Spiritual Perspectives, Spiritual Care, and Recovery-Oriented Practice in Psychiatric Mental Health Nurses" (2018)

University of Texas at Tyler Scholar Works at UT Tyler

Nursing Theses and Dissertations School of Nursing

Spring 4-27-2018 Spiritual Perspectives, Spiritual Care, and Recovery- Oriented Practice in Psychiatric Mental Health Nurses Melissa Neathery University of Texas at Tyler

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Recommended Citation Neathery, Melissa, "Spiritual Perspectives, Spiritual Care, and Recovery-Oriented Practice in Psychiatric Mental Health Nurses" (2018). Nursing Theses and Dissertations. Paper 82. http://hdl.handle.net/10950/846

This Dissertation is brought to you for free and open access by the School of Nursing at Scholar Works at UT Tyler. It has been accepted for inclusion in Nursing Theses and Dissertations by an authorized administrator of Scholar Works at UT Tyler. For more information, please contact [email protected]. SPIRITUAL PERSPECTIVES, SPIRITUAL CARE, AND RECOVERY-ORIENTED

PRACTICE IN PSYCHIATRIC MENTAL HEALTH NURSES

MELISSA NEATHERY

A dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy School of Nursing

Susan Yarbrough, PhD., R.N., Committee Chair

College of Nursing and Health Sciences

The University of Texas at Tyler April 9, 2018

The University of Texas at Tyler, Tyler, Texas

This is to certify that the Doctoral Dissertation of

MELISSA NEATHERY has been approved for the dissertation requirement on April 9, 2018 for the Doctor of Philosophy in Nursing degree

Approvals:

______Dissertation Chair: Susan Yarbrough, Ph.D.

______Member: Zhaomin, He, Ph.D.

______Member: Belinda Deal, Ph.D.

______Member: Elizabeth Johnston Taylor, Ph.D.

______Barbara K. Haas, Ph.D. Executive Director, School of Nursing

______Yong Tai Wang, Ph.D. Dean, College of Nursing & Health Sciences

I sincerely thank the faculty, administration, and my cohort of UT Tyler’s nursing

PhD program for making this process exciting and rewarding. Every class has been enlightening and contributed to the development of my researcher. My committee is my

“first round draft pick”. I appreciated all of Dr. Yarbrough’s encouragement, support, and direction; Dr. He’s insightfulness and knowledge that helped me to overcome my fear of statistics and allowed me to savor the “a-ha” moments; Dr. Taylor’s and Dr. Deal’s expertise and vast experience with spiritual care that encouraged me and affirmed my focus of scholarship; Dr. Hermann’s guidance in formulating a plan.

Thank you to my family for their encouragement and patience; my husband, Jim, for providing mentoring, insightfulness and cheerleading throughout the entire process; my sons for giving me examples how to learn; my parents for instilling the importance of education.

It was God’s provision and strength that made this possible. I have developed a deeper understanding of Romans 8:28 “And we know that in all things God works for the good of those who love him, who have been called according to his purposes.” Table of Contents

List of Tables ...... iv

List of Figures ...... v

Abstract ...... vi

Chapter 1 Overview of the Dissertation Research Focus ...... 1 Introduction of Manuscripts ...... 2

Chapter 2 Recovery-Oriented Treatment in Mental Illness: Recovery as a Journey, Not a Destination ...... 4 Abstract ...... 4 Recovery Movement ...... 5 Components of Recovery ...... 6 Renewing Hope and Commitment ...... 7 Redefining Self ...... 8 Incorporating Illness ...... 8 Involvement in Meaningful Activities ...... 9 Overcoming Stigma ...... 9 Assuming Control and Becoming Empowered ...... 10 Managing Symptoms ...... 10 Being Supported by Others ...... 11 Nursing’s Role ...... 11 Spirituality/Religion in Recovery ...... 12 Spirituality in Recovery: The Nursing Process ...... 14 Assessment ...... 14 Treatment Planning and Analysis ...... 14 Intervention ...... 15 Evaluation ...... 16 Conclusion ...... 17 References ...... 20

Chapter 3 Recovery-Oriented Model of Care for People with Serious Mental Illness: A Holistic Approach ...... 25 Abstract ...... 25 Recovery-Oriented Practice Model of Care ...... 266 Holistic Approach to the Recovery-Oriented Process ...... 28 Biological ...... 28 Psychological ...... 30 Social...... ………………………………………………………………………..32 Spiritual ...... 33 Environmental ...... 35 Conclusion ...... 36 References ...... 38

i Chapter 4 Spiritual Perspectives, Spiritual Care, and Recovery-oriented Practice in Psychiatric Mental Health Nurses...... 48 Abstract ...... 48 Review of Literature ...... 52 Spirituality and Religiosity ...... 52 Spiritual Care and Spiritual Perspectives ...... 53 Recovery-Oriented Practice ...... 57 Spiritual Care in Recovery-Oriented Practice ...... 59 Theoretical Framework ...... 60 Conceptual and Operational Definitions ...... 62 Research Questions ...... 63 Design ...... 65 Methods...... 66 Sample/ Setting ...... 66 Protection of Human Subjects ...... 67 Instruments ...... 68 Data Collection ...... 73 Analysis...... 74 Results ...... 75 Description of the Sample ...... 75 Research Question 1: ...... 77 Research Question 2: ...... 80 Research Question 3: ...... 82 Research Question 4: ...... 83 Research Question 5: ...... 84 Discussion ...... 86 Strengths and Limitations ...... 92 Recommendations ...... 94 Summary ...... 96 References ...... 98

Chapter 5 Summary and Conclusion ...... 114 References ...... 116

Appendix A: IRB Approval, University of Texas, Tyler...... 117

Appendix B: Survey Introduction, Explanation, and Request for Participation ...... 118

Appendix C: Permissions to Use Instruments ...... 120

Appendix D: Demographic Data Sheet...... 122

Appendix E: Spiritual Perspectives Scale ...... 126

Appendix F: Nurses Spiritual Care Therapeutics Scale ...... 129

Appendix G: Recovery Knowledge Inventory ...... 132

ii Biographical Sketch ...... 133

iii List of Tables

Table 1 Biblical References Supporting Recovery-Oriented Care ...... 19

Table 2 Conceptual and Operational Definitions ...... 65

Table 3 Sample Demographic Information...... 76

Table 4 Collapsed Variables ...... 78

Table 5 Frequencies and Percentages of SPS Mean Responses...... 79

Table 6 Frequencies and Percentages of NSCTS Mean Responses ...... 81

Table 7 Sample Demographics Compared to National Population ...... 87

iv List of Figures

Figure 1. Recovery-oriented mindset self-assessment...... 18

Figure 2. Study conceptual model...... 63

v Abstract

SPIRITUAL PERSPECTIVES, SPIRITUAL CARE, AND RECOVERY-ORIENTED PRACTICE IN PSYCHIATRIC MENTAL HEALTH NURSES

Melissa Neathery

Dissertation Chair: Susan Yarbrough, Ph.D.

The University of Texas at Tyler May 2018 The prevalence of mental illness is well documented with 450 million people suffering with a mental illness worldwide. Nurses are integral to the delivery of mental health services and can influence the provision of individually focused, evidence-based, and culturally competent care. Spiritual care has been shown to enhance coping, improve well-being, and increase satisfaction with care for those in mental health recovery. Three manuscripts presented in this dissertation portfolio explored and addressed the concepts spirituality and spiritual care for those in mental health and substance use recovery. The

Recovery Practice Model was examined and how spiritual care can be integrated into each component of the model was explained. The second manuscript developed the concept of spiritual care in recovery from a holistic nursing perspective. Both of these manuscripts explored spiritual care in various specialties of nursing and the benefits and barriers of providing spiritual care in mental health professions such as psychology, social work, and chaplaincy. It became clear that scant current research existed identifying if and how psychiatric mental health nurses are providing spiritual care to mental health clients. Based on Watson’s Theory of Caring and the Recovery Practice

vi Model, the third manuscript describes the relationships between the spiritual perspectives, frequency of spiritual care, and knowledge about recovery-oriented practice in psychiatric mental health nurses. In completing this dissertation, the researcher contributed to the knowledge of holistic mental health nursing care and provided a foundation for future research to better understand spiritual care and recovery.

vii Chapter 1

Overview of the Dissertation Research Focus

Spirituality and religion are topics of major interest in mental healthcare as empirical studies have shown that healthy spirituality is related to improved quality of life, treatment engagement, emotional comfort, and that spiritual distress can contribute to problematic behaviors (Koenig, King, & Carson, 2012; Pargament & Lomax, 2013).

Spiritual assessment, encouraging health-promoting spiritual beliefs, challenging unhealthy spiritual beliefs, and collaboration with trained clergy are hallmarks of good psychiatric care. However, research indicates that although spirituality and religion are important to many people receiving mental health treatment, they often go unrecognized and unaddressed by hospital staff (Galanter, Dermatis, Talbot, McMahon, & Alexander,

2011).

The Recovery-oriented Practice (ROP) Model of mental health care is the most widely accepted paradigm of treatment, and spirituality is recognized as an integral concept of this model. The American Psychiatric Nurses Association supports the application of recovery-oriented care into all areas of psychiatric nursing, yet the psychiatric mental health (PMH) nurse’s role in providing spiritual care is not well understood. Spiritual assessment and addressing spiritual distress fall under the scope and practices of PMH nursing (American Nurses Association [ANA], 2014), but little is known about the extent of spiritual care being provided by PMH nurses and their understanding of its role in recovery-oriented care.

While providing direct patient care and instructing nursing students to provide evidence-based mental health care, the researcher frequently noted that PMH nurses and

1 other members of the treatment team avoided addressing spiritual issues with clients.

Even though patients recovering from mental illness or substance abuse indicated they were struggling with their spiritual/ religious values and wanted to know how to employ spiritual coping, these issues were often overlooked or minimized. Psychiatric mental health nurses’ comments such as, “Oh, we don’t get involved in someone’s beliefs,” and

“I leave those questions to the chaplains,” and “What does it matter what they [clients] believe spiritually? They just need to take their medicine,” prompted deeper inquiry by the researcher to determine the evidence supporting (or not) spiritual care by the PMH nurse. It is the intent of this dissertation to identify the spiritual perspectives and spiritual care practices of PMH nurses and their understanding of spiritual care in recovery- oriented practice.

Introduction of Manuscripts

Exploring the components of the Recovery-oriented Practice Model provided a foundation to understanding the role of spiritual care in the application of this model. The first manuscript presented in chapter two described the background of the Recovery

Movement and defined and provided examples of the components of recovery-oriented practice. Additionally, the manuscript explored spiritual care and clients’ personal experiences of applying spiritual/ religious themes to their process of recovery. The manuscript, Recovery-oriented Treatment in Mental Illness: Recovery as a Journey, Not a Destination, specifically addressed nurses’ and other healthcare providers’ provision of spiritual care from a Christian perspective and provided support from Biblical references as it was submitted and accepted for publication in The Journal of Christian Nursing.

2 A broader understanding of spiritual care in recovery-oriented treatment is addressed as a holistic nursing modality in chapter three: Recovery-Oriented Model of

Care for People with Serious Mental Illness: A Holistic Approach. Because spiritual care is a core component of holistic nursing, this manuscript explained and provided evidence of how nurses can promote individualized and culturally competent care throughout the recovery process. The purposes of this manuscript were to inform and provide recommendations on how PMH nurses should provide holistic care by adopting a ROP approach to mental health treatment.

Chapter four presents the third manuscript, Spiritual Perspectives, Spiritual Care, and Recovery-oriented Practice in Psychiatric Mental Health Nurses. This descriptive correlational study measured PMH nurses’ spiritual perspectives, frequency of spiritual care and knowledge of ROP. Findings identified variables that contributed to spiritual saliency and spiritual care of nurses and their relationships to ROP knowledge. This research responds to the recommendations identified in previous research regarding the need to explore the inclusion of spiritual care into mental health treatment.

3 Chapter 2

Recovery-Oriented Treatment in Mental Illness:

Recovery as a Journey, Not a Destination

Abstract

Recovery in mental illness is a person-oriented process that focuses on a client’s self-determination, independence, responsibility, empowerment, peer support, and well- being in spite of having a mental illness. This manuscript discusses the background to the

Recovery Movement and describes the eight components of the Recovery-oriented

Practice Model. Readers will learn how nurses in any setting can facilitate recovery and encourage healthy spirituality in clients’ lives. Insights from those who have the lived experience of mental illness recovery are included. As a published article for the Journal of Christian Nursing, Biblical references and Christian context relating to each component of the recovery-oriented process are provided to direct nurses and other healthcare providers to integrate spiritual care into a holistic approach to mental health and substance use treatment.

KEYWORDS: faith community nursing, holistic care, nursing process, recovery- oriented care, self management, spirituality, therapeutic alliance

4 Recovery-oriented Treatment in Mental Illness

Recovery as a Journey, Not a Destination

The term recovery has various meanings and connotations. When a football team fumbles, but then has a recovery, the team has regained possession of the ball and is now in control of it. When nurses transfer a patient post-surgically to the recovery area, it implies that a procedure was done to the patient and now begins the process of returning to a pre-illness state of health. Do these two examples have relevance to recovery in mental illness? Is recovery from alcohol addiction, depression, or schizophrenia a state of being symptom –free? Does recovery mean that a person has complete control of the illness? This article will examine how the concept of recovery in mental illness has changed, components of recovery, and how Biblically-focused spiritual care can enhance recovery.

Recovery Movement

For the first half of the 20th century, mental illness was viewed as a deteriorating and severe condition that often required life-long institutionalization (Drake & Whitley,

2014). With the discovery of psychotropic medications and United States President John

F. Kennedy’s 1963 speech to Congress promoting deinstitutionalization, many people with mental illnesses were released from institutions to ill-equipped and poorly funded community settings (Test & Stein, 1978). The enactment of the Americans with

Disabilities Act in 1990, the Surgeon General’s Report in 1999 and the President’s New

Freedom Commission on Mental Health in 2003 advanced the concept of recovery and identified the need for effective and evidence-based mental health care. By the turn of the century, there was a popular shift in mental health treatment from a medical model to a

5 recovery model of care. The medical model considers recovery as regaining previous level of functioning and alleviation of symptoms in response to medicine’s treatments aimed to cure a mental disease.

In contrast, the recovery model defines recovery as “a process of change through which individuals improve their health and wellness, live self-directed lives, and strive to reach their full potential” (Substance Abuse Mental Health Services, [SAMHA] 2012). In fact, new terminology is preferred in the recovery model: instead of a person recovering from mental illness, we say a person is in recovery. The term recovery is “often referred to as a process, an outlook, a vision, a conceptual framework or a guiding principle”

(Jacob, 2015, p. 117). The most recent report from the Surgeon General (U.S.

Department Health and Human services, 2016) refers to recovery in substance abuse as broader than abstinence or remission to include changes in “behaviors, outlook, and identity”. Recovery is a holistic approach and is understood to be a journey, not a destination. Various terms are used synonymously in the mental health rehabilitation literature that focus on the emerging concept of the recovery model including recovery- oriented practice, recovery to practice, patient-oriented care, and consumer-based approach.

Components of Recovery

In response to the confusion about what was meant by recovery, Jacobson and

Greenly (2001) presented a conceptual model of recovery that considered internal conditions (attitudes, experiences, processes) and external conditions (policies, treatment practices, circumstances) experienced by those recovering. This helped to clarify the interrelationships of factors influencing recovery and identified recovery as a multi-

6 faceted concept. In order to be considered “recovery-oriented” programs must contain four critical dimensions: 1) being person-oriented, 2) person involvement, 3) self- determination/ choice, and 4) growth potential (Farkas, Cagne, Anthony, & Chamberlain,

2005). Davidson, O’Connell, Tondora, Lawless and Evans (2005) conducted a concept analysis and identified several critical aspects of recovery: renewing hope and commitment, redefining self, incorporating illness, involvement in meaningful activities, overcoming stigma, assuming control, becoming empowered, managing symptoms, and being supported by others. To provide health-promoting and evidence-based care, nurses must adopt a recovery-oriented view when interacting with people with mental illnesses to promote and nurture recovery that focuses on God as the ultimate source of identity, strength, and purpose.

Renewing Hope and Commitment

Having a sense of hope in the prospect of living a purposeful and meaningful life is essential in recovery. Some purport that hope is the core component of recovery that allows someone to believe that all other recovery aspects are possible since without hope, the recovery process will not be instigated or maintained (Park & Chen, 2016). For those in recovery, hope correlates with fewer psychiatric symptoms and conversely, hopelessness is associated with increased symptom severity (Waynor, Gao, Dolce,

Haytas & Reilly, 2012). Although hope is critical for all people in recovery, sources of hope are specific to each person as are the threats to become hopeless as described by mental health consumer Peter Amsel (2012), “Hope can be lost over virtually anything, no matter how seemingly insignificant; had I allowed myself to enter that stream of hopelessness, I may well have lost my battle with this illness altogether” (p. 85).

7 Redefining Self

Identity can be defined as “persistent characteristics which make us unique and by which we are connected to the rest of the world” (Slade, 2009, p. 82). After experiencing symptoms and receiving a mental illness diagnosis, people in recovery must not define themselves solely by a diagnosis. A healthy self-concept is based on the many characteristics, abilities, traits, and behaviors a person has. Davidson and Strauss (1992) identified the four steps of redefining a healthy sense of self in recovery as discovering the possibility that an identity apart from a diagnosis exists, validating one’s strengths and limitations, putting aspects of one’s identity into action, and using the enhanced sense of self to address other aspects of recovery. Scotti (2012) describes his experience:

“They say that recovery is knowing oneself under new circumstances, redefining one’s role, and reevaluating oneself to develop a new sense of respect for oneself. After living in darkness for many years and having died to my old self, thinking that my life was over and futile, a new birth emerged from within me that has made my life more meaningful and purposeful than before” (p. 14).

Incorporating Illness

Although mental illness should not define someone, it cannot be denied either.

Recognizing and accepting that one has a mental illness enables that person to seek treatment, cope, and pursue a meaningful and fulfilling life despite the need to possibly adjust for limitations. A systematic review of coping strategies in mental illness found that acceptance of mental illness is associated with more efficacious coping (Phillips,

Francey, Edwards, & McMurray, 2009). Salsman (2012) describes her experience: “In the beginning, denial became my defense. I was angry and resentful” (p. 9), but then

8 progressed to “I made an effort to open my eyes, to become very aware of myself. I made a decision to stop wallowing in self-pity and to become responsible for the course my life would take” (p. 10).

