Care matters: spiritual care by nurses from feminist perspectives Dorothy Grosvenor Thesis presented in fulfilment of the requirement of the degree of Doctor of Philosophy The University of Edinburgh 2005 Table of Contents DECLARATION 2 TABLE OF CONTENTS 3 ACKNOWLEDGEMENTS 8 ABSTRACT 9 INTRODUCTION 10 The structure of the thesis 12 CHAPTER ONE Spirit, body and caring: theories and concepts 15 Definitions of spirit and spiritual 16 Spirit-breath Spiritual 17 Spirit/soul Spirit-mind-psyche-self 19 Contemporary or ‘new age’ spirit 20 Feminisms and spirit/body 25 Spiritual care and nursing care 29 Nursing incomplete without spiritual care Nursing care is spiritual 31 Other literature on spiritual care by nurses 33 Nursing and caring as gendered 35 Nursing as caring Nursing as woman’s gendered work 36 Gendered caring, patriarchy and spirit-mind/body dualisms 37 Caring work taken for granted in private and in public 38 The invisibility of caring in nursing Invisible ‘being there’ 41 Being and doing as practical caring 42 Self-abnegation in caring roles 43 Caring is slave morality 45 2 Caring for the person who is a patient 48 Spirit as bodily self Pain confounds body/mind dualism 50 Meaning in self-as-body 51 Self as embodied memory 52 Out-of-body 53 Feminist informed spiritualities and theologies 55 Patriarchal constructions of spirit/body 57 Spirit holy/body sinful Silenced women 59 Refeminising the spiritual 61 Beyond dualisms of body/spirit man/woman 63 Divine women: Goddess, Wicca 64 Whole body healing 66 Beyond binaries 69 Towards reintegration of dualisms: deconstructing gendered bodies Summary 72 CHAPTER TWO A different standpoint 74 Standpoint Epistemologies 75 Historical basis Developing a specifically feminist epistemological standpoint 76 Feminist empiricism 77 Ethical/political stance of feminist standpoint 80 The perversity of supernatural/natural worlds 81 Reverting to essential woman/man? 83 The politics of knowledge 85 Creating knowledge 86 Everyday knowledge Community of knowers 87 Issues of credibility, worthwhileness and adequacy 89 Credibility, worthwhileness, adequacy ‘Situated’ knowledges: social interaction rather than the “God-trick” 90 Feminist knowledge differs from non-feminist knowledge 91 Reflecting on my role in the thesis and issues of bias 92 Reflexivity Conversational interviews 94 Narrative or stories 95 Information about study participants 96 Conversing and constructing the research materials 97 Preliminary conversations: a focus group One-to-one interviews 98 Indirect and contextual approach to knowledge creation 100 3 Digression and development of discussion 101 Individuals and community of knowers Discursive discussions 102 Concluding interviews conversations 103 Ethical aspects of conversational interviews 104 Transforming and understanding the interview materials 105 Computer assisted programmes Transforming talks to transcripts and texts 106 Developing meanings in themes of spirit, spiritual care and nursing care 107 Codes and concepts 108 Theoretical themes Dilemmas of individuals and communal context 109 Difficulties with articulating nursing 110 Locating conversations in a wider theoretical community of knowers Summary 110 CHAPTER THREE Spirit and spiritual care 112 Spirit and spiritual: it’s difficult to say what ‘it’ is 113 Sensitive issues Spirit as religious/cultural 116 Cultural /religious 119 It’s how you live your life 121 Spiritual care by religious believers 122 Spiritual care or nursing care? 126 Spiritual care as religious/nursing care 128 Negative aspects of nurses’ personal spiritual beliefs 132 Secular spirit 133 The great disappearing act 134 Spiritual supermarket 136 There’s something 137 Spiritual kaleidoscope 138 Spirit as energy 139 Spirit as healing energy 140 Spirit as energy in therapeutic touch 142 Spirit means uniqueness, essence, self, me 144 Spirit as self 145 Spirit as self-discovery 147 Spirit as psyche or person 148 Spirit as self-esteem 150 The dying person or spirit 153 Dying soul or spirit? 157 Dying sprit or psyche? 158 4 Reflecting on feminism and spiritualities in conversational contexts 161 Summary 162 CHAPTER FOUR Meaning purpose and fulfilment 164 Universal biological need for spiritual meaning purpose and fulfilment Meaning purpose and fulfilment in healing 166 Nurses and spiritual care as meaning purpose and fulfilment 168 Don’t know where I’d even begin 169 Time talk and teamwork 173 Meaning purpose and fulfilment in dying, suffering and loss 175 Religious soul in meaning purpose and fulfilment in dying Meaning purpose and fulfilment in relationships 180 ‘Feet on the ground’ meaning purpose and fulfilment 186 Meaninglessness of meaning purpose and fulfilment How you lived helped meaning purpose and fulfilment in dying 186 Practical care: doing and being affects meaning purpose and fulfilment 188 Summary 190 CHAPTER FIVE Nursing care and spiritual care 192 Care, comfort, communication and companionship as spiritual care 193 Being and doing as spiritual care Being human 195 It’s hard to put words to it 196 The care you just GAVE unconsciously 198 Intrinsic care The ethos of care 201 Everyday care: was it spiritual? 