BY: DIANE CERAVOLO, RN, MS, ROGER GRIFFITHS and OLIVIA HELFER, MLS
"Spirituality is part of the basic human experience. Whenever we search for meaning in life or for a connection outside of ourselves, we are acting as spiritual beings. Spirituality exists in our connections to other humans, our environment and to the unfolding universe beyond."
— Mary Jo Kreizter, PhD, RN
Sisters of Charity Hospital in Buffalo, New York, part of Catholic Health System, is 18 months into its pilot project to integrate relationship-based care into every day clinical practice, focusing on caring and compassion as essential features. We do so with what we call spiritual care rounds, conducted by a chaplain and a nurse leader, targeting the nursing staff's foundational relationship with self through spirituality. We believe that focusing on intentionally living our mission "to reveal the healing love of Jesus to those in need" not only strengthens relationships with colleagues and patients, but also can be directly related to positive patient outcomes.
Relationship-based care views three relationships as essential for healing to occur. The first is with self. Self-care encourages the care provider to choose healthy, self-oriented actions in order to come to work energized and excited. This lays a foundation for the second: a healthy relationship among colleagues, which, in turn, provides a framework for teamwork and collaboration. Such behavior is essential in providing quality and safe care, therefore establishing the third relationship — between care provider and patient.1
We want these three relationships to flourish, so we began by concentrating on the foundational relationship with self. We developed the spiritual care rounds program to offer nursing staff a way of identifying and supporting their own spiritual needs, using Roger Griffiths, a hospital chaplain, and Diane Ceravolo, RN, director of professional nursing practice, as guides.
Research supports our concept: An international study in 2012 showed a positive correlation between individual spirituality and organizational citizenship behavior, which are behaviors of the individual that promote the functioning of the organization. When nurses are nurtured spiritually, they become more emotionally connected to their organization and act in ways that exhibit more organizational citizenship behavior.2
But we viewed our project as much more than an exercise in organizational theory. We were convinced that forging a healthy partnership between nursing and the department of spiritual care to support the nursing staff's spiritual needs could create a higher sense of purpose and connectedness to patient care. This, in turn, would reinforce the significance of nursing care and create a greater connection to the Sisters of Charity Hospital's mission and values.
THE PROGRAM BEGINS
For our pilot, we chose nurses on evening and night shifts, a busy group that often has less contact with organizational leadership and front-line mangers. Our goals were:
- As individuals, our staff would become more grounded spiritually.
- As a team, our staff would grow more connected to each other and to the mission and values we share.
- As a community, we would grow in compassion and connectedness, and our growth would lead us to greater excellence of care and more positive outcomes for our patients.
The foundation of nursing is a holistic orientation to care for mind, body and spirit, so we believe nursing is inherently spiritual in nature. By connecting nurses to the Catholic Health System mission and thanking them for their unique service, we hoped we would not only nurture the caregivers, but that we also would see them experience greater engagement, increased job satisfaction and enhanced relationships with patients.
Our project began in the summer of 2014, when we began making spiritual care rounds one evening every other week at the Sisters of Charity Main Street Campus. For each rounding session, we moved from unit to unit to provide support and encouragement to staff, patients and families. Nursing staff, the primary focus group, were given the opportunity to "huddle" for prayer and/or a blessing, and, if they wished, they could suggest patients in distress or pain who might benefit from individual visits.
Even in a society that is increasingly "spiritual not religious," and in a workplace with staff and patients who represent diverse backgrounds and beliefs, the formal role of a hospital chaplain was essential to our project. We strove for inclusivity, and in preparing for spiritual care rounds, the chaplain researched and selected a prayer or meditation from one of the major world religions or from a great spiritual thinker.
A SUMMER'S WORTH OF EXAMPLES
On the inaugural night of our rounds, we selected St. Paul's poetic words about love in 1 Corinthians 13, "Love is patient; love is kind." The message, with its relevance to care providers and their service to others, seemed to resonate with staff. We tied this reading to cosmic love and the compassion nurses have for those under their care. Unlike God, however, their resources are limited, making it very important that they take care of themselves and each other, caring for self in order to care for others more fully.
At our rounds two weeks later, we used a meditation written by the Buddhist monk and spiritual leader Thich Nhat Hanh, to illustrate mindfulness. In the story, someone asks the Buddha, "Sir, what do you and your monks practice, how do you pray?" The Buddha answered, "We sit, we walk, we eat."
We spoke about the importance of being present in every moment, every action, every thought, including the simple activities of "sitting, walking, and eating." This second session ended with a breathing exercise and centering prayer.