Involvement in Meaningful Activities

Recovery is enhanced by pursuing goals and roles that have significant meaning to the person in recovery. Feeling fulfilled in family roles (sibling, child, spouse, or parent) or societal roles (employee, church member, friend, hobby participant) promotes recovery. Recovery approaches enhance constructive use of leisure and activities that a person finds meaningful and enjoyable, thus emphasizing the importance of “making life better rather than making life less bad” (Iwasaki, Coyle, Shank, Messina, & Porter, 2016, p. 54).

Overcoming Stigma

Stigma comes from the negative stereotypes and assumptions about people who have mental illness. Self-stigma refers to the process of adopting and internalizing negative assumptions about oneself. Unfortunately, societal stigmatization of mental illnesses affects people worldwide (Seeman, Tang, Brown, & Ing, 2016). Stigmatization interferes with care-seeking behaviors (Corrigan, Druss, & Perlick, 2014), promotes discrimination (Rusch, Angermeyer, & Corrigan, 2005), and decreased adherence to treatment (Kamaradova et al., 2016). Therefore, recovery requires a person to not internalize stigmatizing beliefs, promote accurate depictions of mental illness, and support policies that eliminate discrimination.

9 Assuming Control and Becoming Empowered

Assuming responsibility for the recovery process is crucial for developing a healthy sense of self and health-promoting behaviors. As opposed to previous views that it was psychiatry’s job to “fix” people with mental illness, the locus of control is on the person to make healthy choices and changes to promote recovery. Instead of feeling helpless to the influences of mental illness, empowerment enables people to fight stigma, demand rights, promote awareness, and obtain effective available treatment and resources. Through her own recovery process that has propelled the recovery-oriented model, Deegan (1997) describes empowerment as “founded on values which include a profound reverence for the subjectivity of other human beings, a belief that they can act to change their situation, an understanding that power is not finite but can be shared and created, and the willingness to love and be transformed by the love of those we serve” (p.

15).

Managing Symptoms

Some people experience a complete alleviation of mental illness symptoms, but many others experience recurrences throughout the lifetime. Sometimes symptoms are more controlled and less severe than other times. Symptom management may include medication, counseling, stress management and lifestyle changes. Decades ago, the term treatment compliance described a patient’s response to treatment, but because of its connotation of coercion, treatment adherence or management is used. This shift in focus acknowledges that a person has choices and autonomy in how to incorporate therapeutics into one’s life and recognizes that a person with mental illness is an active participant in their care (Vuckovich, 2010).

10 Being Supported by Others

Instead of being alienated, a person with a mental illness needs to be connected to and supported by others. Positive relationships enhance recovery by providing role modeling, resources, encouragement, information, and understanding. Research exploring subjective and objective reports of social support by people with mental illness indicate a significant association with recovery (Corrigan & Phelan, 2004) and coping (Davis &

Brekke, 2014). Sometimes called peer specialists or consumer-providers, individuals with experiences of living successfully with mental illnesses that support others with mental illnesses is a growing modality in recovery. Professional peer providers obtain training and certification in helping others by promoting hope, advocacy, resources, socialization skills, and sharing their lived experience to engage others in treatment (Salzer, Schwenk,

& Brusilovskiy, 2010).

Nursing’s Role

No matter what setting, nurses are in a unique and advantageous position to promote and nurture recovery for people with mental illnesses and substance abuse.

Nurses must remember that recovery is what clients do, and facilitating recovery is what nurses and other mental health professionals do. Through the therapeutic alliance, nurses address self-concept, decision-making, resource attainment, social support, advocacy, and self-care activities while conveying empathy, dignity, and respect for each person’s lived experience. In conjunction with SAMHA, the American Psychiatric Nurses Association provides interprofessional education to enhance recovery-oriented practice. Interventions specified in the Psychiatric Mental Health Standards of Practice address the needs of those in mental illness recovery (American Nurses Association [ANA], 2007). Recovery-

11 oriented nursing care is not a list of additional activities needing to be tacked on to a treatment plan. Instead, it should reflect a mindset, attitude, and motivation that is integrated into all aspects of the nursing process (see Box 1). Nurses have the power to create a milieu that enhances recovery and provide the care that is needed to recover:

“Choice, option, information, role models, being heard, developing and exercising a voice, opportunities for bettering one’s life: these are the features of a human interactive environment that supports the transition from not caring, to caring, from surviving to becoming an active participant in one’s own recovery process” (Deegan, 1996, p. 92).

Interestingly, recovery-oriented care may also benefit nurses. Kraus and Stein (2013) found that case managers who worked for facilities with perceived higher levels of patient-focused services reported less burnout and higher job satisfaction.

Spirituality/Religion in Recovery

Many mental health service consumers and mental health professionals view spirituality as an integral aspect of well-being during recovery and in life in general. The one common conclusion in scholarly literature about spirituality and religiousness and mental health is that there is no consistent definition of spirituality and religiousness. In general, religion is seen as a system of beliefs, doctrine, and rituals that is shared by a group of followers (Koenig, King, & Carson, 2012). Spirituality tends to be a broader concept that encompasses personal transcendence and meaning. However, spirituality and religion both refer to “the feelings, thoughts, experiences, and behaviors that arise from a search for the sacred. The term ‘search’ refers to attempts to identify, articulate, maintain or transform. The term ‘sacred’ refers to a divine being, divine object, Ultimate Reality or

Ultimate Truth as perceived by the individual” (Hill et al., 2000, p. 66). Based on this

12 conceptualization, spirituality/religiousness is not deemed “good” or “bad”. The feelings, thoughts, experiences and behaviors that result from the search for the sacred can be acceptance, hope, fulfillment, strength or guilt, self-blame, abandonment, or isolation.

Mental health services consumers and providers can work together to identify the role of spirituality/religiousness in the promotion or hindrance of recovery.

Many people with health-promoting spirituality believe that recovery is rooted in a connection to God and search for a relationship with Him. Dr. Daniel Fisher, a psychiatrist with previous diagnosis of schizophrenia, has advocated extensively for the recovery model says, “[Recovery] is essentially a spiritual revaluing of oneself, a gradual developed respect for one’s own worth as a human being. Often when people are healing from an episode of a mental disorder, their hopeful beliefs about the future are intertwined with their spiritual lives, including praying, reading sacred texts, attending devotional services and following a spiritual practice.” (Fisher, n.d.). Faith and religious beliefs can be sources of hope, meaning, self-concept, empowerment, support and motivation to take responsibility for treatment (see Table 1). Ho et al. (2016) found that spiritual experiences influences sense of self, philosophy of life, growth after episode of acute symptoms, and peacefulness for people in recovery from severe mental illness. The innate desire to feel connected, inspired, and strengthened by a power greater than oneself is core to the recovery narratives of many people (Slade, 2009). In fact, themes such as hope, reconciliation, faith, grace, fellowship, surrender, regeneration, and belief are entwined throughout the recovery process (Fallot, 2001).

13 Spirituality in Recovery: The Nursing Process

Assessment

Nurses can address spirituality of those in recovery throughout the nursing process. Initially, a nurse must examine his/her own beliefs about mental illness/ substance abuse, recovery, and spiritual care. As with any form of care, it should be offered ethically, effectively, and within the nurse’s scope of practice. Nurses must assess a person’s spiritual beliefs and how those beliefs influence clients’ understanding of recovery. Motivational interviewing and formalized spiritual assessments can identify health-promoting beliefs that should be encouraged and strengthened or recovery barriers that should be acknowledged and explored. Spiritual assessment guidelines identified by

Gomi, Starnino, and Canda (2014) include developing a therapeutic alliance, identifying client’s readiness to discuss spirituality, focusing on past and present spiritual strengths, considering the client’s cultural context, and “letting the client direct whether and how spirituality can be used in an assessment to develop treatment plans” (p. 452).

Treatment Planning and Analysis

Core tenants of recovery-oriented treatment are promotion of client autonomy, empowerment, and decision-making (Slade et al., 2014). The client is seen as a member of the treatment team and ideally works in collaboration in the development of the treatment plan. Care recipients of recovery-oriented programming desire strengths-based and self-management approaches (Kidd, Kenny, & McKinstry, 2015). Therefore, spirituality aspects should be included in the treatment plan based on the client’s direction. Goals focused on employing spiritual strengths and addressing spiritual deficits

14 can promote overall recovery and spiritual resources such as church attendance, worship, service, and chaplaincy are means of enhancing several components of recovery.

Intervention

Based on accurate assessment and planning, nurses can encourage the healthy role of spirituality in clients’ lives. Nurses can direct spiritually seeking clients to consider spiritual beliefs that encourage and guide recovery or nurture the faith of those who have a spiritual religious grounding. Nurses can promote one’s spiritual recovery journey in many ways:

• Encourage clients to develop a healthy God-based view of self

• Treat clients in ways that convey dignity, value, and respect

• Encourage participation in meaningful spiritual activities such as prayer,

reading scriptures, worship and attending services

• Listen to client’s personal journey through discussion and encourage further

exploration through writing, art, or photovoice (expression of experience

through multi-media)

• Acknowledge the value and uniqueness of clients’ experience

• Encourage clients to focus on helping others and provide opportunities to do

• Suggest and help clients accept divine strength to manage treatment

• Pray with clients that request prayer for divine interventions such as wisdom,

insight, grace, forgiveness, and physical and emotional strength

• Provide information for supportive community resources that are congruent

with the client’s spiritual and recovery needs

15 • Help in reframing negative thoughts to Biblically-aligned ones

• Encourage client to accept love and support from family, peers, providers,

support groups, and religious community

• Explain that relapse is not an indication of failure but is often a part of the

overall recovery process and an opportunity to grow spiritually and

emotionally.

• Connect client to a peer provider (a person who is trained to share his or her

lived experience of recovery to promote recovery and resilience in others)

Faith can be a source of hope, understanding, and strength in recovery as described by Grazia (2012), “It was times like these I realized God was with me and had been with me all along. He didn’t actually give me what I’d asked for (a life free of anxiety and sadness), but he put it within my reach. Looking back now, I see he had done this all along but he required me to work for it so I could be a better and stronger person”

(p. 133).

Evaluation

Treatment “success” cannot be solely based on reduced symptomatology, fewer hospitalizations, or decreased relapses. Nurses must also consider goal attainment of spiritual needs and growth. With on-going collaboration, nurses can identify whether or not clients view the role of spirituality in their recovery as beneficial or not. Helping a client to determine if a treatment goal was unrealistic can help to determine if a plan modification is needed. Sometimes an intervention must be changed to be better suited to the client’s needs. For example, to increase socialization, feelings of connectedness, and opportunities for service, a client may set a goal to attend church. If an initial visit was

16 not positive, the nurse can further explore with the client specific church characteristics the client is looking for. A nurse can provide realistic expectations by explaining that it may require visits to several churches before a client finds one that is a “fit”. Mental health service consumers identify positive outcomes of treatment partnerships if providers promote the acceptance of mental illness, management of symptoms, improvement in self-esteem and development of positive meanings and life goals

(Anthony, 2008) and nurses can incorporate spiritual outcomes into all of these. Nurses should periodically engage in self-assessment to verify that they are adhering to a recovery-oriented mindset and approach. Figure 1 provides reflective questions to help assure congruence between nurses’ personal beliefs about recovery and their actions.

Conclusion

The perspective that mental health and substance use treatment consists of professionals telling passive patients what to do is becoming a paradigm of the past. The current view that recovery-oriented care is a collaborative partnership that views the person with a mental illness holistically is gaining momentum. Core components are well-aligned with one’s spiritual life themes. Nurses must remember that, “There are many pathways to recovery. It is self-directed and empowering with a personal recognition of the need to change and transform. There is a holistic healing process, with a gradual return to mind, body, and spiritual balance based on the individual’s personal cultural beliefs and traditions” (Baird, 2011, p. 147). Thus, nurses should promote healthy spiritual/ religious practices and beliefs for people in recovery that are open to accepting that approach. Nurses help those on the journey of recovery to discover God’s

17 path that leads to understanding (Psalm 119:32) and life (Psalm 16:11). From a Christian perspective, Table 1 provides scriptural references in support of each component of ROP.

1. Do you believe that people with mental illness can get better? 2. When you see someone in a symptomatic state of mental illness, do you imagine them being in recovery in the future? 3. Do you focus on the person and not the disease? For example, refer to someone as a “person with schizophrenia” rather than “a schizophrenic.” 4. Do you remind people that they are the expert on their experience? 5. Do you encourage people to consider various options when deciding on treatments? 6. Do you encourage people to ask questions about their diagnoses and recommendations? 7. Do you listen to people’s stories and view each one as a unique experience? 8. Do you assess each patient’s source of hope, meaning, and supports? 9. Do you acknowledge and reinforce each patient’s positive qualities and abilities? 10. Do you professionally confront others who use derogatory language about people with mental illness or perpetuate stigma? 11. Do you advocate for the rights of people with mental illness? 12. Do you encourage clients to imagine themselves in six months and describe how they would like to be? 13. Do you write treatment goals with the client and use empowering language? For example, ‘Patient will identify 5 realistic methods of managing symptoms’ instead of ‘Patient will be compliant with treatment.’ 14. Do your treatment plan interventions use verbs such as “promote”, “enhance”, “encourage”, “assist”, “teach”, “offer” and “reinforce”? Figure 1. Recovery-oriented mindset self-assessment.

18 Table 1 Biblical References Supporting Recovery-Oriented Practice Recovery-oriented model component Scriptural reference Renewing Hope and Commitment Psalm 62:5, psalm 130:5, Romans 8:25, Romans 15:13, Psalm 42:11, Hebrews 10:23, Proverbs 13:12, Psalm 33:22 Redefining Self Hebrews 11:1, Jeremiah 29:11, I John 3 1-3, Ephesians 2:10, I Samuel 16:7, Jeremiah 30:17 Incorporating Illness 2 Corinthians 5:17, Proverbs 3:7-8, Romans 5:3-4, Psalm 25:5, Involvement in Meaningful Colossians 3:12, Hebrews 6:10, I Peter 4:10, Proverbs 16:3, Ephesians Activities 6:7, Psalm 90:17, Matthew 5:16. Ephesians 2:10, Overcoming Stigma Psalm 9:18, Psalm 25:3, I Timothy 5:5, Psalm 119:114, Genesis 1:27, Assuming Control and Becoming Roman 5:4, Romans 15:13, Isaiah 40:31, Psalm 31:24, Philippians Empowered 4:13, Managing Symptoms 1 Corinthians 6:19-20, Romans 12:1, 2 Chronicles 15:7, 3 John 1:2, Psalm 119: 66, I Corinthians 9:27 Being Supported by Others Galatians 6:2, John 15:12, Philippians 2:4, Ecclesiastes 4:9-10, Proverbs 12:26, Psalm 133:1, I Thessalonians 5:11

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24 Chapter 3

Recovery-Oriented Model of Care for People with Serious Mental Illness:

A Holistic Approach

Abstract

Spiritual care is a core component of holistic nursing. Yet in mental illness treatment, spiritual care is often omitted or undervalued. The concept of recovery in mental illness has evolved from a sole focus on symptom elimination to promotion of well-being and quality of life. Instead of the goal of recovery being “symptom-free” or

“cured”, it is viewed as regaining hope, purpose, identity, and support by holistically addressing the physical, psychological, social, spiritual, and environmental needs of a person with mental illness. Recovery-oriented practice (ROP) promotes one’s potential for a fulfilling life by focusing on strengths and resources in collaboration with an individual’s healthcare provider. The purposes of this article are to inform and reinforce the holistic principles of ROP and the role of nurses in promoting them. Nurses must adopt a recovery-oriented mindset and integrate holistic care into all dimensions of nursing process.

Keywords: spiritual care, mental illness, recovery, holistic care, recovery-oriented practice

25 Recovery-Oriented Model of Care for People with Serious Mental Illness:

A Holistic Approach

To many health care professionals, ‘recovery’ implies ‘cure’ where a person returns to their pre-morbid level of functioning. For example, someone diagnosed with bronchitis receives an antibiotic and eventually is able to participate in all physical activities as prior to the infection without lingering effects. However, recovery is viewed differently in mental healthcare. Although some people who experience an episode of mental illness never experience another, others live with the reality that mental illness is a chronic condition requiring specialized treatment including symptom management and the utilization of various coping strategies, especially for those with a serious mental illness. A serious mental illness (SMI) is a condition that requires individualized management and often negatively impacts on the ability to engage in desired life activities (Substance Abuse and Mental Health Services Administration [SAMHSA],

2012). Persons with SMI are considered a vulnerable population and experience increased health disparities. The treatment of SMI has changed over the past several decades and recovery has become a more comprehensive and holistic endeavor. The

“mind-body-spirit-emotion-environment” approach of holistic nursing is compatible with the approach of recovery-oriented practice (ROP) utilized in the treatment of those with

SMI. All nurses, regardless of specialization or area of practice, can adopt a recovery- oriented mindset to promote functioning, well-being, and health in patients with SMI.

Recovery-Oriented Practice Model of Care

For the first half of the 20th century, mental illness was believed to be a deteriorating and chronic condition that often required life-long institutionalization

26 (Drake & Whitley, 2014). However, the discovery of psychoactive medications, decreased economic resources, and policy changes promoting deinstitutionalization forced a shift to outpatient and community treatments for persons with mental illness. By the turn of the century, there was a popular perspective change in mental health treatment from a ‘Medical Model’ to a ‘Recovery-Oriented Practice Model’ of care. The medical model defined recovery as an attainment of previous level of functioning and alleviation of symptoms in response to medication aimed to treat a mental disease. Paternalistic by nature, the medical model approach of prescribing medicine to patients who are expected to be compliant limited patient engagement and autonomy in treatment. It also placed little emphasis on addressing the individual’s social support, personal identity issues, spiritual well-being or other medical problems. The primary medical model focus is on the psychiatric symptoms, not the person. In contrast, the Recovery-Oriented Practice

Model defines recovery as “a process of change through which individuals improve their health and wellness, live self-directed lives, and strive to reach their full potential”

(SAMHA, 2012). A turning point in the understanding of recovery was initiated by

Anthony (1993) who proposed that “a person with mental illness can recover even though the illness is not cured” (p. 15). The preferred terminology in ROP: instead of a person

“recovering from” mental illness, a person is “in recovery” (Davidson & Roe, 2007).

