Finding the Hidden Professional Culture of Mental Health Nursing—Spiritual Care for Individuals with a Co-morbid Life-Limiting Illness

Abstract

People with severe mental illness are dying up to thirty years earlier than the general population. The limited literature on their experience of dying indicates that they often suffer from inequities in their access to healthcare services, and further, what care they do receive is frequently poor. Living with both a mental illness and facing death can engender spiritual concerns and dying at a younger age is a risk factor for spiritual despair. Hence, addressing spiritual concerns can be an important dimension of mental health nursing care. The aim of this ethnographic study of 11 senior and experienced mental health nurses was to determine if the culture of the mental health service impacted their spiritual care for those patients who were facing death. The data highlighted that the nurses felt comfortable in providing spiritual care when the person was suffering from psychosis. Yet, the results also revealed that nurses felt disempowered by the dominance of the biomedical culture, in which they felt unable to articulate their care. However, it was identified that their spiritual care was inherent within the professional values, knowledge, and skills of mental health nursing and framed through their therapeutic relationships. Therefore, strategies need to be used by the organization to assist nurses to reclaim their power and assist the mental health service to further develop and engage in spiritual care practices.

Introduction

People with severe mental illness are more likely to die at a younger age than those in the general community (Plana-Ripoll et al., 2019). Yet, little research has been done on their end-of-life care needs, including spiritual care (Butler & O’Brien, 2018; Relyea et al., 2019; Wilson et al., 2020). The development of a life-threatening illness can engender or increase spiritual concerns and prompt spiritual reflection (Borneman et al., 2010; Bruce & Boston, 2011; Delgado-Guay et al., 2011; Edwards et al., 2010; Gielen et al., 2017; O'Callaghan et al., 2020; Penman et al., 2013; Ronaldson et al., 2012). Further, it is generally known that dying at a younger age than the general population often puts people at greater risk of experiencing spiritual distress (Balboni & Balboni, 2018; Chochinov et al., 2009). A person with an enduring mental illness can have an increased risk of spiritual distress due to the many losses and trauma they experience over a lifetime. These losses and trauma may lead to spiritual distress through the fear of not having enough time to live out one’s dreams and ambitions (Chochinov et al., 2009; Hui et al., 2011). Spiritual distress can be described as a sense of personal disintegration or a diminished sense of self. It can encompass feelings of despair, helplessness, and meaninglessness (Hui et al., 2011).

The concept of spirituality is nebulous and open to a myriad of interpretations, from the secular to the religious (Russinova & Cash, 2007; Steinhauser et al., 2017; Stephenson & Berry, 2015). An Australian study by Jones et al. (2019) established that for people with a severe mental illness, spirituality included finding “comfort, tranquillity, strength, happiness, hope and understanding” (p. 351). Moreover, the concepts embedded in the definition of spirituality, such as existential concepts of meaning and hope intertwine with the concepts of the ‘Recovery Movement’ which is mandated to be the basis of contemporary mental health care throughout most Western countries (Fukui et al., 2012; Nolan et al., 2012; Webb et al., 2011).

Yalom (2008) an existential psychiatrist argued that there was a correlation between the “fear of death and the sense of a life not lived” (Yalom, 2008, p. 49). The premise is that the less a person fulfills their potential dreams, the greater the person’s ‘death anxiety’. Disappointment in life not fully lived fuels ‘death anxiety’ (Yalom, 2008). If this premise is true, then what does it hold for the individual who, because of an enduring mental illness, has not been able to fulfill their dreams?

Studies have found that for people with a mental illness spirituality gave them hope and meaning and was important to their well-being (Huguelet et al., 2016; Hustoft et al., 2013; Nolan et al., 2012; Smith & Suto, 2012; Walsh et al., 2013). Adams et al. (2020) found that individuals with religious or spiritual beliefs had significantly higher coping skills, less depression severity, and less social anxiety. Spiritual beliefs can aid recovery and lessen psychotic and other symptoms of mental illness (Das et al., 2018; Harris et al., 2015; Huguelet et al., 2016; Mohr et al., 2012). Yamada et al. (2020) found that most mental health service recipients wanted the mental health system to offer more spiritual support to them and their families as a resource for their recovery.

