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Steve Fouch

Excluding the spiritual from patient care: what is the NMC up to?

Steve Fouch is CMF Head of Communications, and was formerly the CMF Head of Nursing. He has worked in community nursing, HIV & AIDS and palliative care. He serves on the International board of Nurses Christian Fellowship International.
The views expressed do not necessarily reflect those of CMF.

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In some ways, it speaks of the nature of our times that we have created a special category of care and labelled it ‘spiritual’.  In truth, all nursing and medical care has recognised that spiritual needs exist and need to be paid attention to as part of the proper care of any patient.  These spiritual needs are variously defined, but essentially we would all recognise them: the need for significance, the need for forgiveness, connectedness and relationship, the need for purpose and meaning. This was so implicit, that along with good hygiene, cleanliness, warmth, physical safety and diet (amongst others), it was an integral part of care in such a manner that it did not need separating out.

The Royal College of Nursing felt there was a need and produced some helpful guidelines in 2011, following on from similar guidelines for the NHS in Scotland and Wales, and latterly the General Medical Council’s.  However, I fear that these standards and good intentions have been honoured as much in the breach as in the observance.

Before the middle of the 20th Century, most nursing and medical staff were Christian believers – part of a wider, culture that implicitly accepted the Christian faith as normative (even if the majority probably practiced half-heartedly, and believed only in part). That which we call ‘spiritual’ was an implicit part of the daily life of most Westerners, much as it is for about 84% of the world’s population today. The natural outworking of these spiritual needs was to be found in an expression of Christian or other religious faith – in prayer, religious ritual, reading of scripture, etc. all of which would be as much a part of the normal warp and weft of healthcare provision as the ward round or bed baths!. Modern Europeans are the exception, not the norm, in regarding faith as a private, optional extra.

Which means it comes as something of a real surprise to find that the new NMC Code does not mention spiritual care at all.  Physical and psychosocial care certainly, but spiritual needs are dropped (see Clause 3).  Arguably, spiritual care may be implicit within two sub-clauses:

3.1 pay special attention to promoting wellbeing, preventing ill health and meeting the changing health and care needs of people during all life stages

3.2 recognise and respond compassionately to the needs of those who are in the last few days and hours of life

But that is very open to interpretation!

It seems that in the very earliest drafts of the new NMC Code, spiritual care was, allegedly far more explicit.  It was certainly not included in the June 2014 consultation document to which CMF responded.

Why is this? Is it because we are a secular society now, with no need for religion in the public sphere?  Yes, I think that sadly misguided attitude plays a very significant part. Furthermore, the literature suggests that where an explicit religious faith or spiritual life of some kind is not a part of the nurse or doctor’s daily life, they struggle to understand or engage with the spiritual health of their patients.

However, the massive and rapidly growing body of academic work on spiritual care in nursing and chaplaincy literature in particular, shows that addressing spiritual needs does not need to be tied with explicitly religious practice, and that paying attention to these needs has significant impacts on recovery, relapse rates and prevention of illness for physical and mental illnesses.

In an age of evidence based practice, to ignore this evidence seems somewhat ostrich like, to say the least. It does not fit in with a certain world view, so it becomes evidence that we can choose not to see.  Yet the GMC and RCN and some parts of the NHS do claim to see this evidence, and to want to put it into practice. So why doesn’t the NMC?

In the 2008 draft of its Code the NMC clearly states:

Clause 1) You must treat people as individuals and respect their dignity.

Clause 35) You must deliver care based on the best available evidence or best practice.

Yet this new version of the Code makes the following, rather chilling statements:

Clause 32) ‘You must put aside your own personal and cultural preferences when considering the needs of those in your care’

Clause 94) ‘You must ensure that you do not express your personal beliefs (including political, religious or moral beliefs) to people in a way that may exploit their vulnerability or cause them upset or distress.’

On the surface this sounds very reasonable, and any Christian health professional would be in agreement with their secular colleagues that religious coercion or proselytism of vulnerable patients is not acceptable.  Our care should always be patient centred. Yet there is no counterbalance in these statements (unlike the GMC’s  ‘’Good medical practice’) that seeks to recognise that everyone has beliefs which influence their choices and style of care, and that in some contexts the patient may choose to ask the doctor or nurse caring for them about their beliefs.

I have had this happen on many occasions, and always because someone was coming to terms with a life limiting illness and wanting to know how others coped, what faith or world view informed my ability to deal with life’s problems.  One deals with such requests and questions with sensitivity and professionalism, but to ignore them is frankly uncaring, not treating the patient as an individual with complex needs.

It is a very human thing to ask such questions and to respond compassionately, but with these two clauses, the NMC has effectively said that this whole area is taboo. You can’t talk about it, even if a patient asks you out of a genuine need.

So, spiritual care is off the agenda according to the NMC. Not explicitly, but implicitly.  We no longer respect or treat with dignity the spiritual needs and questions of our patients.  We do not deliver care based on the best available evidence or practice, because the NMC has, for whatever reason, decided it does not fit in with modern nursing practice. If we cannot see it, weigh it, measure it or cost it, it is not real or worth doing anything about!

A growing body of nurse academics working in this field is lobbying the NMC to rethink this, because ultimately it will be patient care that suffers. In the meantime, arm yourself with the evidence; respond to genuine questions and expressions of spiritual needs with kindness and openness; care for the whole person. The NMC may not value this, but your patients will.

Posted by Steve Fouch
CMF Head of Nursing

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