Rather than illness-centered language, ROP uses person-centered terminology such as “a person with schizophrenia” rather than “a schizophrenic” and “mental health service consumer” rather than “patient” (Jensen et al., 2013). The most recent report from the

Surgeon General refers to recovery as broader than “remission” to include improvement in “behaviors, outlook, and identity” (U.S. Department of Health and Human Services,

27 2016). A Recovery-oriented practice approach acknowledges that people with continuing symptoms can have a meaningful life and aspirations despite continuing to experience the effects of mental illness (Davidson, 2016). Symptom management is seen as only one aspect of overall treatment.

Substantial literature explores the current concept of recovery from serious mental illness regarding definitions, processes, experiences, outcomes and competencies.

Recovery-oriented practice purports that recovery is not linear and that relapses are not considered ‘failures’, and even if an individual does not have complete control of all SMI symptoms, they still may experience hope, purpose and fulfillment in their lives. To be considered recovery-oriented, there are fundamental components that must be operationalized in the provision of ROP treatment.

Holistic Approach to the Recovery-Oriented Process

Biological

For many, psychiatric symptom management is enhanced with use of medications. The most appropriate type, route, schedule, and dosage should be determined collaboratively between the health provider and the consumer. Psychotropics must not be the only category of medications considered, but treating all physical conditions is essential especially since consumers have poorer mental and physical health outcomes including greater mortality rates. The co-occurrence of significant medical morbidities is overwhelmingly supported by evidence. In the US, people with SMI have mortality rates 2 to 3 times greater than that of the general population mostly due to compromised medical health status (Crump, Winkleby, Sundquist, & Sundquist, 2013).

Leading causes of death among people with SMI were found to be heart disease, suicides,

28 accidents, and malignant neoplasms. Suggested possible etiologies include weight gain caused by medications, decreased physical activity, smoking, substance use, and inadequate social support (Paschall, Miller, & Svendsen, 2006). In many instances, the physical healthcare of people with SMI is neglected (Robson & Gray, 2007; Maj, 2009) partly due to stigmatizing beliefs held by health professionals and lack of clarity regarding providers’ roles and responsibilities for providing medical care (Kilbourne,

Greenwald, Bauer, Charns, & Yano, 2012).

Recovery-oriented practice focuses on the need to provide integrative care collaborating efforts across medical specialties. Interestingly, providers who believe that recovery from SMI is possible are more apt to work collaboratively (Lee, Crowther,

Keating, & Kulkarni, 2013). Best practices for ROP include consistent monitoring of physical indicators, connecting patients with primary care providers, encouraging health promotion activities, assisting with navigation of the healthcare system, and increasing communication between caregivers (Ezell, Siantz, & Cabassa, 2013). Individuals who attended support groups focused on promoting self-management of comorbid diseases demonstrated increased visits to medical providers and increased medication adherence

(Druss et al., 2010). Evidence also shows that engaging consumers in planning and problem-solving to address medical needs increases well-being and functioning

(Goldberg et al., 2013). Similarly, a systematic review of research exploring the integration of general medical and psychiatric self-management interventions confirmed improvement in the lives of people with SMI (Whiteman, Naslund, DiNapoli, Bruce, &

Bartels, 2016). Programs claiming to be based on ROP principles stress the need for all staff to be trained on the significance of co-morbidities, how to assess for them,

29 identifying the consumer’s understanding of them, and how to cooperate with staff from various services to support consumers (Lee et al., 2013).

Psychological

Focusing solely on symptoms, disability, and diagnoses as sources of one’s identity are factors that interfere with developing healthy social support and motivation for treatment. Roe and Ben-Yishai (1999) propose that if an individual with SMI does not resolve their identity as “ill self” then the process of recovery cannot progress. Applying stigmatizing labels and attitudes to oneself can hinder recovery. Providers that adhere to the medical model of psychiatric care, “with its role as expert, its application of labels

[i.e.”mental patient”] and its structures for efficiency and objectivity is experienced at best as neutral and often as negative” (Weis-Farone & Pickens, 2007, p. 48).

Recommendations to guide health providers in ROP include influencing perceptions of individuals with SMI as “people first and are not defined by their service use or diagnosis” (Le Boutillier et al., 2011, p. 1471).

Recovery-oriented practice encourages the development of healthy and realistic self-perceptions acknowledging that one has an SMI but is not defined by it. A healthy and realistic self-concept correlates with hope and those who are hopeful are more likely to engage in problem-solving and be actively involved in managing their illness

(Buckley-Walker, Crowe, & Caputi, 2010). It is important to help people develop interests and build on talents. Recovery-oriented practice approaches include working collaboratively with consumers to set realistic goals based on their personal strengths, teaching self-affirmation, conveying a belief in one’s capabilities, and helping them to develop coping techniques (Park & Chen, 2016). Evidence indicates that providers who

30 are perceived by consumers to be caring, collaborative, competent, good listeners, reassuring, and who reinforced “normal” rather than “mentally ill” identities were more treatment engaging (Green et al., 2008). It is essential that providers see the growth potential in an individual experiencing SMI symptoms and focus on the “inherent capacity of any individual to recover, regardless of whether, at the moment he or she is overwhelmed by the disability, struggling, living with or living beyond the disability”

(Farkas, Gagne, Anthony, & Chamberlain, 2005, p. 145).

Another psychological aspect of ROP for people with SMI is enhancement of self-determination and autonomy. The role of providers is to assist individuals in making and achieving personal goals rather than telling them what to do. In fact, the ROP posits that their unique personal traits, experiences, and circumstances should be the platform for treatment. People with SMI cite various reasons for dropping out of treatment including the perception of lack of empathy from providers, not feeling validated, not being allowed to participate in decision–making, and dissatisfaction with services

(O’Brien, Fahmy, & Singh, 2008).

Most recipients of mental health services prefer to be offered options and asked about their opinions regarding treatment (Park et al., 2014). Although a consumer’s decision-making capacity must be considered, ROP emphasizes the importance of caregiver and patient both sharing information that results in agreed decisions for treatment (Dixon, Holoshitz, & Nossel, 2016). The most significant contributions nurses make to ROP processes are interpersonal engagement, compassionate listening, discussion of options, provision of choices, discussion of future plans and goals, and offering encouragement (Cleary, Horsfall, O’Hara-Aarons, & Hunt, 2013).

31 Social

Social isolation for people with SMI results from disease-related factors and societal influences. Residual symptoms of a mental illness, and possible side effects of medications, may make social interactions challenging and additional support may be needed to assist them in integrating into the community (Gerson, & Rose, 2012).

Stigmatization must be addressed on a social policy level as well as individually for those experiencing it since it perpetuates social exclusion and limits opportunities for social integration (Gaebel, Rössler, & Sartorius, 2017). Higher levels of external and internal stigma correlate with low levels of social support (Chronister, Chou, & Liao, 2013).

Internalized stigma (also called self-stigma) is one’s adoption of societal stigmatizing opinions into one’s own thoughts and occurs in 41.7% of people with SMI (Gerlinger,

2013). The effects of both external and internal stigmatization are deceased service utilization and delayed treatment (Rüsch et al., 2009; Clement et al., 2015; Corrigan,

Druss, & Perlick, 2014) and lower self-esteem and hopelessness (Corrigan, Rafacz, &

Rüsch, 2011). Cechnicki, Angermeyer, and Bielariska, (2011) found that for some people with SMI, the deleterious effects of stigmatization were more devastating than the mental illness itself.

Community involvement and integration is an essential component of recovery for people with SMI (Bromley et al., 2013). Community integration “entails helping consumers to move out of patient roles” (Bond, Salyers, & Rollins, 2004, p. 570).

Treatments that provide evidence-based social skills training, supported employment, and social/ leisure opportunities can help people overcome discomfort, isolation, stigma, and lack of daily structure. People with SMI who are engaged in their communities find them

32 to be sources of help, a way to manage risk, address stigma, give back, provide meaning in life, and improve quality of life (Bromley et al., 2013; Burns-Lynch, Brusilovskiy, &

Salzer, 2016; Kaplan, Salzer, & Brusilovskiy, 2012).

In its holistic approach, ROP views the recipient of care as people with SMI as well as their families. Knowing that the social environment influences recovery, family roles and interactions must be assessed, and if needed, interventions integrated into treatment. Families are significant influencers on those with SMI as recovery is not a solitary process. Family relationships may provide support and stability or may be a source of tension and alienation (Cohen et al., 2013; Schön, Denhov, & Topor, 2009).

Addressing the expectations of family members and facilitating communication between family members is paramount since being able to fulfill family roles is a sign of successful recovery (Reupert, Mabery, Cox, & Stokes, 2015). Holistic nurses can recognize the uniqueness of each person’s situation and recovery needs to better facilitate recovery when the family is recognized as a vital and integral component to recovery.

Spiritual

Helping an individual with SMI to find hope and meaning in their situations is a core component of ROP (Gordon, Ellis, Siegert, & Walkey, 2013). Based on religious and spiritual assessments, treatments can be formulated that are client-centered, individualized, and culturally appropriate. Discussions of spiritual/existential topics are seen as recovery-promoting and integral to holistic care (Andvig & Biong, 2014; Gordon et al., 2013; Koslander, da Silva, & Roxberg, 2009), and spiritual/ religious activities are often valued as ways to cope and decrease the effects of mental illness in one’s life

(Starnino, 2014; Russinova & Cash, 2007). Studies consistently show that there is a

33 significant prevalence of religiosity and spirituality in people with SMI (Russinova &

Cash, 2007; Brandt, Mohr, Gillieron, & Huguelet, 2012) and that they would like religious/spiritual issues to be included in their treatment process (Mohr & Huguelet,

2014). Spiritual themes such hope, peace, forgiveness, purpose, serenity, strength, and acceptance are often embedded into the recovery process. Faith can provide a source of strength for maintaining control in an individual’s life, developing a sense of empowerment, and adhering to the recovery process.

Although spirituality can promote connectedness with self, nature, or a higher power, spirituality can also be recovery-promoting when people are supported by a spiritual/ religious community. For instance, people with schizophrenia, who had low rehospitalization rates, were found to have active religious lives that provided a strengthening of internal values and a context for affirming social interactions (Sells,

Stayner, & Davidson, 2004). Healthcare professionals can encourage faith community attendance and participation in religious activities and behaviors such as prayer, reading sacred writings, attending services, participating in traditions, and engaging in spiritual support groups that a consumer finds helpful (Cabassa, Nicasio, & Whitely, 2013;

Yamada et al., 2014). Recovery-oriented practice providers can facilitate faith-based community support and collaborate with spiritual leaders as appropriate for each person’s wishes, beliefs, and level of functioning (Starnino, 2014) as long as the spiritual/ religious community does not perpetuate stigmatization and exclusion (Virdee et al., 2016).

Unfortunately, spiritual care is overlooked in mental health care (Chidarikire, 2012), but strengthening healthy spirituality and incorporating meaningful spiritual activities to

34 promote recovery is an integral aspect of holistic and culturally competent care (Whitley,

2012).

Environmental

An individual’s surroundings have significant influences on their mental state.

Recovery-oriented practices reinforce the need for stable housing and employment based on patient needs and availability. Compared to those without mental illness, people with

SMI are more likely to be living in poverty (Luciano, Nicholson, & Meara, 2014). Even those receiving governmental assistance find it difficult to meet basic needs (National

Council on Disability, 2012). The homeless population consists of a higher percentage of individuals with SMI than found in the general population (Viron, Bello, Freudenreich,

& Shtasel, 2013). An estimated one fourth of the homeless population in the US has a

SMI (National Coalition for the Homeless, 2009). Although disability caused by mental illness may make it difficult to hold down a job for some people, many want to work and are able to manage various degrees of employment especially in supportive and accommodating workplaces (McDowell & Fossey, 2015).

Recovery-oriented practice components of engaging in meaningful activities and becoming empowered can be actualized through appropriate housing and employment resources. In recent years, the ROP movement has endorsed a Housing First approach (as opposed to Treatment First) claiming that SMI cannot be managed unless adequate housing is obtained. Padgett, Stanhope, Henwood, and Stefancic (2011) found that people with SMI are able to maintain stable lives in the community after experiencing homelessness. The availability of housing is crucial to being able to benefit from treatment and minimize risk for relapse of mental illness and other medical conditions,

35 and types of structured programs should be adapted to each individual’s needs

(Tiderington, 2017). People with SMI who are employed to some degree have increased self-esteem, ability to manage symptoms, and social outlets compared to those who are non-working (Provencher, Gregg, Crawford, & Mueser, 2002). Although stressful employment may exacerbate symptoms in psychiatrically vulnerable people, the benefits of work, such as finding meaning and a sense of self-pride, and increased financial resources are recovery-promoting (Dunn, Wewiorski, & Rogers, 2008). In fact, most people with SMI want to work and identify employment as a treatment goal, but some require assistance with individual placement and support (Bond & Drake, 2014; Drake,

Bond, Goldman, Hogan, & Karakus, 2016).

Conclusion

The recovery-oriented practice approach to treatment is a holistic approach that offers a spectrum of options to meet the medical, psychiatric, social, psychological, occupational, spiritual, and emotional needs of those with SMI. Individuals, families, and communities are supported and guided to develop a plan of recovery centered on wellness, strengths, hope, and empowerment. As the largest work force in health care, nurses are interfacing with individuals, groups, and communities with SMI across the treatment continuum. Holism is a cornerstone of nursing and is congruent with ROP’s focus on promoting hope and autonomy through holistic and culturally sensitive care and by enabling inter-professional collaboration. Nurses value the promotion of hope, social inclusion, and self-management of physical and mental processes and view their roles as attending to physical, emotional, spiritual, and social needs of their patients and promoting a healthy milieu (Brimblecombe, Tingle, Tunmore, & Murrells, 2007; Gray &

36 Brown, 2017). Because nurses are knowledgeable in physical, mental, spiritual, and social issues, they can play key roles in infusing ROP principles into all areas of healthcare, thus fulfilling the mandate to transform mental healthcare to be driven by consumer and family needs that focuses on promoting resilience and facilitating recovery (U.S. Department of Health and Human Services, 2005).

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47 Chapter 4

Spiritual Perspectives, Spiritual Care, and Recovery-oriented Practice in

Psychiatric Mental Health Nurses

Abstract

Problem: Spiritual well-being is associated with quality of life in people with mental illness, but little is known about psychiatric mental health (PMH) nurses’ provision of spiritual care. Evidence supports the value of promoting spiritual well-being in mental health recovery process and nursing governance bodies and national mental healthcare regulators support spiritual care as a mental health-promoting approach. The question, however, is: Are PMH nurses providing it?

Purpose: To explore spiritual perspectives, frequency of spiritual care, and to determine if certain variables explain PMH nurse-provided spiritual care.

Research Questions: This study measured spiritual perspectives and frequency of spiritual care among PMH nurses and the relationships between these variables. It also explored how spiritual care is explained by nurse characteristics, spiritual perspectives, and knowledge of recovery-oriented practice.

Design/ Methodology: Watson’s Caring Theory and the Mental Health Recovery-

Oriented Model of Care guided this cross-sectional descriptive correlational study. A convenience sample of PMH nurses across the United States was recruited to complete questionnaires about personal characteristics, spiritual perspectives, spiritual care, and knowledge of ROP.

Results: On average, the 171 PMH nurses in this sample had high spiritual perspectives and low to moderate frequency of provision of spiritual care. Nurses who viewed

48 themselves as ‘spiritual and religious’ provided more spiritual care and had higher levels of spiritual perspectives than those who viewed themselves as ‘spiritual but not religious’. Significant contributors to spiritual care were spiritual perspectives, years of experience as a PMH nurse, and providing care to those receiving substance use treatment.

Keywords: nursing, psychiatric nursing, mental health nursing, spirituality, spiritual perspectives, spiritual care, recovery-oriented practice

49 Spiritual Perspectives, Spiritual Care, and Recovery-oriented Practice in Psychiatric

Mental Health Nurse

Over the past several decades, a holistic approach to nursing has become increasingly expected. Current nursing scholars support spirituality as a core component of holistic and culturally-competent care as well as an aspect of quality nursing care

(Biro, 2012; Wilson, 2012). The American Nurses Association (ANA) considers optimal nursing care to include enabling patients to live with as much religious or spiritual well- being as possible (ANA, 2015). The Joint Commission (TJC) standards and the

International Council of Nurses (ICN) Code of Ethic state that culturally sensitive and holistic nursing care should consider and respect patients’ spirituality and religiosity

(TJC, 2014; ICN, 2012). The ANA Code of Ethics supports the promotion of nurses’ personal health and well-being which includes “attending to spiritual or religious needs”

(ANA, 2015, p. 19). Even though positive outcomes of spiritual care include benefits to nurses as well as patients’ well-being, psychological adaptation, increased coping with illness, identification of purpose and meaning, and resiliency (Koenig, King, & Carson,

2012) spiritual care is the least understood and implemented component of nursing care

(Chan, 2010).

There has been a significant increase in nursing literature focused on spiritual care over the past three decades and multidisciplinary evidence indicates that spirituality is associated with better physical and mental health, quality of life, and resilience (Koenig,

King, & Carson, 2012; Hufford, Fritts, & Rhodes, 2010). Much research focuses on the role of spirituality in coping with medical conditions such as cancer (Thune-Boyle,

Stygall, Keshtgar, & Newman, 2006), HIV (Medved, 2016), cardiovascular disease

50 (Trevino & McConnell, 2014), those requiring palliative care (Cobb, Dowrick, & Lloyd-

Williams, 2012) and many others. A preponderance of nursing research on spiritual care focuses on palliative and oncology specialties (Cockell & McSherry, 2012; Cullen, 2016) with far less addressing spirituality in psychiatric/mental health (PMH) nursing.

