
“I think it’s [spirituality]something that comes from, you know, it’s not related
to the material things, it’s not related to the physical, it is something that
comes from inside from whatever you want to call it, whether that be spirit or
the soul or whatever……it’s about happiness….balance, it’s about
contentment with where you are and who you are in your life. I don’t think it’s
necessarily about faith…..individual spirituality is more about looking inwards”
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Georgia offered insightful views on spirituality throughout the interviews which culminated in her linking her thoughts with a new way of recognising spirituality by
identifying “soul ache”. She initially talked of spirituality being:
“more diffuse, is more broad, it’s much harder to define, its maybe just a
suspicion or an intuition that we are more than matter….there is more than the
dimension you have got, the body, the mind and I would say you have got
another dimension which makes us truly human because I believe, my own
personal belief is that we are spiritual beings in a physical body……..The
other things I remembered is that it’s about uncovering that purpose that you
have for being here”.
She then developed this by saying that:
“I have coined my own term, soul ache” which she used when presentations
were much deeper than the physical and include “life concerns” (Georgia1).
She explained this term came from her observation that many people had this [‘soul ache’] and wanted to talk about their life concerns and be listened to. When
consulting she suggested having this awareness of “soul ache” in her mind helped her to provide truly holistic care which integrated spirituality.
Tara and Mia appeared to be unsure about what spirituality meant. They offered very interesting views of spirituality which surprised me; Tara talked about “spirits” whilst Mia mentioned “spiritualism”. The context for the spiritualism comment was in regard to when she felt a spiritual dimension occurred in her practice and it appeared she confused the term as she did not expand to talk about spiritualism as it is defined but
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continued to reflect on when she felt a deep connection with a patient during an emotional consultation i.e. terminal care.
Tara suggested that:
“Spiritual I supposewould be almost not human, the spirits of the dead and
things like that…. the only thing I can think of is you know people having
spirits of their relatives coming back to see them so it would be something like
that (Tara1).
Finally there was a real acknowledgment of the difficulty defining spirituality: “It’s a term we use but we don’t know what we are talking about” (Ana1) “I’m struggling in my own head with definitions” (Ana1)
“You can’t quite put your finger on it” (Tanya1)
“It’s woolly isn’t it….it’s kind of not an easy thing” (Georgia 1) 7.3.2 Spirituality and Religion:
All of the participants attempted to articulate differences between spirituality and religion. Most suggested there could be a link but four participants made a distinction between the two. Those who differentiated spirituality and religion focused on
religion as “guidance” and a “belief in God”. They suggested that religion was:
“…a set of guidance and principles which you can adopt and adhere to and
there’s a church and maybe there’s a doctrine and a ritual” (Georgia1)
“about people’s beliefs but also it’s about feeling, it’s about I guess following a model in life and beliefs…a set of rules, obviously not rules but I guess a set
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of guidance that gives you value in order to live your life in a way that you do
that in a positive way” (Tanya1)
Those who felt that spirituality and religion could be interlinked or that they were the same tried to consider whether there was a difference between the two. Mia and Lucy felt spirituality and religion were the same or almost the same:
“Is there a difference? I don’t suppose there is really…..they must be interlinked to a certain extent” (Mia1)
“I don’t think there is a difference….” (Lucy1)
Those who saw them as linked but different tried to articulate the difference:
“I do think it’s a different thing from religion [spirituality], religion can be very dogmatic, a set of rules. Spirituality is how you live” (Ana1)
7.3.3 Spirituality in the Consultation:
During interview 1 exploration with the ANPs considered whether there were
particular consultations when spirituality seemed to be apparent. It appeared that this usually occurred with more complex presentations where patients attended a
number of times with several issues, often multiple pathology and polypharmacy. One example given was when seeing patients with depression. Georgia said that patients struggling with depression often appeared to have a level of what she termed “dis-ease”:
“I can explain to myself that not all is well in their world, there was a sense that they hadn’t really found themselves or found a niche for themselves in
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She recognised that she often addressed spiritual issues with patients with
depression and she noticed that they often lack any “hope” that things can be better or different. She suggested that she had confidence in acknowledging that spirituality was part of her holistic practice and she could support patients to find a place of
“hope”.
