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What about nursing’s ‘fourth dimension’?

The NMC’s revised code of conduct makes no specific mention of spirituality. Critics say spirituality deserves to be included because it is a part of everyday care. The other three dimensions of holistic care – psychological, social and physical – are included. However, the regulator argues that spirituality is covered by the mention of human rights. Furthermore, it is a complex subject and is not included in the other regulators’ codes of conduct.

There is no mention of spirituality in the Nursing and Midwifery Council’s revised code of conduct – an omission that concerns an increasingly vocal number of nurses.

While the new Code, which came into effect on March 31, says nurses must respect and uphold people’s human rights, it also says they must make sure they do not express their political, religious or moral beliefs in an inappropriate way.

The NMC argues that spirituality and religious freedom fall under the umbrella of human rights and insists it would be wrong to highlight one right above all others.

NMC director of continued practice Katerina Kolyva says the NMC has chosen the ‘most sustained and proportionate approach’. ‘We cover spirituality by referring to not just human rights but also dignity, compassion and all aspects of care.’

Dr Kolyva says nurses must remember that the Code is a regulator’s document that sets out professional standards to protect the public, not to represent nurses’ views. She adds: ‘Spirituality was not a subject that came through strongly in the consultation.’

In 2010, the RCN conducted a survey on spirituality in nursing care with more than 4,000 of its members. Of those, 83% considered spirituality and spiritual care a fundamental aspect of nursing and 90% agreed or strongly agreed that spiritual care enhances the overall quality of nursing care. Of the 139 nurses who answered a question on identifying spiritual needs, 95% said they had encountered patients with spiritual needs. But 92% said they were only ‘sometimes’ able to meet patients’ spiritual needs.

Complex concept

The survey also highlighted that spirituality means different things to different people and cannot easily be defined. A significant number of nurses said spirituality is about finding meaning in the good and bad events of life; others said it is to do with relationships and the way a person conducts their life.

Shoehorning such a complex concept into the Code would not have been easy, suggests RCN head of policy Howard Catton: ‘At the heart of the philosophy of nursing care is the notion of treating the whole person: mind, body and soul. Spirituality is a broader concept that includes and goes beyond religious beliefs.’

Picture credit: Alamy

He wants the NMC to supplement the Code with further guidance clarifying the reference to human rights.

‘We can see how important spirituality is to our members,’ says Mr Catton. ‘If the term human rights is used on its own, people may think it is the right to family life or privacy, so it needs to be explained whether it encompasses religious beliefs and values as well.’

The International Council of Nurses’ (ICN) code of ethics refers to spirituality, stating: ‘In providing care, the nurse promotes an environment in which the human rights, values, customs and spiritual beliefs of the individual, family and community are respected.’

NHS England published revised chaplaincy guidelines in March, which emphasise the importance of full access to chaplaincy services for people who do not have a religion or belief.

The governments of the other UK countries have also stressed the importance of meeting patients’ spiritual care needs.

In April, the Welsh Government published a Health and Care Standards framework, which says person-centred care ‘recognises that care should be holistic and so include a spiritual, pastoral and religious dimension’.

Welsh mental health services are subject to the Mental Health Measure (Wales) 2010. This law places a duty on health services to ensure all patients with mental health problems in secondary services receive care and treatment plans. One of the eight domains of these plans focuses on spiritual needs.

Dr Kolyva points out that spirituality is not directly referenced in other healthcare regulators’ codes. ‘The General Medical Council uses similar language to ours and does not mention spirituality specifically,’ she says. ‘The ICN code does but it is a network of the profession and not a regulator.’

In a bid to get the NMC to incorporate the word ‘spiritual’ into the Code, two nurse academics known for their contribution to the development of spirituality in the profession, Linda Ross and Wilfred McSherry, are collecting nurses’ views on its omission. They plan to discuss the feedback with the NMC in coming weeks. Dr Ross, who is based in Wales, says: ‘So many nurses are taken aback that spirituality is not included in the Code, considering it as an everyday part of care.’

Nurses have their say on spirituality and the Code

‘We should respect patients’ spirituality but you can’t make people working as a healthcare professional in the NHS “become spiritual” as a requirement of their job’ – RCNi Facebook

‘Leaving spirituality out of the Code is a huge omission. I was shocked because there is overwhelming evidence in national initiatives, guidelines and spiritual care competencies that spiritual care is a fundamental aspect of holistic nursing care. The NMC is giving its members the wrong message about an essential component of nursing care’ – sent to Linda Ross and Wilfred McSherry

‘Spiritual care is absolutely part of the provision of holistic care but it is not the sole responsibility of nurses. Specialists in spiritual care – chaplains – are employed by trusts specifically for that purpose’ – email to Nursing Standard

Mixed messages

She cites the four dimensions of holistic nursing care as psychological, social, physical and spiritual. ‘These four dimensions are always talked about in nursing care so I do not know why spirituality is not in the Code. It includes the other three dimensions of holistic care.’

Staffordshire-based Dr McSherry, who also works in clinical practice, stresses that the NMC’s pre-registration education standards state that nurses must carry out comprehensive assessments that take account of ‘physical, social, cultural, psychological, spiritual, genetic and environmental factors’.

‘They are saying that nursing students need to be skilled and competent on spirituality at the point of registration but then spirituality is not in the Code, so it is a mixed message,’ he says.

Dr McSherry and Dr Ross are also concerned that the only explicit reference to spirituality in the Code is negative, warning registrants not to express religious beliefs in an inappropriate way.

Dr Kolyva says nurses should use their ‘professional judgement’ to determine what is appropriate professionally.

While the NMC has no plans to revise the Code, Dr Kolyva says it would consider defining more clearly what aspects fall under the broader definition of human rights: ‘We already have a glossary and we could make it more explicit about what we mean by the term human rights and what it includes’.

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