Mental illness is the leading cause of disability with a worldwide cost of nearly

$2.5 trillion annually (World Health Organization, 2011). In response, the National

Institute of Mental Health (NIMH) made the research of innovative treatment approaches and personalized care a high priority (NIMH, n.d.). The integration of spiritual care in the provision of holistic nursing care is an example of an innovative way to personalize and individualize care to meet the recovery needs of those with mental illness. The concept of

‘recovery’ from mental illness is viewed as a non-linear, personal journey of experiencing a fulfilling and meaningful life in spite of having a mental illness (Davidson et al., 2007). Rather than viewing recovery as an achieved state of being symptom-free, recovery capitalizes on key concepts: hope, meaning, empowerment, self-determination, community involvement, overcoming stigma, and individualized care (Slade, 2009).

Literature supports attending to spiritual needs and promoting healthy spirituality as a way to address these recovery concepts and decrease the effects of mental illness in a person’s life (Starnino, 2014; Russinova & Blanch, 2007; Ashcroft, Anthony, &

Mancuso, 2010).

The American Psychiatric Nurses Association (APNA) supports recovery- oriented principles and their integration throughout PMH practice (APNA, 2017). At the same time, the Psychiatric-Mental Health Nursing Scope and Standards of Practice specify that health promotion should consider one’s spirituality (ANA, 2014). However,

51 no current research was found to determine the extent of spiritual care provided by PMH nurses or if spiritual care contributes to PMH nurses’ knowledge of or adherence to recovery-oriented practice (ROP) principles. Nurses’ failure to address the spiritual needs of people with mental illness may limit recovery since spirituality provides meaning, significance, guidance, community, and connection in their lives, especially during times of stress and crisis (Pargament, 1997). The purposes of this study were to explore PMH nurses’ spiritual perceptions, examine the nature of spiritual care provided by PMH nurses, and determine if spiritual perceptions, spiritual care, and nurse characteristics contribute to ROP.

Review of Literature

Spirituality and Religiosity

The increased interest in research focusing on spirituality and religiosity in nursing over the past two decades has produced a variety of inconsistent definitions

(Reinert & Koenig, 2013). The exploration of spirituality in nursing that emerged in the

1960’s primarily focused on religious practices, but postmodernism influenced a paradigm shift to view spirituality as an existential and personal experience that can occur apart from religious doctrine (Blasdell, 2015). Although some studies attempt to tweeze out the differences between spirituality and religiosity, most experts claim that the two concepts overlap and have commonalities (McSherry, 2006; Moreira-Almeida &

Koenig, 2006; King & Koenig, 2009; Zinnbauer et al., 1997; Taylor, 2002). Baldacchino et al. (2013) contended that spiritually-based coping strategies include religious and non- religious activities and beliefs. Moberg (2008) claimed that spirituality and religiosity are

“so interrelated that they can also be studied together as religion/spirituality” (p. 102). In

52 a review of spiritual assessment tools, Sessanna, Finnell, Underhill, Chang, and Peng

(2011) found that the concept of spirituality was frequently used interchangeably with religion and much research about spirituality provides definitions that include religious concepts (Reinert & Koenig, 2013). Therefore, this research is based on a conceptualization of spiritualty that does not exclude religiosity from spirituality and may include aspects of religiosity as proposed by Koenig, McCullough, and Larson (2001) as a “personal quest for understanding answers to ultimate questions about life, about meaning, and about relationship to the sacred or transcendent, which may (or may not) lead to or arise from the development of religious rituals and the formation of community” (p. 18). This definition is congruent with Watson’s Caring Theory and the instruments used in this study that ask about possible non-religious and religious activities that are expressions of one’s spirituality.

Spiritual Care and Spiritual Perspectives

Although spiritual care is well-accepted as a fundamental component of nursing care, its definition remains elusive and healthcare providers are uncertain and have differing opinions as to what constitutes spiritual care (McSherry & Jamieson, 2011). In general, spiritual care is the provision of nursing interventions with the intent of attending to the human spirit that support and promote a patient’s spiritual health (Baldacchino &

Formosa, 2010; Pesut, 2009). More specifically, spiritual care is a nurse’s ability to facilitate meaning, hope, purpose, fulfillment, transcendence, presence, belief systems, religious coping or adaptation and healing (Taylor, 2002). Ramezani et al. (2014) conducted a concept analysis of spiritual care and identified the defining attributes as being intuitive, patient-centered, meaning-centered, focused on exploring the spiritual

53 perspective, creating a spiritually nurturing environment, and a healing presence.

Teaching spiritual care often includes teaching students to define, identify, and assess patients’ spiritual questions and distress; helping students therapeutically engage in spiritual discussions; increasing students’ awareness of institutional spiritual resources and need for referral (Vlasblom, Steen, Knol, & Jochemsen, 2011; Taylor, 2007).

However, Timmins, Neill, Murphy, Begley and Sheaf (2015) found that some nursing education textbooks do not define spiritual care nor do they endorse or explain how to provide spiritual care, and Pesut (2009) identified a lack of emphasis on student self- awareness of spirituality and its relationship to spiritual care.

Nursing literature from the 1990’s and 2000’s provides foundational insights to the understanding of spiritual care and factors influencing the provision of that care.

Dennis (1991) identified listening and spending time with patients as core components to spiritual care as did Emblen and Halstead (1993) who additionally identified praying with the patient, reading spiritual passages, and making a referral to a chaplain. Grant (2004) contended that spiritual care resulted in patients experiencing inner peace, feeling a sense of meaning in their illness, and enhanced coping. Nurses felt personally rewarded and emotionally connected to patients (Van Dover & Bacon, 2001; Sellers & Haag, 1998).

Characteristics of spiritually competent nurses were identified as having an awareness of self, able to handle one’s beliefs, being self-reflective, and respecting boundaries in the nurse-patient relationship (Van Leeuwen & Cusveller, 2004; Lauterbach & Becker,

1996). Thus, nurses’ provision of spiritual care was found to be influenced by their personal values and beliefs (Baldacchino, 2006; Carroll, 2001), personal level of

54 spirituality (Taylor, Highfield, & Amenta, 1999; Ross, 1995; Belcher & Griffiths, 2005), and personal life experiences (Harrington, 1995).

More recent studies have identified several positive influences that patients experience from having their spiritual needs addressed including enhanced coping, improved quality of life, and increased satisfaction with care (Lind, Sendelbach, & Steen,

2011). Likewise, potential benefits that nurses receive from providing spiritual care include increased job satisfaction, closeness of relationships, and professional commitment (Chiang, Lee, Chu, Han, & Hsiao, 2016; Alotaibi, Paliadelis, & Valenzuela,

2016; Baldacchino & Formosa, 2010; Deal & Grassley, 2012). Although nurses feel that spiritual care is a fundamental component of quality nursing care (McSherry & Jamieson,

2013), nurses continue to describe barriers to providing spiritual care such as limited time, insufficient management support, increased workload, feelings of inadequacy, lack of clear guidelines of the nurse’s role, and lack of preparation and competence (Elliott,

2011; Cockell & McSherry, 2012; Wong & Yau 2010; Tiew & Creedy, 2012; Deal &

Grassley, 2012; Pesut, 2016; Rushton, 2014; Cook, Breckon, Jay, Renwick, & Walker,

2012). No research has focused on nurses’ spirituality, extent of spiritual care, attitudes, or barriers of spiritual care specifically by PMH nurses.

Because spiritual care is considered a core component of nursing practice, it is important to understand how spirituality is perceived and addressed by nurses (Mohr,

2006). Several studies explore nurses’ and nursing students’ spiritual perspectives in specific locations and specialties (Cruz, Alshammari, Alotaibi, & Colet, 2017; Steenfeldt,

2016; Musa, 2016; Chew, Tiew, & Creedy, 2016; Dunn, Handley, & Dunkin, 2009) indicating that the most universally demonstrated correlational factor of a nurse’s

55 provision of spiritual care is the understanding and significance of spirituality in the nurse’s own life. Personal spiritual awareness (Ozbasaran, Ergul, Temel, Asian, &

Coban, 2011; Ronaldson, Hayes, Aggar, Green, & Carey, 2012; Chiang et al., 2016) and degree of personal spirituality (Labrague, McEnroe-Petitte, Achaso, Cachero, &

Muhammad, 2015) are strongly related to the provision of spiritual care. Chan (2010) found that nurses who had religious/ spiritual beliefs and had higher perceptions of spiritual care were more likely to provide spiritual care. Ronaldson et al. (2012) found a statistically significant correlation between spiritual perspectives and spiritual care (r

= .37, p = .02) for palliative care nurses (n = 43) but not for acute care nurses (n = 50).

However, in another study of acute care nurses (n = 767), Chew et al. (2016) found significantly significant main effects between providing spiritual care and personal level of spirituality (p < .001). The association between spiritual perspectives and spiritual care has not been explored in PMH nurses.

Other than spiritual perspectives, researchers have identified nurse characteristics that positively correlate with the provision of spiritual care. Ronaldson et al. (2012) found that the only demographic characteristic that significantly related to providing spiritual care in palliative care nurses was years of experience (p < .05) and nurses in the

Netherlands provided more spiritual care if they were older, had more experience, and worked in settings other than a hospital (Van Leeuwen & Schep-Akkerman, 2015). A study of nurses in Turkey found that pediatric and psychiatric nurses reported higher sensitivity to spiritual care than other specializations (Ozbasaran et al., 2011). The strongest predictor of whether oncology physicians and nurses provided spiritual care was if they had received specific training in spiritual care (Balboni et al., 2013). No

56 research was found to indicate that nurses following any particular religion were more likely to provide spiritual care although nurses indicating they were atheistic, agnostic or had “no faith” scored lower than religious nurses on scales measuring spiritual care and spiritual care competencies (Van Leeuwen & Schep-Akkerman, 2015).

Two studies researched spiritual perspectives in PMH samples. An early study by

Pullen, Tuck, and Mix (1996) assumed that to provide spiritual care, PMH nurses must have a spiritual perspective. They used the Spiritual Perspectives Scale (SPS) to study spiritual perspectives in 84 PMH nurses who were primarily female, Caucasian, and

Protestant. A mean score of 5.212 was higher than SPS scores of other nursing specialties and the authors considered explanations such as “nurses self-selection for mental health as a specialty” and “the intimate daily contact with clients” (p. 95). Male psychiatric nurses in Sweden reported higher self-rated spiritual competence than females. Years of nursing experience explained 26% of the variance in spiritual care. However, males comprised only 21% of the sample and spiritual care competence was assessed by only two items on a questionnaire (Ewalds-Kvist, Algotsson, Bergström, & Lützen, 2012).

Recovery-Oriented Practice

The recovery-oriented practice (ROP) approach to mental health treatment has been touted by treatment providers as the most widely accepted guiding paradigm to mental health services (Waldemar, Arnfred, Petersen, & Korsbek, 2016). Recovery- oriented practice conceptualizes recovery as “a process of change through which individuals improve their health and wellness, live self-directed lives, and strive to reach their full potential” (Substance Abuse and Mental Health Services Administration

[SAMHA], 2012). Rather than focusing solely on eliminating mental illness symptoms

57 with medication, mental health treatment began to focus on the client’s total functioning within the community and requires active client participation in treatment planning to ensure that their psychological, medical, social and spiritual needs are met. The foundational principles require mental health providers to support consumers (term used instead of patients in recovery-oriented practice) in developing meaningful and fulfilling lives by promoting hope, purpose, autonomy, community and social engagement, and attainment of personal goals (Slade & Longden, 2015).

Some studies looked at how consumers evaluated the effectiveness of providers in implementing recovery-oriented principles and found inconsistencies between the espoused principles and the practice of providing recovery-oriented care (Piat & Lal,

2012; Hungerford & Fox, 2013; Chen, Krupa, Lysaght, McCay, & Piat, 2013). Stuber,

Rocha, Christian and Johnson (2014) identified personal characteristics of outpatient mental health professionals that contributed to the provision of ROP competencies among various mental health clinicians. With a sample of 813 mental healthcare providers that included psychiatric nurses (6%), researchers found several variables that were associated with higher recovery-oriented competencies among these care providers: having a 4-year degree, increased years of experience, and increased job satisfaction. The strongest predictors were being an employment specialist (p = .01), receiving 2-3 days of in-depth training on recovery-oriented practice (p = .007), working on care management teams (p

= .004), and total years of experience (p = .003). Results specific to nurses were not reported. Many researchers highlight the need for further research in identifying personal characteristics of providers who provide ROP and factors that promote providers’ abilities to actualize ROP principles. A systematic review of research exploring how ROP

58 principals were integrated into inpatient psychiatric settings found that definitions of recovery were vague and ROP principles were more rhetorical than practical. However, most practitioners viewed their promotion of hope through collaborative treatment planning with consumers as their primary means of providing ROP (Waldemar et al.,

2016).

To better understand how nurses view their role in providing recovery-oriented care, Cleary, Horsfall, O’Hara-Aarons, and Hunt (2013) identified compassionate listening, discussing treatment options and future plans, giving encouragement, and promoting optimism and hope as the most significant nursing interventions in fostering recovery in patients. Consumers with experiences of hospitalizations on acute psychiatric units identified nurses as being ‘recovery-oriented’ if they demonstrated empathy, respect, attentiveness, and hopeful attitudes (Gunasekara, Pentland, Rodgers, &

Patterson, 2014). Even though research indicates that PMH nurses are knowledgeable about the recovery-oriented model of care, they may still lack confidence in providing

ROP-based interventions (McLoughlin & Fitzpatrick, 2008; Gale & Marshall-Lucette,

2012).

Spiritual Care in Recovery-Oriented Practice

Concepts of hope, meaning, purpose, community involvement, and self-concept/ autonomy are held as core components of recovery-oriented practice. Importantly, these concepts also represent core outcomes of spiritual care. Therefore, spirituality has been identified as a core dimension of recovery (SAMHSA, 2011) and a foundational component of ROP (Gordon, Ellis, Siegert, & Walkey, 2014). Although recovery experts claim that spiritual care is congruent with person-centered care, spirituality as a source of

59 healing and recovery has not been consistently integrated into treatment, thus potentially minimizing the effectiveness of ROP (Ruddick, 2010). To answer the question “What is the work of ROP?”, Chester et al. (2016) conducted a literature review of 21 qualitative research articles. They found two prominent themes: alleviating stigma and responding to complex health needs. Supporting consumer spirituality and providing spiritual care were not identified in any study. Mental health providers may not initiate discussion of religion and spirituality despite spirituality being theoretically relevant to the ROP approach

(Bass, Tickle, & Lewis, 2014). Even though PMH nurse–patient discussions of spiritual/existential topics were seen as recovery-promoting (Andvig & Biong, 2014;

Gordon & Ellis, 2013), spiritual needs are rarely addressed in nursing plans of care

(Kevern, Walsh, McSherry, 2013; Chidarikire, 2012) and spiritual care has not been identified as a competency skill of providing ROP (Cusack, Killoury, & Nugent, 2017).

Although many researchers have examined spirituality in mental health treatment, their findings indicate several gaps in research focused on spiritual care, ROP, and mental health nurses. Little is known about barriers PMH nurses experience in providing spiritual care. No current research has examined the relationship between spiritual perspectives and spiritual care in PMH nurses or if spiritual perspectives and provision of spiritual care relates to PMH nurses’ knowledge of ROP.

Theoretical Framework

Jean Watson’s Theory of Caring and the Recovery-oriented Practice Model of

Care served as the foundational underpinnings of this study. Watson’s Theory of Caring views the role of a nurse to assist with patients’ gratification of biophysical, psychophysical, and psychosocial needs and the promotion of optimal health within a

60 helping-trust relationship characterized by warmth, empathy and dignity. Authentic care can be provided when nurses are aware of their own attitudes, health, perspectives, and emotions. Watson’s theory is one of the few nursing frameworks that considers spiritual concepts, but is the only one that specifically identifies an overall goal of nursing to intentionally engage the spiritual dimension in transpersonal caring. The caring model posits that caring for the “unity of mind-body-spirit” (Watson, 1985, p. 129) potentiates healing and wholeness and therefore, the spiritual dimension of nursing care is important since it keeps nursing from becoming dehumanized and cold (Watson, 2012). Watson’s definition of nursing includes spiritual concepts: “transpersonal attempts to protect, enhance, and preserve humanity and human dignity; integrity and wholeness, by helping a person find meaning in illness, suffering, pain, and existence and to help another gain self-knowledge, self-control, self-caring, and self-healing wherein a sense of inner harmony is restored regardless of the external circumstances” (Watson, 2012, p. 65). The provision of holistic nursing care also requires the nurse to attend to one’s own spiritual needs as well as others.

Recovery-oriented practice experts emphasize the nonlinearity of the recovery process and describe recovery processes as fostering meaning and purpose, assisting in the development of an identity of dignity apart from stigma, promoting autonomy and self-determination, and assisting in the management of symptoms. Many ROP practitioners believe that addressing someone’s spiritual needs can promote recovery

(Gordon et al., 2013; Andvig & Biong, 2014). There is a high degree of congruence between Watson’s Caring Model and the ROP Model. Watson’s explanation of transpersonal caring is that it promotes mental-spiritual growth and encompasses “finding

61 meaning in one’s own existence and experiences, discovering inner power and control, and potentiating instances of transcendence” (Watson, 1985, p. 74) that occurs as a nurse maintains a patients’ dignity and belief in positive change. Both approaches view treatment as an interpersonal process. Central to both approaches, the provider views the recipient as who they may become, not solely as they currently are. Treatment is not standardized, but adapted to be congruent with individualistic beliefs, attitudes, and circumstances. Only when holistic recovery needs are met will a patient achieve what

Watson terms “human need satisfaction” (Watson, 2008) and mental healthcare terms

“recovery”.

Based on the literature and principles of Watson’s Caring Model and the

Recovery-oriented Practice Model, the conceptual model guiding this research proposed that the spiritual perspectives and personal characteristics of a PMH nurse influence the spiritual care provided to a patient. Because ROP is holistic and patient-centered and, therefore, addresses spirituality, the study model proposed that personal characteristics, spiritual perspectives, and provision of spiritual care are related to a nurse’s knowledge of recovery-oriented care. The provision of spiritual care and ROP occurs in what Watson calls “transpersonal relationships” and ROP theorists describe as interpersonal therapeutic alliances (see Figure 2).

Conceptual and Operational Definitions

Table 2 presents the major study variables and their definitions.

62 Research Questions

The aims of this study were to measure spiritual perspectives and the frequency of spiritual care, and to determine if spiritual perspectives and knowledge of the recovery- oriented process (ROP) contribute to spiritual care in PMH nurses.