Despite the clear importance of spiritual beliefs to the recovery of people with a mental illness, several authors have claimed that mental health clinicians frequently dismiss spiritual concerns as being part of the person’s pathology (Neathery et al., 2020; Ramluggun et al., 2021) and are reluctant to offer spiritual care out of fear that they might exacerbate or trigger psychotic symptoms (Neathery et al., 2020). Clinicians may feel they do not have the required knowledge to understand and address the person’s spiritual concerns (Elliott et al., 2020; Neathery et al., 2020).

Facing death not only increases the need for spiritual care for this population, but it also raises social justice issues (Reimer-Kirkham et al., 2016). Due to the nature and effects of the illness and societal stigma, individuals with a mental illness and a comorbid life-limiting illness are amongst the most vulnerable and marginalized groups in contemporary society (Donald & Stajduhar, 2019; McNamara et al., 2018). Despite this known detail, poor integration of mental health and physical health services has led to fragmented and hence poor-quality care (AIHW, 2020; Donald & Stajduhar, 2019; Firth et al., 2019).

Spiritual care has been defined as working with issues of meaning in the face of suffering. In the palliative setting spiritual care centers on concerns or fears around dying (Fitchett et al., 2020). A thorough search of CINAHL and Medline Ovid SP databases, including PsycInfo, Scopus, and ProQuest was not able to find any literature on the spiritual care needs of people with an enduring mental illness who were also facing death from a life-limiting illness. In addition, government reports written at the same time and location as the study data was collected, indicated that the culture of mental health services, especially community mental health services, was in crisis, with a culture of bullying and harassment (Stevens, 2017). Stevens (2017) report emphasized that the mental health professionals’ workloads were unmanageable, processes were inefficient and there were unrealistic expectations of staff from managers.

Therefore, this study sought to understand specific systems and processes of health care that either enabled or inhibited the facilitation of spiritual care for this population. The research question was ‘how does the current culture of mental health services impact the mental health nurse’s ability to facilitate spiritual care for individuals with an enduring mental illness who were facing death from a life-limiting illness?’

Methodology and methods

This study used an ethnographic methodology to determine if the culture of this mental health service in one Australian state impacted the nurse’s ability to facilitate spiritual care. A culture is a collective phenomenon that holds at its core, shared and emotionally charged belief systems through which people navigate the uncertainties and chaos of human life (Trice & Beyer, 1993). According to Davis (2009, p. 33) culture is recognized through “the study of its language, religion, social and economic organization, decorative arts, stories, myths, ritual practices.” The concept of organizational culture is useful as it can offer an understanding of the “hidden and complex aspects” of various groups and occupations within the organization (Schein & Schein, 2017, pp. 8–9). Hidden aspects of culture include taken for granted assumptions and values. From an organizational perspective, different occupations or disciplines adopt not only specific skills and knowledge but also the values and norms that define their occupation (Schein & Schein, 2017).