Jane echoed this saying that she always considered spirituality with those patients presenting with low mood or depression and she recognised the need for spiritual care even when a patient is physically well. She suggested that:
“It seems almost a stunting of life if you’re physically well but somewhere something just isn’t reaching its potential and I think that’s got to be something about the spirit”
(Jane1)
At these times she suggested:
“Exploring why their life is out of balance and….. nurturing the spirit” (Jane1)
Three other participants commented on when they felt spirituality became apparent within the consultation and whether it just occurred, was constantly present or when the ANP might consider it. Spirituality was often felt to be present unconsciously in a consultation whilst for some it was regarded as part of how they practiced:
Polly recognised that issues of spirituality were not necessarily introduced as a conscious action:
“In a consultation I think it’s something that sometimes happens. I don’t think it’s always a conscious effort. I think it comes back to whether you are having time to sit and let the person talk and tell you what’s important to them”
161 Whilst Lucy felt that:
“It’s everywhere really [spirituality] everyday of your life” (Lucy1)
Existential issues appeared to be a key area which connected to spirituality. The majority of participants found consultations with terminal patients a natural home for spirituality. They appeared to expect that spiritual questions would come up when talking about terminal issues.
Ana acknowledged that Spirituality:
“sometimes comes up when talking about those life and death issues” (Ana1)
Georgia expressed a similar view:
“sometimes with patients who are bereaved or patients who have a terminal
illness” (Georgia1)
Tanya recognised that existential issues connected with spirituality for her much more comfortably:
“I do find that I can probably connect much better with thinking that my
consultations are spiritually based in those consultations where I am talking
about life and death” (Tanya1)
Four of the ANPs specifically commented on their approach to spirituality within the consultation and acknowledged that it was an area which was important to them professionally. Lucy said that for her it was more than just within her work as an ANP. Rather it was her ethos in life and that for her spirituality infused her being personally and professionally. She said that:
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“my spirituality is really the way I care and the way I understand….It’s more
an integrated thing in the way you work. My ethos in life is this…be kind and
have sort of inner meaning…that’s my spiritual self because who I am and my
life force” (Lucy1)
Ana talked specifically about patients with whom she witnessed a spiritual dimension occurring within the consultation. Ana articulated this by sharing an occasion when she felt spirituality impacted during the consultation. This was with a particular patient she had been seeing who had anorexia whose mum had died suddenly and who was the same age as her daughter. They were coming to the end of two years of consultations as the patient was going to University. Ana said that:
“In hindsight that was a set apart moment in time somehow and there was something different about that time which umh in which you almost forgot
about all the other things that were going on and you wholeheartedly give
yourself in a way to that person but other than that a feeling that it was in
some way spiritual” (Ana1).
An interesting finding which will be discussed in the next chapter was that Georgia
described herself as a “spiritual healer”. This was not suggested by any other ANP and appeared to have been something Georgia had considered very deeply after years of nursing experience, the loss of her mother and her own existential journey. She said that:
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Another key issue identified in relation to spirituality within consultations was about connection. Tanya recognised the importance of a deep human interaction. She stated that:
“you meet someone and you sort of connect with them or you experience
something that feels different to just the normal really that makes you feel
perhaps comforted or complete” (Tanya1).
The idea that a spiritual connection with another was comforting or completed the individual does connect to being human and related to many of the views about spirituality being innately human and leading to connection. This appeared deeply significant.
Georgia took the idea of spiritual connections further in stating that ANPs and GPs undertake a role similar to the role priests played in the past:
“People tell me all sorts of things in the privacy of the consultation….I suspect
in times by gone people would have gone to their priest” (Georgia1) She went on to discuss a conversation she had had with a minister about the similarities in their roles, they concluded:
“there’s certainly an overlap between the ministry and nursing” but“you wouldn’t say that to a patient, you wouldn’t advertise that to a patient but of
course there is because you are listening to a suffering human being and you
are offering them help, support and healing….that’s what a minister does” (Georgia1)
This sense of the ANP role being akin to “ministry” was also raised by Lucy. Both of these participants expressed deeply their sense of vocation in their work. They were
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both able to share deeply their experiences as people and also examples of their work where they gave of themselves to their patients.