Psychiatric Mental Health Nurse

Personal

Characteristics

Knowledge

of ROP Spiritual Care

RQ#5 RQ#4 Spiritual Perspectives RQ #2

RQ #1

Figure 2. Study conceptual model.

The research questions were:

1. What is the nature of spiritual perspectives of PMH nurses as measured by the

Spiritual Perspectives Scale?

2. What is the frequency of spiritual care provided by PMH nurses as measured

by the Nurses Spiritual Care Therapeutics Scale?

3. What is the relationship between PMH nurses’ spiritual perspectives and the

frequency and types of spiritual care they provide for psychiatric patients?

63 4. To what extent is the knowledge of ROP of PMH nurses explained by their

spiritual perspectives and personal characteristics such as gender, age, self-

perception of spirituality/ religiosity, religious affiliation, years of PMH

nursing practice, education and employment?

5. To what extent is the frequency of spiritual care provided by PMH nurses

explained by spiritual perspectives, knowledge of ROP, and personal

characteristics such as gender, age, self-perception of spirituality/ religiosity,

religious affiliation, years of PMH nursing practice, education and

employment?

The primary hypothesis was built on the research questions and proposed that spiritual care provided by PMH nurses can be explained by their spiritual perspectives, personal characteristics, and knowledge of ROP.

64 Table 2

Conceptual and Operational Definitions

Variable Conceptual definition Operational definition Spiritual Nursing Nursing care consisting of Nurse Spiritual Care Therapeutics Scale (NSCTS) Care identifying and addressing spiritual consisting of 17 Likert-type 5-point items where needs to sustain another person by participants are asked to identify how often they facilitating meaning, hope, purpose, have provided specific spiritual therapeutics fulfillment, transcendence, presence, during the past 72 or 80 hours engaged in nursing belief systems, religious coping, practice (Mamier & Taylor, 2014). Total scores and/or adaptation and healing range from 0 to 68 with higher scores indicating (Taylor, 2002). more spiritual care rendered. Spiritual An individual’s personal Spiritual Perspectives Scale (SPS): containing 10 Perspectives understanding and attitudes Likert-style items on a response scale ranging regarding their personal spiritual from 1 to 6. Six items measure spiritual beliefs and beliefs, the extent to which those four items measure spiritual behaviors. (Reed, beliefs are held, and the degree to 1987). Total scores range from 10 to 60 with which the individual engages in higher scores indicating stronger spiritual beliefs spiritually-related interactions (Reed, and practices. 1987). Knowledge of The level of knowledge regarding Recovery Knowledge Inventory (RKI) containing Recovery-Oriented the principles and components of 20 Likert-style items with a response scale ranging Practice ROP, an approach to mental from 1 to 5 (Bedregal, O’Connell, & Davidson, healthcare that implements strategies 2006). Fifteen items must be reverse-scored. to promote “a process of change Higher scores indicating more knowledge about through which individuals improve Recovery-oriented Practice. their health and wellness, live self- directed lives, and strive to reach their full potential” (SAMHSA, 2012). Personal Demographic, education, and As reported on demographic data sheet: responses Characteristics employment, spirituality/religiosity, indicating age in years, length of practice in years, information relating to each gender, race/ ethnicity, marital status, religious participant. affiliation, spirituality/religiosity, type of nursing degree, employment setting, populations served, APNA memberships, ROP training.

Design

A descriptive correlational cross-sectional research design was employed to examine relationships between and among PMH nurses’ personal characteristics, spiritual perspectives, provision of spiritual care, and their knowledge of the recovery-oriented care process. Survey data were collected from PMH nurses using a demographic questionnaire and instruments measuring spiritual perspectives (SPS), spiritual care

65 (NSCTS), and recovery-oriented practice knowledge (RKI). Surveys were available in electronic and paper formats.

Methods

Sample

A convenience sample consisted of 171 English-speaking licensed registered nurses whose primary current practice was to address mental health needs of other people. Inclusion criteria for this study were PMH nurses who were employed or volunteered full-time or part-time and provided at least 72 hours of direct patient care in the past 3 months. Exclusion criteria included nurses who were not licensed as RNs, had not provided at least 72 hours of PMH care in the past 3 months, or were not fluent in

English. Nurse managers, administrators, and nurse educators who did not provide direct patient care were excluded given this study aimed to assess only nurses who were currently providing direct care at the time of the survey. This maintained homogeneity among participants. Nurses employed or who volunteered to deliver PMH care were recruited regardless of age (18 years or older), gender, race, years of professional practice, religious or non-religious persuasion, level of nursing education, area of PMH specialization, or type or location of employment facility.

Participants were recruited through the American Psychiatric Nurses Association

(APNA). Surveys were made available during the three-day APNA Annual Conference held at the Phoenix Convention Center in Phoenix, Arizona in the fall of 2017.

Attendance at the 2017 conference consisted of over 1600 people. Although most attendees were members of APNA, it was not a requirement to attend, but most study

66 participants were APNA members. Following the conference, the survey was posted to the APNA website discussion board Member Bridge.

A priori power analysis was performed to estimate the sample size required for this study. Using G*Power (Faul, Erdfelder, Lang, & Buchner, 2007), an analysis for each of the proposed analyses was conducted, and a minimum of 119 participants for the proposed linear multiple regression was the largest sample indicated. The following parameters were used: power of .90 (90%), alpha of .05, and medium effect size of .15 which was assumed based on lack of prior evidence in literature. A minimum of 20% additional participants were projected to be obtained to account for any incomplete or unusable surveys. Therefore, a minimum of 143 participants was the target sample size to be recruited for this study.

Protection of Human Subjects

The proposal for this study was submitted to the University of Texas at Tyler

Institutional Review Board (IRB) for approval (see appendix A). Although IRB approval from APNA was not required, the Associate Executive Director of the APNA Board was consulted via telephone and the researcher explained the proposed study. No further

APNA authorization was required. Each survey provided an explanation of the general purpose of the study, assurance of anonymity of responses, potential risks and benefits of participation, and a reminder that participants could stop answering at any time.

Participants were informed that the completion of the survey was estimated to take 7-10 minutes. The risks of completing the surveys were negligible and this was indicated on the survey introduction which included an explanation of implied consent (see Appendix

B). Electronic devices used for data collection at the APNA Conference were password

67 protected and only the researcher had access. Completed paper surveys were kept in a locked case and only the researcher had access.

Instruments

Data were obtained utilizing a demographic data form, the Spiritual Perspective

Scale, Nurses Spiritual Care Therapeutics Scale, and the Recovery Knowledge Inventory.

Permissions to use all instruments were obtained from the respective authors (see

Appendix C).

Demographic-data form. The Demographic Data Form was used to collect information to describe the sample. The first five questions determined participants’ eligibility. Once determined eligible, the participants provided information about gender, age, race, ethnicity, marital status, religious affiliation, perceived self-spirituality/ religiosity, education, employment, APNA membership, and spirituality and recovery training. A list of possible barriers to providing spiritual care was provided and participants were asked to rank the three most significant barriers they experienced or list other possible barriers that were not listed. An optional write-in response question asked participants to describe in their own words what they understand spiritual care in PMH nursing to be (see Appendix D). The Demographic-data form was created by this investigator based on current research, consultation with expert researchers, and personal experience as a PMH nurse.

Spiritual Perspective Survey (SPS). Reed (1987) viewed spirituality as an everyday human experience and designed the Spiritual Perspectives Scale (SPS) to measure an individual’s spiritual perspective, the extent they held spiritual perspectives, and the frequency they engaged in spiritually related behaviors and interactions (see

68 Appendix E). The SPS has been widely used and consists of 10 items that are rated on a

6-point Likert scale ranging from 1 to 6. Total scores range from 10 to 60 with higher scores indicating greater spiritual perspectives. Four items measure frequency of spiritually-based social interactions and six items measure views of personal spirituality.

Frequency of spiritually-based interactions such as, “How often do you share with others the problems and joys of living according to your spiritual beliefs?” are rated from 1 (Not as all) to 6 (About once a day). Views of spirituality such as, “I seek spiritual guidance in making decisions in my everyday life.” are rated from 1 (Strongly disagree) to 6

(Strongly agree).

Initially, Reed administered the SPS to convenience samples of hospitalized terminally ill adult patients (n =100), non-terminally ill hospitalized adult patients (n

=100), and non-hospitalized healthy adults (n =100) who were predominantly Caucasian

(81%) with a reported religious background (92%) and having a mean age of 60 years.

Cronbach’s alpha for each of the three groups ranged from .93 to .95 (Reed, 1987). Inter- item correlations ranged from .57 to .68. The SPS was constructed based on literature review and expert consensus. Construct validity was supported by data collected from open-ended questions and by the known-groups technique in which subjects with more spiritual participation scored higher on the SPS as would be theoretically predicted for an instrument measuring spiritual perspectives. Research using the SPS in adult samples report consistently high Cronbach’s alpha scores ranging from .86 to .94 with no redundancy in inter-item correlations (Campesino, Belyea, & Schwartz, 2009; Shores,

2010; Dunkin & Dunn, 2009; Brush & McGee, 2000; Dailey & Stewart, 2007). In addition, the SPS has demonstrated criterion-related validity and discriminate validity

69 (Reed, 1986, 1987). In a sample of African-American women, Dailey and Stewart (2007) conducted factor analysis that revealed a two-factor structure (‘spiritual behaviors’ and

‘spiritual beliefs’) accounting for 72% of the variance demonstrating that the model fit well onto the data. Additionally, the results of an exploratory factor analysis from a study on the Korean translated version (n = 230) provided preliminary evidence for construct validity. All 10 items were loaded onto one factor accounting for 81% of the variance

(Suk-Sun, Reed, Youngmi, & Jina, 2012). Cronbach’s alpha reliability for the SPS in this current study was .94.

The Nurse Spiritual Care Therapeutics Scale (NSCTS). The provision of spiritual nursing care was measured using the Nurse Spiritual Care Therapeutics Scale

(NSCTS) developed by Mamier and Taylor (2014; see Appendix F). Scale development was based on consultation from a panel of spiritual care experts and an extensive literature review. The NSCTS measures the frequency of 17 spiritual therapeutics

(interventions) provided by a registered nurse during a 72-80 hour timeframe.

Therapeutics are “ways of being or actions taken by a nurse with the intent to promote patient health-in this case, spiritual health” (Taylor, 2008, p. 155). The 17 items are rated on a 5-point Likert scale ranging from 1 (Never) to 5 (At least 12 times). Total scores range from 17 to 85 with higher scores indicating more frequent provision of spiritual care practices. Participants are asked to rate how often a specific therapeutic was provided. Content validity was based on extensive literature review and panel of experts.

Nine published spiritual care experts rated items using content validity index and items with score of .78 or greater were retained and the scale content validity index was .80 (Taylor, 2008). Based on NSCTC results from a sample of 554 nurses,

70 exploratory factor analysis supported one factor and factor loadings ranged from .407 and .836 to account for 49.5% of the variance. Item to total correlations ranged from .40 to .80 and the Cronbach’s alpha was .93. Convergent validity was supported by the correlations between the NSCTC and the Duke University Religiosity Index subscales

(DUREL; Koenig, Parkerson, & Meador, 1997) and the Daily Spiritual Experience Scale

(DSES; Underwood & Teresi, 2002). Based on open-ended questions added for the study, no additional forms of spiritual therapeutics met inclusion criteria (Mamier &

Taylor, 2014). In an analysis of scales measuring spiritual care, Garssen, Ebenau, Visser,

Uwland, and Groot (2016), reported “The scale that showed the best construct validity for the assessment of nurses’ attitudes toward and engagement in spiritual care practices in a wide population is the recently published NSTS of Mamier & Taylor” (p. 6). Both the

SPS and the NSCTS were selected for this study as opposed to other instruments because of their performance in samples of nurses, use in diverse diagnostic settings, applicability regardless of subject religion, congruent definitions of spirituality, and ease of use.

Cronbach’s alpha reliability for the NSCTS for this study was .93.

Recovery Knowledge Inventory (RKI). Based on a Connecticut state-wide initiative to advance the recovery-oriented practice of mental health care, the RKI was developed to measure providers’ knowledge and attitudes towards recovery-oriented practices (Bedregal, O’Connell, & Davidson, 2006; see Appendix G). The RKI contains

20 items that are rated on a 5-point Likert scale ranging from 1 (Strongly Disagree) to 5

(Strongly Agree) with total scores ranging from 20 to 100. Fifteen items must be reverse- scored. Higher scores indicate higher levels of knowledge about ROP. There are four subscales: roles and responsibilities, nonlinearity of the recovery process, roles of self-

71 definition and peers in recovery, and expectations about recovery. The Cronbach’s alpha scores for the four domains were 0.81, 0.70, 0.63, and 0.47 respectively indicating that the internal consistencies for the first three components were moderate to high, the fourth component was low. The authors noted the weak psychometric properties of

“expectations about recovery” domain and the need for further research but deemed it important to practice and thus it remained in the instrument. Overall reliability coefficient scores for the total scale scores have been 0.83 (Meehan & Glover, 2009), 0.79

(Marshall, Deane, Crowe, White, & Kavanagh, 2013), 0.82 (Peebles et al., 2009), and

0.79 (Salgado, Deane, Crowe, & Oades, 2010).

The Dutch version of the RKI was found to be unsuitable due to low reliability scores resulting from loss of subtleties of meaning when translated (Wilrycx, Croon, van den Broek, & Nieuwenhuizen, 2012). Hungerford, Dowling, and Doyle (2015) found the

RKI suitable with Australian samples and Gaffey, Evans, and Walsh (2016) found it suitable in a study conducted in Ireland of a predominantly nursing sample (77%, n =

176). Ofina (2016) administered the RKI to 917 community health workers. Exploratory factor analysis determined factor structure and was followed by confirmatory factor analysis. Based on eigenvalues, scree plot, factor loadings and reliability, a single factor was retained consisting of 10 items termed “Recovery Process”. The 10-item survey yielded a Cronbach’s alpha of 0.83. The 20-item version was administered in this current study and Cronbach’s alpha scores of the four subscales were .42, .64, .65, and .86.

Therefore, the psychometrically robust 10-item version was used in the data analysis as established by Ofina (2016). For this current study, the RKI-10 Cronbach’s alpha was

0.84.

72 Data Collection

After IRB approval, data were collected at the APNA Annual Conference in

Phoenix, Arizona October 18-21, 2017. A table near the poster exhibit was manned by the primary researcher and a data collection assistant. Because there was no internet accessibility in the conference center, electronic surveys were not administered using four devices (laptops/ tablets) as initially planned. However, a quick response (QR) code enabled participants to access the Qualtrics® survey on their personal smart phones or devices. Paper forms were available for those unable to access the survey on their phones or if they preferred a paper version. All surveys began with an introductory letter, brief explanation of purpose, risks and benefits, and that completion of the survey implied consent. The survey took approximately 7-10 minutes to complete. The researcher and data collection assistant provided a brief explanation of the study and participant requirements for the conference attendees who showed interest. Each participant was offered a t-shirt as an incentive gift to thank them for their time and attention after completing the survey. As paper surveys were completed, they were stored in a locked case under the constant supervision of the researcher. Twice a day, completed paper surveys were compiled and stored in a locked room. Following the conference, a link to the surveys was made available on the APNA Member Bridge which is a website for

PMH nurses to post announcements, opportunities, and discussion threads. On this site, an invitation to participate and survey link were made available to access the Qualtrics® questionnaire. The Qualtrics® system prohibited more than one completion per URL address so that a participant could not complete the survey more than once. Overall, 143

73 usable surveys were completed during the APNA conference, and 28 were completed afterwards.

Analysis

Data collected online via Qualtrics were downloaded into Statistical Package for

Social Sciences (SPSS, version 23) and data from paper surveys were manually entered into the SPSS database. Some items on the RKI were reverse coded according to author instructions. Data were screened prior to analyses and searched for missing values and outliers. No demographic or personal characteristic categories used in the analysis had more than three missing values and no participant omitted more than three answers. A preset alpha of .05 for significance and a 95% confidence interval were applied. The sample of 171 was adequate to maintain a power of .9 in all statistical tests when missing cases were deleted. Based on inspection of boxplots of all continuous variables, no outliers existed. Cronbach’s alpha was measured to determine internal consistency for all instruments. Normalcy of distribution was computed for all instrument scores, and homoscedasticity, independence, and linearity for regression variables were tested.

Although SPS and NSCTS distributions were skewed, no other violations of assumptions were revealed. Averages of scores from the SPS, NSCTS, and RKI were used in analysis and were therefore considered interval data.

All continuous variables were analyzed using descriptive statistics: means, standard deviations, frequencies, percentages, and ranges. Frequencies and percentages were calculated for all categorical variables. Paired t-tests, one-way ANOVA’s and correlations were computed to identify which variables were significantly related to spiritual perspectives and frequency of provision of spiritual care. Multiple regressions

74 with hierarchal factor loading were conducted to identify variables contributing to knowledge of ROP and frequency of spiritual care.

Results

Description of the Sample

A total of 197 participants initiated the survey, 93 electronically and 94 via paper,

26 of whose responses were excluded due to ineligibility, missing pages, or providing the same response to all Likert-scale questions. Overall, 171 eligible participants completed the survey: 86 via Qualtrics® survey and 85 via paper surveys. The sample size of 171 exceeded the previously calculated minimum estimate of 143 based on the parameters of .90 power, .05 level of significance, and .15 medium effect size (Faul et al., 2007).

The descriptive information of the sample is presented in Table 3. Most of the participants were female (n = 151, 88%), non-Hispanic White (n = 116, 67.8%) and married or in a domestic partnership (n = 107, 62.6%). Eighty-three of the participants held master’s degrees (48.5%) and 51 (29.8%) held bachelor’s degrees. The mean age of the participants was 50.25 years (n = 170, SD = 12.07) ranging from 23 to 79 years. The mean length of time in PMH nursing was 16.04 years (n = 166, SD = 12.79) ranging from

1 to 56 years. When asked about spirituality/religiosity and religious affiliation, most were Christian Protestant (n = 78, 45.6%) and viewed themselves as religious and spiritual (n = 99, 57.9%).