The goal of an ethnographic study is the analysis of culture (De Laine, 1997). Ethnography is a qualitative research methodology that offers interpretive explanations of what people believe and value and how they act within a particular timeframe and location (LeCompte & Schensul, 1999). A cultural analysis can provide an understanding of the ambiguities and conflicting beliefs within a specific culture, such as a mental health service (Lakeman, 2013). It can also offer an understanding of the values and beliefs that have shaped mental health nursing practice. Furthermore, a cultural study could offer valuable insights into the complex and hidden aspects of the organization (Schein & Schein, 2017). A specific genre of ethnography known as focused ethnography was used to analyze the different layers of culture embedded within the organization. Focused ethnography examines subgroups within a culture, such as the culture of mental health nursing and medicine (Knoblauch, 2005; Rio et al., 2021). Focused ethnography evolved from medical ethnography in order “to study distinct and delineated health concepts” (Roper & Shapira, 2000). Focused ethnography was used as a data collection method as it allows for the unique needs of different populations (Morse, 2007) and does not require direct observation, especially, when the people of interest are from a vulnerable group (Morse, 2007). In this study, it was not possible to directly observe the spiritual care of people with a mental illness who were facing death from a life-limiting illness due to logistical and ethical issues and so data were collected by interviewing expert key informants. Focused ethnography uses key informants who have knowledge and experience specific to the culture being studied (Higginbottom et al., 2013). For this focused ethnography key informant participants had knowledge of the service culture and a willingness to discuss their views and experiences in relation to spiritual care (Morse & Field, 1996).

In-depth semi-structured interviews were conducted with 11 mental health nurses who were recruited from inpatient and community-based units within a metropolitan mental health service. Interviews occurred over a ten-nth period. The inclusion criteria for participants were that they were caring for or had cared for a person with both a mental illness and a life-limiting illness. A general email was sent to the heads of units to invite the potential participants into the study. Flyers were also placed where mental health nurses would see them. The flyers requested that if the nurse was interested in participating in the research, they should contact the researcher. They were then given an information sheet with details of the study and a consent form. Open-ended interviews were conducted either in a private space on the nurse’s unit or the interviewer’s office. An interview sheet based on a literature review was used to guide interview questions.

The interviews took 45–60 min. With permission, interviews were audiotaped. To assist with transparency and trustworthiness verbatim parts of the transcripts are included anonymously in this paper (Tong et al., 2007). The data analysis was through an “iterative, cyclic, and self-reflective process” (Higginbottom et al., 2013, p. 6). The iterative and cyclical analysis was undertaken by continual re-reading of transcripts to compare and contrast and to look for meaningful patterns, including differences and similarities in the data (Chang, 2008; Roper & Shapira, 2000), and thereby identify study themes (Boadu & Higginbottom, 2014). Roper and Shapira (2000) highlighted that when working within one’s own culture or subgroup, such as when using focused ethnography, it is important to examine one’s own beliefs, values, and socialization. Hence, the research process included the use of a reflective journal where the researcher’s beliefs and values were noted. The reflective journal included how the interactions within the interviews were influenced by the researcher’s cultural background.

For the data analysis, we used a combination of Chang’s (2008) and Roper and Shapira (2000) 10 phases. These were Step 1. Codes were assigned to answers to the research questions. Initial coding was undertaken using descriptive labels. The contents of descriptive label segments were then summarized (Roper & Shapira, 2000). Step 2. We then combined Chang (2008) and Roper and Shapira (2000) methods for analysis. We initially sorted for patterns according to Roper and Shapira (2000) method and looked for cultural themes according to Chang’s method. Step 3. Sort for outliers according to Roper and Shapira (2000). Step 4. Analyze inclusions and omissions i.e. This is a reflective step that examines what aspects of the data are included or not included. Step 5. Connect the past with the present. Step 6. Analyze relationships between self and others. Step 7. Compare with other studies. Step 8. Contextualize broadly. Step 9. Compare with social science constructs and ideas.10. Generalize constructs and theories (Chang, 2008; Roper & Shapira, 2000).

Ethics Approval for this study was granted by the Human Ethics Research Committee from both the University and the clinical setting where the study took place. Ethics approval number-OFR # 146-HREC/16/SAC/123.

Results

Two major themes were constructed through the data analysis. The first theme centered on the spiritual care offered by the nurse when the individual was experiencing psychosis. The second theme centered on the organization’s cultural support and inhibitors for the provision of spiritual end of life care by the mental health nurse. This theme included the subthemes of (i) the availability of time to engage in meaningful conversations and thus provide spiritual care and (ii) the support offered through nursing leadership.