7.3.4 Boundaries and Emotional Connection:
When the participants talked of emotional connections with their patients they stated that boundaries needed to be understood, considered carefully and held to maintain the professional relationship. This theme is significant because of its connection to the concepts of availability and vulnerability where boundaries are important in order to avoid patient harm and maintain a degree of personal and vocational safety for the ANP.
During the interviews, boundaries were often talked about. A number of the ANPs talked of, or indicated that there was a “line” within the role which was the boundary for professional practice. Some ANPs initially wondered whether this should be a set line. Whilst there was an awareness of a definitive line in terms of responsibility to patients there were also contradictory acknowledgements that the “line” could and should move depending on different situations. The ANPs appeared comfortable with this.
Several of the ANPs talked about this “line” acknowledging that at times they felt
they had crossed it and this necessitated them “pulling back” and/or considering the
depth of relationship that could or should occur within the consultation. Ana suggested that:
“Maybe I have crossed it [the line] or just touched it a little bit too close and then I will pull back a little” (Ana1)
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“Sometimes we cross boundaries depending on the feedback we get and
there are so many influences that we have that are sort of tailored by the way
we react or relate to people. I think it’s very complicated at times, we’re human” (Tara1)
The recognition of “being human” was mentioned by several participants with some suggesting that in order to build a relationship based on trust with a patient there was
a need to recognise a “blurring of the line” and allow the patient to see you as a human and not just a professional. Lucy recognised that:
“it’s like trying to keep a professional level but trying to come over as
someone who actually does care…you want them to know you have a bit
deeper understanding and empathy I suppose for people……. It [the line]
goes up and down; it’s all over the place I think. It depends on the situation I
think and it depends on the condition of your patient… I don’t think you can actually draw a line as everyone is an individual… ” (Lucy1)
Despite the desire for the participants to come across as “human” and someone who cared all acknowledged their professional code of conduct and recognised that there were certain boundaries that should not be crossed. There was an understanding of the issues related to professionalism. ANPs felt uncomfortable when a boundary had been crossed or something impacted on them personally. All of the ANPs recognised that boundaries helped maintain a level of safety for both patient and ANP and were aware of the impact of not retaining boundaries in practice.
166 Jane reflected that the line was:
“tricky… because some of the people have known me for 19 years….. you bring yourself into the relationship but I think there are private issues which
need to be kept private as it’s a professional role”
Mia voiced the difficulties sometimes of staying within the professional boundary and recognised that:
“there is a line you shouldn’t cross, you should keep a distance but doing this sort of job as a nurse I don’t think you can stay at the side of the line and be what I would consider a little cool” (Mia1)
Some participants recognised the emotional impact for them as they worked close to this “line” and recognised it could lead them to burnout if they “gave too much of
themselves consistently”. Giving of self, similar to how Ana gave wholeheartedly to a
patient with anorexia, can be costly and the extent of giving would not be possible with every patient.
Lucy recognised that to protect oneself you:
“can’t get overinvolved” (Lucy1)
Mia suggested there were times when you felt you were becoming too involved and: “I need to wind it up [the consultation] to keep it in that boundary sort of thing” (Mia1)
After talking about the concept of “a line” as a boundary several of the participants gave examples of issues relating to events which they connected with spirituality.
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Ana and Tara when considering spirituality both talked about issues related to prayer which had affected them. For Ana this was how she felt personally:
“I do remember one lady who wanted to pray with me…..she was the one of
those women who wanted to pray with everyone…I said yes because I felt it
was rude to refuse….I found that quite uncomfortable” (Ana1)
Tara discussed the issue of the nurse who had been suspended for praying with a patient:
“I remember that doctor or nurse who got struck of or reprimanded because
she said she would pray for a patient and that was inappropriate and I