75 Table 3

Sample Demographic Information

Variable (n = 171) n % Variable (n = 171) n % Race/Ethnicity (n=170) Marital Status (n = 171) Non-Hispanic White 116 67.8 Single, Never Married 31 18.1 Hispanic White 11 6.4 Married/Partner 107 62.6 Black or African American 24 14 Widowed 5 2.9 Amer. Indian/Native Alaskan 1 0.6 Divorced 27 15.8 Asian 12 7 Separated 1 0.6 Native Hawaiian/Pac. Islander 1 1.2 Multiple Races 5 2.9 Highest Degree (n = 171) Diploma 2 1.2 Gender (n=171) Associate’s Degree 8 4.7 Female 151 88.8 Bachelor’s Degree 51 29.8 Male 20 11.2 Master’s Degree 83 48.5 DNP 13 7.6 Region US Employment (n = 161) PhD 7 4.1 Northeast 34 19.9 Other 7 4.1 Southeast 29 17.0 Midwest 36 21.1 Population serve (n = 171) West 36 21.1 Adults: Non-substance 115 67.3 Southwest 26 15.2 Adults: Substance Use 21 12.3 Adults: Military 9 5.3 APNA Member (n = 171) Child/Adolescent 11 6.4 Yes 161 94.2 Forensics 4 2.3 No 10 5.8 Other 11 6.4

Attend APNA’s RTP Training Employment Set. (n = 171) Yes 20 11.7 Inpatient 95 55.6 No 151 88.3 Out-patient partial 4 2.3 Out-patient clinic 47 27.5 Attend Other Recovery Training? Home Health 1 0.6 Yes 19 11.1 School 2 1.2 No 152 88.9 Other 19 11.1

76 Variable (n = 171) n % Variable (n = 171) n % Received Spiritual Training? Religion (n = 169) Yes 26 15.2 Christian, Protestant 78 46.2 No 145 84.8 Christian, Catholic 44 25.7 Buddhist 7 4.1 Spiritual/Religious (n = 171) Hindu 2 1.2 I am spiritual and religious 99 57.9 Jewish 3 1.8 I am spiritual but not religious 60 35.1 Other 11 6.4 I am religious but not spiritual 4 2.3 Religion does not play a 24 14.0 role in my life I am neither spiritual nor religious 8 4.7

Prior to running regression analysis and calculating differences between groups, age, years of PMH experience, self-perceived spirituality/religiosity, and religious affiliation were broken into categories and low-frequency categories of self-perceived spirituality/religiosity and religious affiliation were collapsed based on the interest of this study. See Table 4 for explanation of personal characteristic variable groupings.

Descriptive information was also obtained for each major variable in the study.

Research Question 1: What is the nature of spiritual perspectives of PMH nurses as measured by the Spiritual Perspectives Scale?

Higher scores on the SPS represent a more salient spiritual perspective in a person’s life (Reed, 1987). The average total score was 41.95 (SD = 10.85) with a possible range of 10 to 60. The sample’s average individual item mean score was 4.70

(SD = 1.2) indicating high saliency of spiritual perspective in the lives of PMH nurses completing this survey. The highest individual item mean score was 5.18 (SD = 1.31) in response to item five Forgiveness is an important part of my spirituality. The lowest individual item score was 4.13 (SD = 1.55) in response to item two How often do you

77 share with others the problems and joys of living according to your spiritual beliefs?

Mean frequencies and percentages of each SPS item are presented in Table 5.

Table 4

Collapsed Variables

Variable Percent Age 23–35 16.5 36–45 15.9 46–55 25.9 56–65 37.6 66–80 4.1 Years of PMH Experience 1–4 23.5 5–10 23.5 11–17 16.3 18–30 17.5 31–56 18.1 Self-Perceived Spirituality/ Religiosity I am spiritual and religious 75.9 I am spiritual but not religious 35.1 I am religious but not spiritual + I am 7.0 neither spiritual nor religious Religious Affiliation Christian, Protestant 46.2 Christian, Catholic 26.0 Buddhist + Hindu + Jewish + Other 13.6 Religion does not play a role in my life 14.2

78 Table 5

Frequencies and Percentages of SPS Mean Responses

Less than About About About once a once a once a once a About Item Not at all year year month week once a day 1. In talking with your family or friends, 11 10 14 34 55 47 how often do you mention spiritual 6.4% 5.8% 8.2% 19.9% 32.2% 27.5% matters? 2. How often do you share with others the 19 14 7 49 50 32 problems and joys of living according to 11.1% 8.2% 4.1% 28.7% 29.2% 18.7% your spiritual beliefs? 3. How often do you read spiritually 17 20 13 30 50 41 related material? 9.9% 11.7% 7.6% 17.5% 29.2% 24.0% 4. How often do you engage in private 11 4 4 18 40 94 prayer or meditation? 6.4% 2.3% 2.3% 10.5% 23.4% 55.0% Disagree Agree Strongly more than more than Strongly disagree Disagree agree disagree Agree agree 5. Forgiveness is an important part of y 10 1 3 18 42 97 spirituality 5.8% 0.6% 1.8% 10.5% 24.6% 56.7% 6. I seek spiritual guidance in making 11 11 10 33 45 61 decisions in my everyday life. 6.4% 6.4% 5.8% 19.3% 26.3% 35.7% 7. My spirituality is a significant part of 9 8 10 25 39 80 my life. 5.3% 4.7% 5.8% 14.6% 22.8% 46.8% 8. I frequently feel very close to God or 19 7 6 16 59 64 “higher power” in prayer, during worship, 11.1% 4.1% 3.5% 9.4% 34.5% 37.4% or important moments in my daily life. 9. My spiritual views have had an 9 3 9 17 52 81 influence upon my life. 5.3% 1.8% 5.3% 9.9% 30.4% 47.4% 10. My spirituality is especially important 9 8 9 22 50 73 to me because it answers any questions 5.3% 4.7% 5.3% 12.9% 29.2% 42.7% about the meaning of life.

T-tests and one-way independent ANOVAs were run to determine if statistically different total mean SPS scores existed between groups. The results were interpreted combined with those from the nonparametric Mann-Whitney U and Kruskal-Wallis tests due to the non-normal distribution in PMH nurses’ spiritual perspectives. The results showed there were no statistically significant differences in SPS scores based on gender,

79 age, years of PMH experience, employment setting, education, or populations served.

Significant differences were found between self-perceived spirituality/religiosity, F(2,29)

= 42.7, p < .001, and religious affiliation categories, F(3, 55) = 20.1, p < .001. Those who considered themselves to be ‘spiritual and religious’ had more salient spiritual perspectives (M = 5.17, SD = .89) than those who perceived themselves as ‘spiritual but not religious’ (M = 4.33, SD = 1.10). Those who identified as Protestant Christians had more salient spiritual perspectives (M = 5.12, SD = .86) than those who were Catholic

Christians (M = 4.85, SD = 1.06) or other religions (M = 4.44, SD = 1.18) or for whom religion did not play a role in their lives (M = 3.30, SD = 1.27).

Research Question 2: What is the frequency of spiritual care provided by PMH nurses as measured by the Nurses Spiritual Care Therapeutics Scale?

Higher scores on the NSCTS represent more frequent provision of spiritual care.

The average total score was 42.98 (SD = 15.28) with a possible range of 17 to 85. The sample’s average individual item mean score was 2.54 (SD = .90) indicating the average frequency of providing spiritual care being between 1-2 times and 3-6 times in the last 72 hours of nursing for the PMH nurses completing this survey. The highest individual item mean score was 3.3 (SD = 1.40) in response to item seventeen After completing a task, remained present just to show caring. The lowest individual item score was 1.7 (SD =

1.08) in response to item fifteen Offered to read a spiritually nurturing passage (e.g., patient’s holy scriptures). Mean frequencies and percentages of each NSCTS item are presented in Table 6.

80 Table 6

Frequencies and Percentages of NSCTS Mean Responses

Never 1–2 3–6 At least 12 Item (n = 171) (0 times) times times 7–11 times times 1. Asked a patient about how you could 40 61 38 14 18 support his or her spiritual or religious 23.4% 35.7% 22.2% 8.2% 10.5% practices. 2. Helped a patient to have quiet time or space 38 60 42 14 17 for spiritual reflection or practices. 22.2% 35.1% 24.6% 8.2% 9.9% 3. Listened actively to spiritual themes in a 18 44 47 28 34 patient’s story of illness. 10.5% 25.7% 27.5% 16.4% 19.9% 4. Assessed a patient’s spiritual or religious 23 44 45 21 38 beliefs or practices that are pertinent to health. 13.5% 25.7% 26.3% 12.3% 22.2% 5. Listened to a patient talk about spiritual 15 50 51 24 30 concerns. 8.8% 29.2% 29.8% 14.0% 17.5% 6. Encourages a patient to talk about his or her 15 57 37 14 18 spiritual coping. 8.8% 33.3% 21.6% 8.2% 10.5% 7. Encouraged a patient to talk about how 44 57 37 14 18 illness affects relating to God (or transcendent 25.7% 33.3% 21.6% 8.2% 10.5% reality). 8. Documented spiritual care you provided in a 29 55 43 16 28 patient chart. 10.0% 32.2% 25.1% 9.4% 16.4% 9. Discussed a patient’s spiritual care needs 44 63 35 15 14 with colleague/s. 25.7% 36.8% 20.5% 8.8% 8.2% 10. Arranged for a chaplain to visit a patient. 63 42 36 11 18 36.8% 24.6% 21.1% 6.4% 10.5% 11. Arranged for a patient’s clergy or spiritual 65 46 29 14 15 mentor to visit. 38.0% 26.9% 17.0% 8.2% 8.8% 12. Encouraged a patient to talk about what 23 43 46 27 32 gives his or her life meaning amidst illness. 13.5% 25.1% 26.9% 15.8% 18.7% 13. Encouraged a patient to talk about the 50 42 35 27 17 spiritual challenges of living with illness. 29.2% 24.6% 20.5% 15.8% 9.9% 14. Offered to pray with a patient. 102 37 17 8 7 59.6% 21.6% 9.9% 4.7% 4.1% 15. Offered to read a spiritually nurturing 107 29 22 6 7 passage. 62.6% 17.0% 12.9% 3.5% 4.1% 16. Told a patient about spiritual resources. 41 48 42 17 23 24.0% 28.1% 24.6% 9.9% 13.5% 17. After completing a task, remained present 22 31 42 25 51 just to show caring. 12.9% 18.1% 24.6% 14.6% 29.8%

T-tests and one-way independent ANOVAs were run to determine if statistically different mean NSCTS scores existed between groups. The results were interpreted combined with those from the nonparametric Mann-Whitney U and Kruskal-Wallis tests due to the non-normal distribution in PMH nurses’ frequency of provision of spiritual care. The results showed there were no statistically significant differences in NSCTS scores based on gender, age, years of PMH experience, employment setting, education, populations served, or religious affiliation. Significant differences were found between self-perceived spirituality/religiosity, F(2, 36) = 3.81, p < .005. Those who considered themselves to be ‘spiritual and religious’ provided more frequent spiritual care (M = 2.68,

SD = .93) than those who perceived themselves as ‘spiritual but not religious’ (M = 2.39,

SD = .85).

Research Question 3: What is the relationship between PMH nurses’ spiritual perspectives and the frequency of spiritual care they provide for psychiatric patients?

The relationship between SPS and NSCTS variables was assessed with Pearson’s correlations and the non-parametric Spearman’s rho coefficient due to the violation of the normality assumption of both scales. Both the parametric and non-parametric tests produced a statistically significant, but weak, correlation between spiritual perspectives and spiritual care practices (r = .26, p = .001, two-tailed; rs = .28, p < .001). This indicates that more salient spiritual perspectives of PMH nurses were weakly associated with more frequent provision of spiritual care. Similarly, low spiritual persepctive saliency of PMH nurses was weakly associated with infrequent spiritual care. Exploring

82 correlations between items of the SPS and NSCTS revealed the highest correlation between the SPS item In talking with your family or friends, how often do you mention spiritual matters? and the NSCTS item Offered to pray with a patient (r = .34, p < .001).

No items had statistically significant negative correlations.

Research Question 4: To what extent is the knowledge of ROP of PMH nurses explained by their spiritual perspectives and personal characteristics such as gender/religiosity, religious affiliation, years of PMH nursing practice, education and employment?

The average individual item mean of the RKI-10 was 3.36 (range 1-5, SD= .82) indicating a moderate level of knowledge about recovery-oriented practice. A hierarchical multiple linear regression was conducted to identify if nurse characteristics and spiritual perspectives explain the variance in their knowledge of recovery. The first block of predictors included the personal characteristics as measured by participants’ gender, age, self-perception of spirituality/religiosity, religious affiliation, years of PMH nursing practice, education, employment setting and population. In the second block, the spiritual perspectives variable was added to identify the effect of the addition of this variable on the model prediction. The first block of demographic-only model was not significant, F(15, 145) = 1.12, p = .270, R2 = .11, Adj R2 = .02. By adding spiritual perspectives into the second block, the model was not significant, F(16, 144) = 1.38, p

= .162, R2 = .13, Adj R2 = .04. An R² change of .021 was not statistically significant between models, p = .063. In the second model, the only statistically significant predictor was gender, standardized coefficient B = .168, p = .040, indicating that female participants had .168 standard deviations more knowledge of ROP compared to males.

83 The assumptions for regression analyses were assessed for the influence of bias.

Linearity was verified by examining the plot matrix of the relationships between variables and showed none of the patterns were non-linear relationships. Independent observation was verified using the Durbin-Watson statistic. A score of “2” indicates uncorrelated variables and the score for this model was 2.00. Homoscedasticity was verified by inspecting the variances along the line of fit which produced a random pattern, with no cone-shaped pattern. The normal distribution of residuals was verified by inspecting the histogram of standardized residuals and predicted frequencies which produced a bell-curved shape. Multicollinearity was assessed by calculating variance inflation factors and verifying that no scores were greater than 10. These same assumptions were evaluated for Research Question 5 with the same results with the

Durbin-Watson score of 2.02.

Research Question 5: To what extent is the frequency of spiritual care provided by

PMH nurses explained by spiritual perspectives, knowledge of ROP, and personal characteristics such as gender, age, self-perception of spirituality/religiosity, religious affiliation, years of PMH nursing practice, education and employment?

A hierarchical multiple linear regression was conducted. Predictors were entered in three groups. Similar to procedures used with Research Question 4, the first block included a model with all of the demographic variables introduced to observe their relationship and overall fit with the spiritual care provided by PMH nurses. In the second block, the spiritual perspectives variable was entered to observe the effect of its addition into the model and its subsequent contribution to explain variance in knowledge of ROP.

The third group included knowledge of ROP.

84 The demographic-only model was not significant, F(15, 145) = 1.32, p = .195, R2

= .12, Adj. R2 = .03. Participants that worked primarily with substance abuse patients showed significant effects in the model, β = .19, p = .041, indicating that participants who worked with substance abuse patients had a .19 standard deviation increase in spiritual care scores compared to participants who worked in other types of care. The second group model that added spiritual perspectives to the demographics was significant, F(16,

144) = 1.72, p = .049, R2= .16, Adj. R2 = .07. There was a significant R2 change of .04., p

= .010. There were three variables that were statistically significant predictors in the second model. The strongest was spiritual perspectives, β = .28, p = .010. Next was PMH nursing experience in years β = .24, p = .026. Last was working with patients receiving substance use treatment, β = .23, p = .015. Although the model was significant, it explained only 6.7% of the variance in spiritual care frequency.

The third and final model with knowledge of ROP added to the demographics and spiritual perspectives was significant, F(17, 143) = 1.74, p = .043, R2 = .17, Adj, R2

= .07. There was an R² of .01 which was not a statistically significant change in R2 between this final model and the previous model, p = .174. There were three variables that were statistically significant in the final model. The strongest was spiritual perspectives β = .30, p = .006. Next was PMH nursing experience in years β = .25, p

= .022. Last was working with patients receiving substance use treatment, β = .24, p

= .012. Although the model was significant, it explained only 17.1% of the variance in spiritual care.

85 Discussion

This descriptive correlational study of psychiatric mental health nurses explored the nature of spiritual perspectives and frequency of spiritual care and the relationship between these variables as well as explored contributors to knowledge of recovery- oriented practice and provision of spiritual care. This study identified significant differences between groups in their spiritual perspectives and provision of spiritual care.

Although the correlation between spiritual perspectives and provision of spiritual care was weak, significant predictors were identified to explain variances in spiritual care, but not recovery-oriented practice.

The nationally representative sample for this study of 171 PMH nurses was predominately female (89%), non-Hispanic white (68%), married or in domestic relationship (63%), and between 56 to 65 years old (38%). Participants reported an average of 16 years of PMH practice experience and the sample was highly educated with

60% having earned a master’s or doctoral degree. Most participants identified a religious affiliation (84%), although 40% did not consider themselves to be religious. It is difficult to ascertain if the composition of demographic variables in this sample mirrored those of the entire conference attendees because APNA does not track demographic data of those registering for conferences. Likewise, APNA does not collect demographic data on its membership. The most recent demographic data of PMH nurses in the US is available from the U.S. Bureau of Health Professions of the Health Resources and Services

Administration (2008). Table 7 compares the national data with the demographics of this study’s sample.

86 The sample for this study was very similar to the national PMH nurse population in terms of mean age, gender, and out-patient employment. This study was represented by a larger percentage of Black/ African American and smaller percentage of Non-Hispanic

White, Asian and Hispanic White participants than the national racial/ethnic composition.

There was a much larger percentage of PMH nurses with advanced degrees and a smaller percentage of PMH nurses with bachelor’s degrees in the study sample.

Table 7

Sample Demographics Compared to National Population

Variable U.S. PMH Nurse Population This Study’s Sample Mean Age 50.3 years 50.25 years Male 10.2% 11.0% Female 89.8% 89.0% Non-Hispanic White 79.0% 67.8% Black/ African American 7.5% 14.0% Asian 7.0% 3.3% Hispanic White 12.5% 6.4% Bachelor’s Degree 51.0% 29.8% Master’s/ DNP/PhD 38.6% 60.2% Out-patient Setting Employment 30.0% 27.5%

Literature has shown associations between nurses’ personal characteristics and spiritual perspectives and provision of spiritual care. The current study sample had high saliency of spiritual perspectives indicating that personal spiritual perspectives were significant in the lives of the participants. Those that viewed themselves as ‘spiritual and religious’ had statistically higher spiritual perspectives than those who viewed themselves as ‘spiritual but not religious’. Interestingly, most participants identified a religious affiliation (n = 84%), although 40% did not consider themselves to be religious. This may

87 be explained by people identifying with a religious tradition, but not internalizing religious influences to the point of it becoming part of their self-concept. Participants who were Christian Protestants had statistically significant higher SPS scores than those of other religions or those having no religion. In this study, viewing oneself as religious was related to having more salient spirituality.