Spiritual care offered through the experience of psychosis

Despite previous research that argues that mental health nurses are often reluctant to offer spiritual care (Neathery et al., 2020; Ramluggun et al., 2021), the data from this study found that nurses were not reluctant to offer spiritual care, even when a person was experiencing psychosis. The following comment demonstrated one nurse’s ability to discern between the person’s ongoing spiritual beliefs and delusions and to also understand the importance of and assess her spiritual background.

“Let’s look seriously at this person’s beliefs. You might say that the person is delusional, but if you go deep into her background her beliefs were Christian … when she came to us, she was connected to the church. It wasn’t delusional. When she was talking about her Christian life it was not like ‘I’m God. I’m Jesus’; she was talking about her Christian journey. (P9)”

“…you cannot divide a person. Religion is part and parcel of any person, whether they are mentally ill or not. (P9)”

Another nurse understood the importance of assessing spirituality and she did this by seeking further collateral information.

“…we often see people in a quite manic or psychotic state, where they are very overt and almost evangelical with their faith, which is not in line with their usual presentation. I think we should never discount it as just being psychotic and manic, but we should get collateral information around that and find out what’s usual … to find out what their normal is. (P10)”

This nurse spoke about a woman whose delusions were of a spiritual nature and that her spiritual beliefs were enmeshed with her psychosis. Her listening and not rejecting the spiritual aspects of the person’s delusions enabled her to provide spiritual care while the person was experiencing psychosis and also once they stabilized.

“…what was really good was while her psychosis was settling. I could just listen while she talked about all this psychotic sort of connection, but once she stabilized and she started going back to church she played piano, she sang at church, she was part of a choir, so those things that she spoke about became really important. (P10) “

She further offered spiritual care by asking the person about their beliefs,

I think that clinicians should not be frightened about asking about people’s faith. I think some people keep it quite under cover too, particularly people who’ve experienced psychosis or mania. Psychosis changes their experience but not their beliefs. (P10)”

This nurse initiated spiritual conversations undergirded by a spiritual assessment to understand the person’s world and thus she was better placed to provide spiritual care. Her listening, reassurance, and non-judgmental approach would have provided a safe space for the person to discuss their spiritual concerns. These skills reflect the professional aspects of the mental health nursing culture as she went on to say,

“I think as clinicians we should be able to instigate spiritual discussions because sometimes clients won’t. You might be working with somebody assuming they don’t have a faith and yet it might be something really important to them that you can connect into that is lying dormant underneath because they’re too fearful of disclosing it. (P10)”

Another nurse made a similar point, that rather than ignoring the psychotic experience, the delusions and hallucinations may be part of a person’s spirituality and hence inform their therapeutic care. The nurse voiced her concern that the individuals’ spiritual beliefs may not always be valued and supported.

“I think sometimes we (as an organization) don’t value their spiritual beliefs and may not support them …; because they might be thought to be delusional. …I think it’s important that we give respect to their belief system and find a way to support them as well as supporting their mental health. (P14)”

This nurse spoke about working in ways that can empower the person to manage their spiritual distress.

“If you get rid of those beliefs with some people, it’s almost like they become empty. That’s not how I see them. Or they might feel as if they’ve lost something. Whereas, if you can accept, support and focus more on managing the distress that some of these experiences cause them, you can give them then the power, or whatever it is, to take control and manage their own mental health.

In the past when people have come up with delusional beliefs or hallucinations, whatever, psychotic phenomena, we’ve tended to say, “oh no, you can’t believe that, no, that’s not acceptable; you must have some medication for that”. “We must get rid of that” but thank goodness the culture’s changing and we are more accepting of peoples’ spiritual beliefs. People can manage these beliefs rather than having to get rid of them because it’s part of them as well, the person’s spirituality. (P14)”

Organizational support and inhibitors for spiritual care

The following quotes illustrate that in terms of organizational support, there was a variation across these nurses’ experience. The nurse’s comment below illustrated that they did not know how the organization would support spiritual care.