202 Affirming self-worth as spiritual care 207 Converse of caring 209 I had the skills already Time and touch 211 Nurses’ own inner distress 214 Distress related to personal matters Distress related to management 215 Distress related to doctors 218 Summary 222 5 CHAPTER SIX Spiritualising nursing care 223 Spirit and spiritual care and its meaning for nurses 223 Difficult to say what it is Spiritual care as a gender issue 224 Trust and ethical issues 228 Suffering and grounding care by nurses 229 Suffering meaning medicine and management issues Implications for further research 234 Implications for policy makers, managers doctors and nurses 235 Summary 236 Conclusion 240 REFERENCES 241 APPENDICES 263 List of study participants Letters requesting access to interviewees Information to potential study participants Sample Interview topic/questions Consent form (participation) 6 Acknowledgements I wish to thank all the nurse participants who gave so generously of their time and experiences. Our conversations inspired and motivated me to keep on with the study. Thanks are due to my principal supervisor, Professor Kath Melia, who gave helpful pointers towards the conclusion and to Dr Marcella Althaus-Reid, for invisible support and visible encouragement in thinking and writing feminist theologies The particular rigours of research in nursing studies meant that the friendship and mutual support of post-graduate students in 12 Buccleuch Place was invaluable. Alison, Erna, Irena, Gail, Jo, Lynn, Maggie, and others from time to time have been a wonderfully inspiring community of knowers. Sarah Rhynas gave support and detailed, constructive comments on parts of my thesis at short notice. Each of you has made the post-graduate experience enjoyable, memorable and worthwhile. Thanks are due also to colleagues in the School of Acute and Continuing Care Nursing, Napier University, Edinburgh for taking on some of my work to allow me to write the thesis and also to Iain MacIntosh, Head of School, for his continuing encouragement and financial support which enabled me to study at the University of Edinburgh. Close friends and family have given me unstinting support in many ways over the six years of the study. Ursula Immenschuh brought calm and champagne at just the right times; Jean Cuthbert discussed personal, practical and professional aspects of feminisms. Catherine Grosvenor provided painstaking proof-reading and support and Sarah Grosvenor her lap-top and related encouragement. To each of you, also, thank you for listening to my story of writing a nursing thesis. 7 Abstract The importance of spiritual care by nurses for health and recovery has become increasingly topical in the last decade. However, there is little research into why nurses should give spiritual care. Whilst bodily caring has always been associated with nurses and nursing, spiritual care has been seen as the concern of religious ministers. The steady decline of people belonging to conventional religions in secular British society is paralleled by an upsurge of interest in spiritualities. But why nurses should give spiritual care is unclear. This qualitative, interdisciplinary study aims to explore why nurses are asked to give spiritual care to patients by considering whether there is something amiss with nursing care that would be remedied by the addition of spiritual care. To investigate this, spiritualities and bodily caring are considered in tension with each other. By using feminist standpoint epistemological approaches I propose to: a) allow the everyday experiences of nurses in giving nursing care to be expressed; b) demonstrate that themes of nursing care as comforting, compassionate caring challenge claims that the addition of spiritual care is necessary; c) show that nurses conform to the perverse body/spirit dualisms of dominant patriarchal institutions and cultural norms in describing bodily nursing care as spiritual and d) present living models of nurses and nursing care as meaningful materialist world views. Material for the study was obtained in semi-structured, one-to-one conversational interviews with eighteen experienced practising nurses. Stories of nursing care were interpreted and analysed within nursing theories of spiritual care as either imperative or integral to nursing care. Body/spirit critiques in feminist informed theologies provided a further theoretical