The current study sample had less salient spiritual perspectives with a mean SPS total score of 42 than obstetrical and neonatal nurses in a study by Dunn, Handley, &

Dunkin (2009) who had a mean score of 55 (n = 33, SD = 4.6). The participants in the

Dunn, et al. study were all Christian which supports the influence of religious affiliation on nurses’ spiritual perspectives and is congruent with this study’s findings that religious affiliation influences spiritual perspectives. Similarly, this current sample had lower spirituality saliency based on SPS scores as compared Shores (2010) study of undergraduate nursing students (n = 205, M = 5.04, SD = 0.9) and Ricci-Allegra’s (2015) study of hospice and palliative care nurses (n =104, M = 4.92, SD = .96). However, the current study had higher spiritual saliency compared to Australian acute care nurses (n =

50, M = 3.7, SD = 1.3) in a study by Rondaldson et al. (2012) who described the sample as younger and having more atheist/agnostic nurses than in this current study.

As mentioned in the review of literature, little is known about spiritual care and spiritual perspectives in PMH nurses. Therefore, a comparison of this study’s results to other current studies of PMH nurses in the US is impossible to make. Twenty years ago,

Pullen, Tuck, and Mix (1996) studied spiritual perspectives of PMH nurses and reported an item mean SPS score of 5.33 (n = 84, SD = .56) as compared to 4.70 in this current study sample. In the Pullen et al. study, religious affiliation did not indicate statistically

88 different SPS scores as in this study. One explanation for the differences in outcomes between the two studies was the homogeneity of the earlier sample. Pullen et al. reported

96% of their sample being Christian (Protestant and Catholic) and 92% being Caucasian.

Using the Spiritual Attitude and Involvement List to measure personal spirituality, mental health nurses in the Netherlands (n = 160) reported a mean score of 4.0 (Van

Leeuwen & Schep-Akkerman, 2015). This personal spirituality score was lower than this current study, but caution should be taken in comparing scores of different instruments.

Also, important to note was 32% of the participants were under 31 years of age and 38% reported being atheistic, agnostic, or having “no faith” demonstrating that lower spiritual perspectives is influenced by religiosity.

Scores from the Nurses Spiritual Care Therapeutics Scale (NSCTS) resulted in a total mean average of 42.99 and an overall average item score of 2.54 indicating that on average, this sample provided spiritual care therapeutic interventions rarely (about 1-2 times) to occasionally (about 3-6 times) in the past 72-80 hours of patient care. The most frequently provided spiritual care therapeutic was After completing a task, remained present just to show caring (M = 3.30, SD= .90). This is not surprising as this provision and expression of “presence” is also considered an aspect of psychosocial care and is included in the Scope and Standards of PMH Nursing (ANA, 2014). Two survey items that received the lowest mean item scores were Offered to pray with a patient (M = 1.72,

SD = 1.1) and Offered to read a spiritually nurturing passage (M = 1.70, SD = .83).

These findings indicated that on average, these forms of care were provided between 0 and 2 times in the past 72-80 hours of patient care. Offering to pray with a patient is typically viewed as a religious activity (Garrsen et al., 2017) and the low average score

89 was not surprising since nearly 40% of the respondents viewed themselves as non- religious.

The average scores in this study were similar to those reflected in a secondary analysis of data of four studies that administered the NSCTS to nurses in various employment settings and specialties: hospice and palliative care nurses, intensive care unit nurses, nurses working in a Christian health system, and nurses responding to online invitations in nursing journals and websites (Taylor, Mamier, Ricci-Allegra, & Foith,

2017). Combining data from four studies produced response rates for each NSCTS item ranging from n = 1025 to n = 1030. The spiritual care therapeutic provided most frequently was Remained present (M = 3.37, SD = 1.2) and the least frequent spiritual care therapeutic provided was Offered to read a spiritually nurturing passage (M = 1.46,

SD = .79). These two survey item averages ranked similarly in both this current study and the Taylor et al. (2017) aggregate study. However, the PMH nurses in this current study scored higher on average on all but two of the 17 survey items, and scored higher overall

(M = 42.99, SD = 15.28; M = 37.61, SD = 13.18, resp.). The item with the biggest difference was Encouraged a patient to talk about his or her spiritual coping. The PMH nurses reported an item mean of 2.76 and the secondary data response mean was 2.23 resulting in a difference of 0.53. This is not surprising as “encouraging a patient to talk” and “discussing client coping” are foundational to PMH nursing practice.

This study affirms that viewing oneself as religious is related to how frequently one provides of spiritual care. Religiosity has been shown to be a personal resource to nurses and influenced the spiritual care they provided (Taylor, Park, & Pfeiffer, 2014).

However, Chan (2010) did not find significant differences between groups of religious

90 affiliations providing more spiritual care as in this study. Ronaldson et al (2012) found that years of experience as palliative care nurses (M = 9.5 years, SD = 7.5, p < .05) significantly related to providing spiritual care. This current study, however, found that years of experience as a nurse or as a PMH nurse did not significantly correlate with provision of spiritual care although it was a significant predictor in the regression model in the current study. It should be noted that Ronaldson et al (2012) measured spiritual care using the Spiritual Care Practice Questionnaire, thus caution should be taken when comparing scores to the NSCTS.

The significant contributors in the final model predicting the provision of spiritual care were spiritual perspectives, years of experience working in PMH nursing, and working with populations receiving substance use treatment. Demographic variables alone did not produce a significant model but adding the spiritual perspectives variable did produce a significant model. However, adding knowledge of ROP did not explain any change in variance. This study sheds light on the impact that experience as a PMH nurse may have on increasing one’s ability and confidence to identify patients’ spiritual needs and address them. Nurses working with patients receiving treatment for substance use may feel more comfortable including spirituality as a component of patient recovery as opposed to those receiving treatment for other mental illnesses such as schizophrenia, bipolar disorder, or depression. The 12-step model of care is a spiritually-based approach to addictions treatment and this may influence nurses providing substance use care to provide more spiritual care than those working with other populations.

The inclusion of RKI-10 scores did not prove to be a predictor of the model explaining provision of spiritual care. This result was not surprising given the low

91 correlations between RKI-10 scores and SPS scores (r = .014) and NSCTS sores (r

= .95). By adding ROP knowledge to the model, the overall model was significant, but explained only 7.3% of the variance of spiritual care scores. This was the first study to explore the influence of nurses’ spirituality on their understanding of recovery-oriented practice, and the proposed model was based on identifying theoretical links and commonalities between Watson’s Caring Model and the Recovery Model. Although spiritual well-being is integral to the components of recovery-oriented practice, spiritually salient nurses are not necessarily more knowledgeable about ROP nor does being knowledgeable about ROP necessarily influence a nurses’ provision of spiritual care. The primary hypothesis was built on the five research questions and proposed that spiritual care provided by PMH nurses could be explained by their spiritual perspectives, personal characteristics, and knowledge of ROP. This hypothesis was not supported by the findings. Although spiritual perspectives, years of PMH experience, and working in substance use programs were significant factors in the overall model, they explained only

17% of the model. Adding RKI scores to the model did not explain any more of spiritual care.

Strengths and Limitations

The sample in this study reflected the gender, racial/ ethnicity, and length of experience on the PMH profession across the US and was large enough to support the proposed data analyses with adequate statistical power. All PMH nurses attending the

APNA conference were invited to participate, however, one should consider that the study topic might have drawn some nurses to eagerly participate and cause others to avoid participation, thus biasing the sample. Inherent to self-report instrumentation,

92 participants’ perceptions and memories may not be accurate or could be influenced by social desirability. Having back-up paper copies of the survey at the APNA Conference addressed possible sampling bias that would have excluded participants who did not have a smart phone or electronic device on which to access the survey. Having clear inclusion and exclusion criteria potentially limited confounding factors which were enhanced by having a forced exit feature on the electronic survey so that non-eligible participants could not contaminate the data. As this researcher obtained data from a nonprobability convenience sample, the results cannot be generalized to the PMH nurse population.

Another strength was that the research design was based on a well-established nursing theory, Watson’s Theory of Caring and the dominant framework for mental health treatment, The Recovery Model. Both models have guided previous research, but this is the first time they were used together. Likewise, the instruments used were well established and had good psychometric properties. For this study all of the instruments had strong Cronbach’s reliability scores: Spiritual Perspectives Scale (α = .94), Nurses

Spiritual Care Therapeutics Scale, (α = .93), Recovery Knowledge Inventory-10 (α

= .84). Assumption testing for all analyses was conducted. The researcher ran both parametric and nonparametric tests where assumption violations were ambiguous.

Bias was reduced by using electronic data collection that allowed for direct data input into SPSS. Data from paper surveys were double-checked and the data were screened for outliers that indicated erroneous data transcription into SPSS. Crosstabs were examined to verify that data were categorized correctly. A second statistician independently ran analyses to verify the correctness of the researcher’s findings.

93 The primary strength of this research was that it addressed a gap in research about

PMH nurses’ provision of spiritual care and the relationship to their spiritual saliency and understanding of ROP. Currently, there has been no scientific inquiry into these concepts in PMH nurses. Although the regression analyses did not produce models that explained a large percentage of nurses’ knowledge of ROP or frequency of spiritual care, it prepared the way for future research to re-examine nursing care and mental health treatment models to identify other potential factors.

Recommendations

Spiritual care falls under the scope and standards of psychiatric mental health nursing as well as all other specialties of nursing, but there has been little research focused specifically on PMH nurses as compared to nurses in other specialties. Since this study shows that spiritual care is not provided frequently, future research should focus on barriers PMH nurses experience and strategies to reduce those barriers. Current research identified mental healthcare practitioners’ tendency to view patients’ spiritual experiences as pathological (Awara & Fasey, 2008) and fear of imposing or initiating spiritual conversations (Elkonin, Brown, & Naicker, 2014) to be barriers in providing spiritual care. However, these findings have not been replicated in samples of PMH nurses. Besides focusing on barriers, future research should also further explore factors that contribute to spiritual care as the models in this study did not explain well the spiritual care variable. Researchers may want to consider the contribution of spiritual care competencies, personal commitment to religion, number of patients cared for in the past

72-80 hours of PMH nursing practice, and length and type of spiritual care education.

94 This study measured the frequency of spiritual care provided by PMH nurses, but not if that care was effective or therapeutic. For example, an item on the NSCTS stated

After completing a task, remained present just to show caring and a nurse doing this frequently may be viewed as a good spiritual caregiver. However, if a client prefers to be alone, the nurse’s presence may be a source of tension or discomfort. Researching patient perceptions of the spiritual care received from nurses who are either frequent of infrequent providers of spiritual care should be undertaken.

Some practitioners believe that there are times when a client’s spirituality should be incorporated into psychiatric treatment and times it should not (Reeves & Reynolds,

2009). But little evidence-based parameters give clinicians direction on when and how to provide spiritual care to clients recovering from mental illness and substance use.

Nursing education would benefit from research identifying if resources such as Koenig et al.’s (2012) or Taylor’s (2007) texts that offer information about religion, spirituality, and health better prepared nursing students and nurses to provide therapeutic spiritual care.

The study of specific educational strategies to teach spiritual care should be evaluated to determine if a nurse’s confidence and effectiveness increase.

This study identified that nurses who perceived themselves as ‘spiritual and religious’ had greater spiritual perspectives and provided spiritual care more frequently than those who viewed themselves as ‘spiritual but not religious’. Future research should look at facets of religiosity that promote spiritual care. As mentioned in most academic articles about spirituality and religion, these terms need standardization and clarification.

Future studies may help healthcare providers to base their perceptions of their own spirituality and religiosity using clear and universally understood definitions.

95 Lastly, programs educating all mental health practitioners (psychologists, social workers, psychiatrists, peer providers) about the recovery-oriented model should be evaluated for the inclusion of spiritual care principles. Based on this current research, one’s spiritual perspectives did not contribute to the level of knowledge about the recovery-oriented model of care. One’s knowledge of the recovery-oriented model of care did not significantly explain the provision of spiritual care. So, it begs the question:

Are psychiatric mental health nurses knowledgeable about the recovery-oriented model of care and are they supporting clients’ spirituality in promoting recovery? Future research must answer this question.

Summary

This study supports the idea that the saliency of nurses’ own spirituality contributes to their frequency of the provision of spiritual care which was found in the literature review. It should be considered that PMH nurses who practice and integrate spirituality in their own lives are more apt to be aware of and address spiritual needs of their clients. This study also indicates that nurses’ religiosity influences their level of spirituality and frequency of spiritual care provision. However, not found in this study was a model of variables that explain a large percent of variance of frequency of spiritual care.

The relationship between recovery-oriented practice and spiritual care is still unclear. Even though spiritual concepts are integral to ROP, this study did not identify knowledge of ROP as a contributing factor to spiritual care. Likewise, this research did not produce a model of contributing variables that explain knowledge of ROP. This emphasizes the need for future research to address the lack of evidence explaining what

96 factors are significant in predicting healthcare providers are following recovery-oriented principles when providing mental health and substance use treatment.

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113 Chapter 5

Summary and Conclusion

The demand for individualized and holistic treatment of mental illness and substance abuse necessitates healthcare providers to consider the influence that spirituality has on people in recovery. Research has delineated the potential positive physical and mental health benefits of spirituality, while simultaneously exploring the pros and cons of incorporating spiritual care into treatment for those with mental illness

(de Mamani, Tuchman, & Duarte, 2010). The theoretical underpinnings of the Recovery

Model of Treatment support the appropriate inclusion of spiritual care. The health- promoting outcomes of spiritual care are at the heart of mental health and well-being.

However, whether or not psychiatric mental health (PMH) nurses are providing spiritual care or factors contributing to that spiritual care are unclear.

Based on the gap in evidenced-based literature, this research study explored the extent of spiritual perspectives and frequency of provision of spiritual care by PMH

Nurses. Surprising was the weak correlation between these two variables, yet spiritual perspectives was a significant variable of a model predicting spiritual care. The role of religiosity to spiritual perspectives and provision of spiritual care was identified and indicates a vital area for further research. This sample of PMH nurses demonstrated a moderate knowledge of recovery-oriented practice which did not correlated with their spiritual perspectives or frequency of provision of spiritual care. This raises the question of whether or not PMH nurses are considering spiritual issues when providing mental health treatment congruent with the Recovery Model of Care.

114 Spirituality and religiosity in mental health are fascinating concepts that have been fervently debated as the vast complexity of human nature and experience is played out. Based on this researcher’s personal experiences of observing PMH nurses avoiding key spiritual issues of patients or providing excellent spiritual care, the goal of this body of research was to explore and explain the concept of spirituality/religiosity and spiritual care in PMH nursing practice. These portfolio manuscripts focus on how spirituality and spiritual care are defined and applied to general healthcare, mental healthcare, and PMH nursing practice. The research findings illuminate key areas needing future research and have implications for nursing education and the development of spiritual care competencies for PMH nurses.

115 References

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people with mental illness. World Psychiatry, 12(1), 26-32.

116 Appendix A: IRB Approval, University of Texas, Tyler

117 Appendix B: Survey Introduction, Explanation, and Request for Participation

You are invited to participate in a survey as part of a research study entitled Spiritual Perspectives, Spiritual Care, and Recovery-oriented Practice in Psychiatric Mental Health Nurses. This study is being conducted by Melissa Neathery, a PhD in Nursing student at The University of Texas at Tyler. You were selected to participate in this study because you are a psychiatric mental health nurse that provides direct patient care. The purpose of this study is to identify the extent and nature of spiritual care being provided in the psychiatric mental health setting and to identify the relationships between the levels of nurses’ spiritual perspectives, spiritual care, and knowledge of recovery-oriented practice. If you agree to take part in this study, you will be asked to complete an electronic or paper survey, which takes approximately 7-10 minutes to complete. Your survey answers will be stored in Qualtrics®, a web-based survey software platform. Your responses will remain anonymous as no identifying information such as your name or email address will be requested or collected. After your survey is complete, you have the option of receiving a small gift in appreciation for your time and responses. You may not directly benefit from this research; however, your participation in the study may assist in advancing nursing research on this topic. We believe there are no known risks associated with this research study; however, you may quit the survey at any time you wish. Information collected during this study may potentially be shared without identifying information to other researchers interested in putting together your information with information from other studies, or The University of Texas at Tyler Institutional Review Board (the group that oversees research conducted at the University) as part of their monitoring procedure. Information and results may be shared through presentations or publications. Your participation in this study is voluntary. You may refuse to take part in the research or exit the survey at any time without penalty. Please complete the surveys only once. If you have questions about this project or if you have a research-related problem, you may contact the researcher Melissa Neathery at [email protected] or (214) 317-6892 or dissertation committee chair, Dr. Susan Yarbrough, PhD, RN, CNE at [email protected] or (903) 565-5554.If you have any questions concerning your rights as a research subject, you may contact Dr. Gloria Duke, Chair of the IRB, at (903) 566-7023, [email protected] or the University’s Office of Sponsored Research: The

118 University of Texas at Tyler c/o Office of Sponsored Research, 3900 University Blvd., Tyler, TX 75799 If you have read and understood this consent form and agree to participate in this research study, please determine your eligibility to participate based on the inclusion criteria below. Consent is implied when you click on the Qualtrics® survey link. 1. Are you a licensed RN? [ ] Yes [ ] No

2. Is the primary focus of your job or volunteer work to address the mental health needs of others? [ ] Yes [ ] No

3. Have you provided at least 72 hours of direct patient care in the past 3 months? (Note: the term “patient’ refers to individual patients, family members of patients, or groups of patients.) [ ] Yes [ ] No

4. Are you fluent in English? [ ] Yes [ ] No

5. Is this the first time you have taken this survey? [ ] Yes [ ] No

NOTE: If you answered “Yes” to all 5 preceding questions, please continue and complete the survey. If you answered ‘No” to any of the 5 preceding questions, you are not eligible to participate in this study. Thank you for your time.