“Spiritual care is not talked about much. The organization doesn’t talk about it much. Perhaps as individuals we might explore the client’s spirituality, but the organization? I don’t know how the organization would support the client’s spirituality. (P14)”

Another nurse reported that they did not feel discouraged by organizational processes when exploring spiritual issues with their patients and reported that they documented the individuals’ spiritual needs and connections within the patient’s individual care plan. Spiritual care is one aspect of care planning.

“It’s not a formal support. There’s nothing labelled anywhere that I’ve seen that says ‘we support you in this and encourage you’ but certainly I don’t feel unsupported or discouraged … What I tend to do is give the person the care plan, get them to fill it in and then I come back, and we go through it with them. Then if they haven’t put spiritual/religious issues in, I will ask them about it…And if somebody says that they’re particularly connected to a church I will actually put that in there. (P10)”

In contrast, the following nurse voiced the way in which spiritual care was supported in the unit where she worked.

“… she didn’t have long to live. That is why she wanted more time with her priest, and we (the unit) allowed the priest to come and talk to her. … We also encouraged that if she wants to go to church, she can go to church. (P9)”

Another experienced nurse reported that end of life care was poorly done and that she felt helpless” without an end-of-life care plan,

“How was his care being managed within the unit? (Interviewer)”

“I think the doctors here just decided they’d manage it themselves. But it was very poorly done. (P4)”

“I felt quite helpless, when you’ve been a nurse for so long and I haven’t only just done mental health, I’ve done lots of nursing … All different areas, so aged care, and end of life…. I felt quite helpless. There wasn’t an end-of-life plan done. Nothing. (P4)”

When asked, “In what ways does the current culture of the mental health service either support or hinder your care,” a participant nurse reported:

“I don’t know what it is all about sometimes. … it is almost like the organization has lost that connection with people; I haven’t let go of that role …that human connection with people …I think we have lost some of that humanity … I struggle with that - I say it is a matter of being able to be responsive to the person’s situation. I probably break rules, I know I do …I probably do things that the organization would not necessarily support, but I use my clinical judgment to support this. (P11)”

When asked the question, “Did you feel supported in your care of the individual with a life-limiting illness,” one nurse stated,

“I didn’t go to anybody for support… I didn’t avoid ‘clinical reviews’, but I found it very hard to articulate my interventions…. I felt that I was equipped with evidence-based interventions; otherwise, I wouldn’t have used those interventions. I am not quite sure what I would have said in ‘clinical reviews’ … because the person did not fit the ‘core business’ of the team … It was quite hard to articulate to other clinicians at times what I was doing because he didn’t fit the usual criteria for the usual care that we give…And it was hard to justify my interventions at times within the normal criteria of care in the team…I am not quite sure what I would have said in ‘clinical reviews’ … because he was not usual ‘core business’. (P1)”

Despite mental health nurses practising within a culture where they felt silenced and disempowered, with overwhelming demands on their time, nurses in this study were able to ensure they had time for meaningful conversations with their patients. The ability to ensure the necessary time is a supportive factor in facilitating spiritual care. The participants also identified that their support often came through nursing leadership. Data for these two forms of support will be demonstrated in the following two subthemes.

Time to engage in meaningful conversations

When asked the question, “do you feel that you have the necessary time to facilitate spiritual care?” five of the 11 nurses reported that they did within their usual time allocations and five said they needed to make extra time. One nurse stated,

“Absolutely, because we manage our own diaries, we can do that within our schedule … It wouldn’t be an issue for me. (P10)”

One nurse disclosed that although he did not always have the time, he made time for his patient who had a life-limiting illness.