The third rounding session began with a Judean prayer related to the word "compassion" and a brief discussion about how the word in Hebrew has its roots in the word for "womb." The Hebrew etymology makes explicit the maternal, nurturing and caring nature of the word we translate as compassion. We talked about how the Hebrew Bible frequently pairs compassion, as an adjective, with the name of God.
The closing meditation was a breathing exercise using the word for God in Hebrew, YHWH, which is the only word that does not require you to make any articulation. The word itself is a breath, very much like "the yoga breath," so we suggested the care provider staff use this breath/word exercise to breathe in compassion when they needed it for challenging patients.
Our fourth rounds of the summer began with a description of the idea that in Hebrew, there is no distinction between justice and charity. We read the story of the Good Samaritan to emphasize that charity and justice are embraced by all care providers as they give comfort, compassion and care to strangers. This session was especially poignant when, at one of the units, a patient participated in the meditation and voiced her appreciation for the care team. This helped us see the opportunity to expand the spiritual care rounds to more patients, residents, physicians and other members of the hospital staff. Since then we have had attending physicians, house staff and even our neonatal ICU parents participate in rounds.
We have developed more than 30 reflections, including ones on gratitude, intentional presence, happiness, societal isolation and loneliness, vulnerability and worrying (we repeat some reflections, and the Good Samaritan is a favorite). All of the reflections align the work of care providers to the Catholic Health System mission.
From the beginning, our staff seemed to value the opportunity to stop, reflect and "breathe" as a team. They gladly welcomed the blessings, prayers and recognition for their tremendous dedication to and impact on the care of our patients, their families and each other. On several occasions, members of our staff asked for extra support, as in specific prayer requests or to have their hands individually blessed.
One nurse said she keeps a reflection on gratitude in mind during challenges, always looking for the positive. By doing so, she said, she is able to remain grateful, and "gratefulness equates with happiness."
We recently celebrated the 18-month anniversary of spiritual care rounds. During the year, we expanded rounding to include day and night shifts, and we started rounds at our St. Joseph campus. Our vice president of patient care services often participates, seeing this as an opportunity to express leadership's gratitude for staff support of and service to our mission. Unit secretaries often call staff to the desk for a "prayer huddle" as soon as we enter the unit. We have become an accepted and welcomed part of their week.
We now often use the word "reflection" to emphasize the nondenominational spirit of rounds and the inclusivity of all religions. Cookies have been a part of the program since its inception, and if unit activity precludes staff participation in rounds, we leave the cookies and offer thanks. Recently we had someone say, "It's OK if you don't have cookies. We just need a reflection."
We all needed a reflection after the shocking Nov. 13, 2015, terror attacks in Paris. Though the events happened far from our organization, we felt a special need to come together. Offering spiritual care rounds after the tragedy allowed staff to begin to make sense of the unspeakable violence and hate surrounding the attacks. Against that backdrop, we talked about and emphasized the need for compassion and how we can care for our patients and each other with greater love.
Another joint venture has arisen from our partnership between nursing and spiritual care: We are in the midst of creating a spiritual resource handbook for staff. We are constructing mini profiles of our spiritual care staff, including their values and feelings regarding nursing and spiritual care work. These handbooks will be distributed to all nursing units to encourage staff to recognize spiritual care as a resource not limited to patients, but available and invaluable for those who serve our patients.
In January 2016, we will be adopting a "sacred second" to offer staff a moment of reflection after a patient expires. Not only does this honor the life that has passed, but it allows the staff to quietly acknowledge the impact of death on care providers, which can help to circumvent emotional burnout.3
With the successful partnership between nursing and spiritual care, we are researching how to better handle combative patients who become a safety concern to themselves or staff. These people often have underlying dementia, substance addiction or mental health issues, and we have begun to explore the feasibility of having an interdisciplinary team of nursing leadership, spiritual care and security to assess, intervene and support staff in dealing with such challenges. In working together as a team, we not only hope to demonstrate support for fellow staff members but also to offer the patients a higher quality of care.
Spiritual care rounds reflect a significant partnership between nursing leadership and spiritual care as well as our strong commitment to live our Catholic Health System mission and values, "to reveal the healing love of Jesus to those in need" with reverence, compassion, justice and excellence. Every day, our staff faces many personal and professional challenges that come with answering the call to care for the sick. We believe that offering time for spiritual reflection will go a long way to support our staff as they answer their call and live out our shared mission and values.