119 Appendix C: Permissions to Use Instruments

Hello Melissa,

You are very welcome and have permission to use the SPS in your doctoral research, if you decide it will work for you!

I sent along the SPS with other information about its background and scoring, and you can easily obtain updated references through a search of the databases. As you may know, many have used the instrument, either as a questionnaire or in an interview format, with success.

Let me know if you have any questions. Best wishes for your interesting doctoral research into spiritual perspective, spiritual care, and recovery-oriented practice among psychiatric mental health nurses. (I happen to have my MSN in this specialty!)

Sincerely, Pam

Pamela G. Reed, PhD, RN, FAAN Professor The University of Arizona College of Nursing 1305 N. Martin St. Tucson, AZ 85721-0209 [email protected]

Elizabeth Johnston Taylor Thu 1/19, 12:56 PM 2 attachments (204 KB) Download all

Hi Melissa, Of course, would be delighted to have you use the NSCTS. Only three stipulations we make for all users: 1) provide credit when presenting data collected with the tool (ie, just observe usual scholarly etiquette and don’t plagiarize :-) ); provide us with a summary of the study findings when it is completed (e.g., abstract); and, if we ever choose to do further psychometric analyses, be willing to share the raw (electronic) data from just the NSCTS. Of course, if we published this analyses and used your data in a pooled dataset, we’d negotiate authorship etc. with you. (I just pooled the data from four studies in the USA that used the tool, and have put all respective authors on as co-authors

120 (ordered by size of datasets they contributed). In fact, I will attach that manuscript here as it gives further insight about the tool in the Discussion section. I’ll attach our user info for you here as well. Let me know if you have any questions. I’ve cc’ed Iris Mamier, my co-author on the psychometric paper. Beth

From: Bedregal, Luis Sent: Tuesday, July 4, 2017 11:12 AM To: Melissa Neathery Subject: RKI

Dear Melissa: You do have my permission to use the RKI. I am attaching two documents: One is the 20-item RKI form and the other document contains scoring of items, empirically derived dimensions, item narrative, and theoretically derived domains.

The way to score this instrument is to get means for each domain. Then, judge each factor’s mean according to Likert scale (means of 4 and 5 are good and excellent, a mean of three is okay, and means of one and two are not so good).

Do not forget to change scores on items that are reversed (i.e., a score of one will be a five, a two will be a four, a three will remain the same, a four will be a two, and a score of five will be a one).

If you have any more questions about the RKI, please do not hesitate to contact me. Also, if you plan to use our instrument, we will appreciate if you share your results with us.

Good luck!

Luis

121 Appendix D: Demographic Data Form

Age in Years: ______

Race: Which of the following best describes your race?

[ ] White, non-Hispanic [ ] Hispanic or Latino [ ] Black or African American [ ] Native American [ ] Asian / Pacific Islander [ ] Other ______

Are you primarily of Hispanic or Latino origin or decent? [ ] Yes [ ] No

Gender: [ ] Male [ ] Female [ ] Other, Please specify ______

Location of Employment: US state: ______or foreign country:

______

Marital Status

[ ] Single, never married [ ] Married or domestic partnership [ ] Widowed [ ] Divorced [ ] Separated

Which of the following statement best defines your own spirituality and religiosity?

[ ] I am spiritual and religious [ ] I am spiritual but not religious [ ] I am religious but not spiritual [ ] I am neither spiritual nor religious

122 Religious Affiliation

[ ] Christian, Protestant [ ] Christian, Catholic [ ] Jewish [ ] Muslim [ ] Hindu [ ] Buddhist [ ] Other: Please specify: ______[ ] Religion does not play a role in my life

Education

[ ] Diploma [ ] Associate degree [ ] Bachelor’s degree [ ] Master’s degree [ ] DNP [ ] PhD [ ] Other, Please specify ______

Population you primarily serve

[ ] Adults: non-substance use mental illness [ ] Adults: Substance Use [ ] Adults: Military [ ] Child/ Adolescent [ ] Forensics [ ] Other, Please specify ______

Employment Setting

[ ] In-patient hospital [ ] Out-patient partial program [ ] Out-patient clinic [ ] Home Health [ ] School [ ] Parish [ ] Other, Please specify ______

123 Work Experience

How many years since you received your license? ______How many total years in nursing practice? ______How many total years in PMH nursing? ______How many total years in PMH direct patient care? ______Which shift do you primarily work? [ ] Days [ ] Evenings [ ] Nights [ ] Rotation

Are you a member of APNA? [ ] Yes [ ] No

Have you attended RTP training provided by APNA? [ ] Yes [ ] No

Have you attended another Recovery-oriented training program?

[ ] Yes If yes, number of total hours ______[ ] No

Have you received training specific to spiritual care?

[ ] Yes If yes, number of total hours ______[ ] No

Identify the three biggest barriers that you experience to providing spiritual care in your PMH nursing practice. (1= most significant barrier, 2= Second most significant barrier, 3= third most significant barrier)

____ Lack of educational preparation to provide spiritual care

____ Lack of time

____ Lack of support from management

____ Not sure what spiritual care is

____ Do not consider spiritual care necessary in nursing

____ Lack of confidence in providing spiritual care

____ Concern about triggering or contributing to psychotic or distorted religious thinking (ie. religious delusions)

____ Other. Please specify: ______

124 ____ I do not perceive any barriers to providing spiritual care in my nursing practice

Briefly share how you define spiritual care as a PMH nurse (optional):

______

Introduction and Directions: In general, spirituality refers to an awareness of one’s inner self and a sense of connection to a higher being, nature, others, or to some purpose greater than oneself. I am interested in your responses to the questions below about spirituality as it may relate to your life. There are no right or wrong answers. Answer each question to the best of your ability by marking the response that best describes you.

1. In talking with your family or friends, how often do you mention spiritual matters? 1. Not at all 2. Less than once a year 3. About once a year 4. About once a month 5. About once a week 6. About once a day

2. How often do you share with others the problems and joys of living according to your spiritual beliefs? 1. Not at all 2. Less than once a year 3. About once a year 4. About once a month 5. About once a week 6. About once a day

3. How often do you read spiritually-related material? 1. Not at all 2. Less than once a year 3. About once a year 4. About once a month 5. About once a week 6. About once a day

4. How often do you engage in private prayer or meditation? 1. Not at all 2. Less than once a year 3. About once a year 4. About once a month 5. About once a week 6. About once a day

126 Directions: Indicate the degree to which you agree or disagree with the following statements by marking the response that best describe you.

5. Forgiveness is an important part of my spirituality. 1. Strongly disagree 2. Disagree 3. Disagree more than agree 4. Agree more than disagree 5. Agree 6. Strongly agree

6. I seek spiritual guidance in making decisions in my everyday life. 1. Strongly disagree 2. Disagree 3. Disagree more than agree 4. Agree more than disagree 5. Agree 6. Strongly agree

7. My spirituality is a significant part of my life. 1. Strongly disagree 2. Disagree 3. Disagree more than agree 4. Agree more than disagree 5. Agree 6. Strongly agree

8. I frequently feel very close to God or a “higher power” in prayer, during public worship, or at important moments in my daily life. 1. Strongly disagree 2. Disagree 3. Disagree more than agree 4. Agree more than disagree 5. Agree 6. Strongly agree

9. My spiritual views have had an influence upon my life. 1. Strongly disagree 2. Disagree 3. Disagree more than agree 4. Agree more than disagree 5. Agree 6. Strongly agree

127 10. My spirituality is especially important to me because it answers many questions about the meaning of life. 1. Strongly disagree 2. Disagree 3. Disagree more than agree 4. Agree more than disagree 5. Agree 6. Strongly agree

128 Appendix F: Nurse Spiritual Care Therapeutics Scale

Please mark how often you used each of these activities. If you work 12-hour shifts, please consider the last 72 hours of work as the basis for your rating; if you work 8-hour shifts, please report on the last 80 hours.

Note that the word “patient” is used here in a broad sense. Interpret it to mean any person receiving your nursing care (e.g., family members as well as patients). Also, the term “illness” is used. You may need to substitute health challenge, loss, or other circumstance requiring nursing care.

There are no right or wrong answers. Not frequently including a spiritual care activity in your practice could result from your determination that it was not appropriate for the circumstances. Thank you! During the past 72 (or 80) hours of providing patient care, how often have you: Asked a patient about how you could support his or her spiritual or religious practices 1 _____ Never (0 times) 2_____ 1–2 times 3_____ 3–6 times 4 _____ 7–11 times 5 _____ at least 12 times Helped a patient to have quiet time or space for spiritual reflection or practices 1 _____ Never (0 times) 2_____ 1–2 times 3_____ 3–6 times 4 _____ 7–11 times 5 _____ at least 12 times Listened actively for spiritual themes in a patient’s story of illness 1 _____ Never (0 times) 2_____ 1–2 times 3_____ 3–6 times 4 _____ 7–11 times 5 _____ at least 12 times Assessed a patient’s spiritual or religious beliefs or practices that are pertinent to health 1 _____ Never (0 times) 2_____ 1–2 times 3_____ 3–6 times 4 _____ 7–11 times 5 _____ at least 12 times Listened to a patient talk about spiritual concerns 1 _____ Never (0 times) 2_____ 1–2 times 3_____ 3–6 times 4 _____ 7–11 times 5 _____ at least 12 times

129 Encouraged a patient to talk about how illness affects relating to God—or whatever is his or her Ultimate Other or transcendent reality 1 _____ Never (0 times) 2_____ 1–2 times 3_____ 3–6 times 4 _____ 7–11 times 5 _____ at least 12 times Encouraged a patient to talk about his or her spiritual coping 1 _____ Never (0 times) 2_____ 1–2 times 3_____ 3–6 times 4 _____ 7–11 times 5 _____ at least 12 times Documented spiritual care you provided in a patient chart 1 _____ Never (0 times) 2_____ 1–2 times 3_____ 3–6 times 4 _____ 7–11 times 5 _____ at least 12 times Discussed a patient’s spiritual care needs with colleague/s (eg, shift report, rounds) 1 _____ Never (0 times) 2_____ 1–2 times 3_____ 3–6 times 4 _____ 7–11 times 5 _____ at least 12 times Arranged for a chaplain to visit a patient 1 _____ Never (0 times) 2_____ 1–2 times 3_____ 3–6 times 4 _____ 7–11 times 5 _____ at least 12 times Arranged for a patient’s clergy or spiritual mentor to visit 1 _____ Never (0 times) 2_____ 1–2 times 3_____ 3–6 times 4 _____ 7–11 times 5 _____ at least 12 times Encouraged a patient to talk about what gives his or her life meaning amidst illness 1 _____ Never (0 times) 2_____ 1–2 times 3_____ 3–6 times 4 _____ 7–11 times 5 _____ at least 12 times

130 Encouraged a patient to talk about the spiritual challenges of living with illness 1 _____ Never (0 times) 2_____ 1–2 times 3_____ 3–6 times 4 _____ 7–11 times 5 _____ at least 12 times Offered to pray with a patient 1 _____ Never (0 times) 2_____ 1–2 times 3_____ 3–6 times 4 _____ 7–11 times 5 _____ at least 12 times Offered to read a spiritually nurturing passage (e.g., patient’s holy scripture) 1 _____ Never (0 times) 2_____ 1–2 times 3_____ 3–6 times 4 _____ 7–11 times 5 _____ at least 12 times Told a patient about spiritual resources 1 _____ Never (0 times) 2_____ 1–2 times 3_____ 3–6 times 4 _____ 7–11 times 5 _____ at least 12 times After completing a task, remained present just to show caring 1 _____ Never (0 times) 2_____ 1–2 times 3_____ 3–6 times 4 _____ 7–11 times 5 _____ at least 12 times Optional: Are there any other things nurses can do to care for a patient’s spirit? Please describe:

Please share any other thoughts about offering spiritual care therapeutics that you think are important to consider.

131 Appendix G: RECOVERY KNOWLEDGE INVENTORY

Please rate the following items on a scale of 1to 5: 1 2 3 4 5 Strongly Disagree Disagree Not Sure Agree Strongly Agree 1. The concept of recovery is equally relevant to all phases of treatment. 1 2 3 4 5 *2. People receiving psychiatric/substance abuse treatment are unlikely to 1 2 3 4 5 be able to decide their own treatment and rehabilitation goals 3. All professionals should encourage clients to take risks in pursuit of 1 2 3 4 5 recovery 4. Symptom management is the first step towards recovery from mental 1 2 3 4 5 illness/substance abuse. 5. Not everyone is capable of actively participating in the recovery 1 2 3 4 5 process. 6. People with mental illness/substance abuse should not be burdened 1 2 3 4 5 with the responsibilities of everyday life. *7. Recovery in serious mental illness/substance abuse is achieved by 1 2 3 4 5 following a prescribed set of procedures. 8. The pursuit of hobbies and leisure activities is important for recovery. 1 2 3 4 5

*9. It is the responsibility of professionals to protect their clients against 1 2 3 4 5 possible failures and disappointments. *10. Only people who are clinically stable should be involved in making 1 2 3 4 5 decisions about their care. *11. Recovery is not as relevant for those who are actively psychotic or 1 2 3 4 5 abusing substances. 12. Defining who one is, apart from his/her illness/condition, is an 1 2 3 4 5 essential component of recovery. 13. It is often harmful to have too high of expectations for clients. 1 2 3 4 5 *14. There is little that professionals can do to help a person recover if 1 2 3 4 5 he/she is not ready to accept his/her illness/condition or need for treatment. *15. Recovery is characterized by a person making gradual steps forward 1 2 3 4 5 without major steps back. 16. Symptom reduction is an essential component of recovery. 1 2 3 4 5 *17. Expectations and hope for recovery should be adjusted according to 1 2 3 4 5 the severity of a person’s illness/condition. *18. The idea of recovery is most relevant for those people who have or 1 2 3 4 5 are close to completing, active treatment. *19. The more a person complies with treatment, the more likely he/she is 1 2 3 4 5 to recover. 20. Other people who have a serious mental illness or are recovering from 1 2 3 4 5 substance abuse can be as instrumental to a person’s recovery as mental health professionals. * Included in 10-item version

132 Biographical Sketch

NAME: Melissa Neathery

POSITION TITLE: Doctoral Student

EDUCATION/ TRAINING:

INSTITUTION AND DEGREE COMPLETION FIELD OF LOCATION DATE STUDY Baylor University, B.A. May 1986 Psychology Waco, Texas Baylor University BSN August 1987 Nursing Dallas, Texas University of Texas at MSN May 1993 Nursing Arlington Arlington, Texas The University of Texas at Ph.D. May 2018 Nursing Tyler Tyler, Texas

A. Personal Statement

From years of clinical practice and nursing education, I have seen the strong interrelationship between mental health and spirituality and religion. Hearing the desires of people to discuss spiritual issues and the trepidation from healthcare professionals in addressing those issues fueled my area of scholarship and research. Promoting mental illness and substance abuse recovery often requires resolution of spiritual distress and development of healthy spirituality. I hope my contribution to this area of nursing will improve holistic and individualized mental health care.

B. Position

Positions 2007–Present Clinical Assistant Professor, Louise Herrington Baylor University School of Nursing, Dallas, Texas

1995–1999 Adjunct Clinical Faculty, Baylor University School of Nursing 2004–2007 Dallas, Texas

1999–2004 Adjunct Faculty, Missionary, Center for Christian Leadership Tirana, Albania

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1987–1999 Day Program Nurse Coordinator, Charge Nurse, Staff Nurse, Intake Specialist at Green Oaks Behavioral Health Dallas, Texas

C. Academic and Professional Awards

2017 Invited and Accepted into Phi Kappa Phi Honor Society 2016 Invited and Accepted into Alpha Chi National College Honor Society 2016 Dallas/ Ft. Worth Great 100 Nurses 2017 Each Moment Matters Dallas Philanthropic Award 2017 Baylor University Most Impactful Faculty Recognition

D. Membership in Professional Organizations

Alpha Chi Honor Society, University of Texas Tyler Chapter Phi Kappa Phi Honor Society, University of Texas Tyler Chapter Sigma Theta Tau, Honor Society of Nursing, Chapter Eta Gamma National League of Nurses American Psychiatric Nurses Association American Psychiatric Nurses Association, Undergraduate Education Council American Psychiatric Nurses Association, Texas Chapter National Alliance on Mental Illness

E. Publications and Presentations

Neathery, M. (2018). Recovery-oriented treatment in mental illness and spiritual care: Recovery as a journey, not a destination. Journal of Christian Nursing, 35(2), 96– 93.

Neathery, M. (2014). The power of silence. Journal of Christian Nursing, 31(3). 197.

Neathery, M., & Miles, L. (2016). Ethical and legal principles. In American Psychiatric Nurses Association (Ed.), Defining and using psychiatric mental health nursing skills in undergraduate nursing education. American Psychiatric Nurses Association Education Council, Undergraduate Branch Crosswalk Toolkit.

“Spiritual Nursing Care in Promoting Recovery in Mental Illness,” Accepted for podium presentation, Innovations in Faith-Based Nursing Conference, Indiana Wesleyan University, June 18–21, 2018.

“Intentional Strategies to Infuse Recovery-Oriented Practices into the Undergraduate, Nursing Curriculum, poster presentation, American Psychiatric Nurses Association Conference, Hartford, CT, October 18–21, 2017.

134 “Defining and Using Psychiatric Mental Health Nursing Skills in Undergraduate Education,” Webinar presentation for American Association of the Colleges of Nursing Presented, recorded November 30, 2016.

“Undergraduate Council Nursing Education Toolkit,” podium presentation, American Psychiatric Nurses Association Conference, Hartford, CT, October 28–31, 2016.

“Educational Resource Toolkit: What every Educator Has Been Waiting For,” poster presentation, American Psychiatric Nurses Association Conference, Hartford, CT, October 28–31, 2016.

“Effective Student Preparation for Mental Health Practicum,” poster presentation, American Psychiatric Nurses Association Conference, Orlando, FL, October 27– 31, 2015.

“Ethical and Legal Core Competencies for Psychiatric Mental Health Education,” podium presentation, panel discussion, American Psychiatric Nurses Association Conference, Orlando, FL, October 27–31, 2015. “Spirituality and Religion in People with Schizophrenia: A Literature review,” poster presentation, Psychiatric Mental Health Conference, Arlington, TX, April 9–10, 2015.

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