“And do you feel you had the time to give her that she needed? (Interviewer)”

“No, not always, this is just being honest …you know, when you’ve got your favorite patients, you make the time. (P13)”

Similarly, another nurse stated,

“I made time… And I was very flexible, I had to literally bend over backwards because we had to fit in between his treatments and we had to fit in between his good and his bad days …I had to be really, really flexible which was really hard. (P1)”

Likewise, a second nurse said that his time was patient-driven and that he would drop what he was doing if the person he was caring for who had a life-limiting illness requested it.

“She tends to determine the time…. if I got a call from her now, I could drop everything and see her…I don’t see that as being a big issue, to provide that kind of support. (P 11) “

Support through nursing leadership

Nurses were asked what organizational support they had to be able to facilitate spiritual care. Some replied that it was through nursing leadership.

“Do you believe you were given the support you needed to provide quality care? (Interviewer)”

“Certainly not at senior levels. At local management levels, yes, I did … It has been because in the area I work in there is an openness to spiritual care, which is wonderful. This started from the level three (ward nursing leader). (P16)”

“How did you get support? (Interviewer)”

“I have good managers here and they recognize the value in the patients. They’d also been nurses themselves and they knew the clients. (P13)

I believe there are pockets of that happening (spiritual care) … there is a particular nurse leader who has worked with us …and brought out this belief. He can nurture this spirituality in people and we culturally have become more accepting of consumers’ difficulties with these struggles. These kinds of spiritual struggles, and when you accept these struggles, then there is a way that you can support them to manage these things better. (P14).”

Discussion

Mental health nurses in this study were comfortable in discerning between the person’s delusional beliefs and spirituality. They were comfortable in teasing apart the person’s spiritual concerns and delusions or hallucinations and could work with spiritual distress. They considered the importance of the individual’s spiritual beliefs on their mental health. The data from this study suggested that by understanding and connecting with the patient about their spiritual concerns or struggles, mental health nurses were able to provide spiritual care, even if the person was experiencing psychosis. Swinton (2001) maintained that it was a mistake to assume that even when a person’s spirituality becomes distorted due to mental health issues, such as psychosis or a depressive illness, that spiritual issues are aspects of pathology. Discerning between the aspects of the person’s spirituality that are impacting on the person, either negatively or positively, can assist them in their recovery.

The data from this study highlighted that the nurse participants understood the importance of exploring the person’s background to ascertain whether the individual’s belief structure, was congruent with their spiritual history. The palliative care literature highlighted the need to take a spiritual assessment as a preliminary step for determining spiritual well-being or distress. Spiritual care could then be based on the patient’s individual needs (Harrington, 2016; Selman et al., 2018; Wittenberg et al., 2017). From a mental health perspective taking a spiritual history can highlight the effect that spirituality or religion has had on the person’s mental health (Mohr & Huguelet, 2009). It may also reveal potential stress factors that could exacerbate the person’s mental illness and protective factors which could be used to enhance recovery (Mohr & Huguelet, 2009; Moreira-Almeida et al., 2014). Spiritual history taking has been described as a dance between the patient and the mental health professional, with the clinician gently asking questions and the patient taking the conversation in the direction it needs to go (Koenig et al., 2020).

Underscoring the importance of spirituality to the recovery process, Clay (1994) wrote of a spiritual crisis from the perspective of an individual who had a lived experience of mental illness. Clay (1994, p. 3) declared that “for me, becoming ‘mentally ill’ was always a spiritual crisis, and finding a spiritual model of recovery was a question of life or death.”

Similarly, Patricia Deegan, who is a prominent individual in the recovery movement stated,

Distress, even the distress associated with psychosis, can be hallowed ground upon which one can meet God and receive spiritual teaching…those of us who are diagnosed can have authentic encounters with God (which) encourage the healing process which is recovery (Deegan, 2004)

Although nurses articulated that they felt comfortable in providing spiritual care government reports revealed that there was a crisis within the culture of the local mental health services (Deloitte, 2015; Stevens, 2017). The nurses in this study were senior and experienced nurses. However, the power of the dominant biomedical culture of mental health services disempowered them and affected their ability to articulate their practice within everyday review processes, such as clinical reviews. This lack of inclusion meant their spiritual care was often not discussed in the team. Hence their work became hidden.