DIANE CERAVOLO is the director of professional nursing practice, ROGER GRIFFITHS is a chaplain and OLIVIA HELFER is the medical librarian, all at Sisters of Charity Hospital, part of Catholic Health System based in Buffalo, New York.
- Mary Koloroutis et al., Relationship-Based Care: A Model for Transforming Practice (Minneapolis: Creative Health Care Management, 2004).
- Farahnaz Kazemipour, Salmiah Mohamad Amin and Bahram Pourseidi, "Relationship between Workplace Spirituality and Organizational Citizenship Behavior among Nurses through Mediation of Affective Organization Commitment," Journal of Nursing Scholarship 44, no. 3 (2012): 302-310.
- Kara Lofton, "Clinicians Find Solace in Pausing After a Death," Medscape Sept. 30, 2015, www.medscape.com/viewarticle/851905.
A NURSING PERSPECTIVE
As a nurse leader with four decades of practice but with no experience in a faith-based organization, I began my career at Sisters of Charity Hospital three years ago. I have worked in three other facilities during my career, including hospice, a county hospital and the largest health care organization in western New York.
I loved and supported each organization's unique mission, but I felt there was something special in Sisters of Charity's faith-based mission, in the way the nurses interacted with me and with their patients. I described this to colleagues as "kinder and gentler." I did not see myself as a particularly religious nurse, but after having my daughters attend Catholic school for 13 years, I was a firm believer in structure and the sense of a greater community outside the classroom.
One night during spiritual care rounds, I shared my personal thoughts, as a nurse, on gratitude. I explained that direct patient care has the ability to create gratitude every day, with the unique perspective we have on individual and family suffering. I also linked gratitude with happiness and, in turn, the ability to create "joyful work" or "joy at work."
Personally, the rounds have nurtured and reinvigorated the spiritual part of my practice as a nurse leader. On several occasions, Chaplain Roger Griffiths was called away to minister to a patient, and I was able to continue rounds on my own. I found myself relishing the message and the ability to reconnect as a nurse to the importance and nobility of our wonderful profession.
— Diane Ceravolo
A CHAPLAIN'S POINT OF VIEW
Before being called to the chaplaincy, I served as the director of youth and children's ministry for a large urban congregation, where the work of nurturing the spiritual growth of young people was inherently messy and unstructured. In this setting, I learned the importance of integrity to mission goals and the power of trusting relationships in fostering a healthy spirituality. As a chaplain resident at Sisters of Charity Hospital, I established trusting relationships with a number of the nursing staff, and, from them, I began to learn about their concerns and struggles as well as their joy and compassion.
I can see the spiritual growth of members of our care team. The word "vocation" has come up again and again for me as I think about and pray with them here at Sisters of Charity. The work of nurses requires so many gifts, and it is a privilege to be able to speak to those gifts and connect them to our shared mission and values.
Throughout these rounds, we have shared tears and laughter, built up our community and empowered and encouraged those who bring healing to people in need. During one particular night of rounds, we gathered behind the unit desk. The team on duty included people from the Jewish, Muslim and Christian faith traditions, as well as one nurse who describes himself as spiritual, not religious. While it had not been the practice before, on this particular night the team held hands. A simple action, but it was a powerful experience for me. I went home that night with a tremendous feeling of hope.
— Roger Griffiths
A LIBRARIAN'S NOTES
As a medical librarian, I am approached daily about finding information that supports an idea. Typically the concern has to do with patient care, and to truly practice in an evidence-based manner, research has to support the idea. That's where I come in, turning to the world of clinical publishing online and in print, in a hunt for published literature on a topic. The goal is to determine if the idea has been tested, how, where, and whether evidence supports it.
One day, Diane Ceravolo approached me about compiling research on spirituality and its effect on nursing practice. She explained how she hoped that by caring for the nursing staff spiritually, their behavior toward each other and patients would benefit. To nurture the nursing staff, she wanted to offer spiritual care rounds, a time for reflection and encouragement that promotes caring for the self in order to care for others. Had anyone tried this, she wondered, was there anything relevant in the literature?
I know what a crucial role nurses play in caring for patients, and after listening to her idea, I was excited about it myself. I plunged into the Nursing Reference Center (one of the leading evidence-based resources), the Cumulative Index to Nursing and Allied Health Literature (better known as CINAHL), and PubMed.
I was pleased to find highly relevant articles. Interestingly enough, I noticed much of the literature was from international journals, and most of the articles touted the benefits of spirituality and its effect on nurses and patients. Armed with this evidence from all over the world, Diane was able to document support for her idea of offering spiritual care rounds and make progress toward their implementation.
— Olivia Helfer