However, despite the crisis within the culture of the local mental health services, the nurse’s motivation for providing this care was founded on the values and beliefs of the professional culture of mental health nursing. The results of this study revealed that mental health nurses provided spiritual care through the therapeutic relationship. Mental health nurses used their core skills to form strong bonds of mutual trust, that allowed a space to explore issues of meaning and the person’s individual spirituality.

Lakeman and Hurley (2021) argue that mental health nursing has become aligned with medicine and that being subsumed under the biomedical discourse renders the care practices of nurses invisible. As some nurses in this study were unable to discuss their practice within their team clinical reviews, their care was also rendered invisible, as were the care needs of the person facing a life-limiting illness that did not fit the ‘core business’ of the organization. In this instance the term ‘core business’ related to a specific diagnostic population who were viewed as having a priority for treatment within the service. However, within the mental health service governance documents, the term ‘core business’ of the service was found to be poorly defined (Deloitte, 2015).

Despite this barrier to spiritual care, the participants indicated that they provided care that was ‘congruent with the beliefs and values of the professional culture of mental health nursing. Spiritual care is based on the ‘therapeutic use of self’ and includes exploring the patient’s spiritual perspective and understanding what gives the person’s life meaning (Ramezani et al., 2014). Therefore, it could be contended that spiritual care is synonymous with the skills mental health nurses use in everyday practice. That these everyday practices are not included in team clinical reviews is of concern. For high quality and complete care, these everyday practices need to be reviewed within the health care team and made transparent to ensure their continuation and development.

The participants also reported they were able to shape their workday and ensure they had enough time to have meaningful conversations with their patients. Similarly, a Swedish study by Gabrielsson et al. (2016), concluded that sound professional nursing practice occurs when nurses are confident and take responsibility for shaping their own nursing care. As the mental health nurses in this study were largely senior and experienced nurses, this may explain how they had the personal agency to draw on their professional skills despite the organizational culture. Professional agency supported by nursing leadership enabled them to retain some of their power and continue practice according to their professional values. They ensured they had enough time for spiritual care. Legitimate tasks, such as working with the skills and knowledge of the profession of nursing, as opposed to fulfilling tasks that are unrelated to nursing, increase intrinsic motivation (Muntz & Dormann, 2020). McAllister et al. (2013) identified that the intrinsic rewards of mental health nursing were linked to the appreciation of the trust placed in them to bear witness to human distress and an authentic connection with others.

Limitations of the research

A limitation of this study (common to qualitative research) is that participants may have chosen to be interviewed because they had an interest in spiritual care. Hence, the data and findings may have led to different conclusions from different participants.

The study was undertaken in one area of South Australia and therefore may reflect that specific mental health system at that time. Hence the findings may not apply to other mental health service contexts.

Development strategies

The data from this study highlighted that in some circumstances, such as within clinical review processes, senior nurses felt powerless and unable to articulate their spiritual care. Therefore, those in leadership positions need to ensure nurses feel confident in expressing their views within their teams. One strategy for developing such confidence may be shared professional reflective sessions where nurses are encouraged to discuss their nursing practices. These could include practices, such as the ‘therapeutic use of self’ which is used as the basis for spiritual care.

The development of collegial learning spaces in which nurses, medical practitioners, and other disciplines share educational and practical experiences would be useful in engendering trust, cooperation, and communication (Darbyshire & Ion, 2018; Rushton et al., 2009). Such reflective processes could counter a culture in crisis and assist in the further development of spiritual care. Also, educators of mental health nurses need to consider methods of education that will provide nurses with the confidence to articulate their practice with other disciplines.

Conclusion

Despite broader organizational pressures, the data suggested that nurses maintained their nursing agency and practised according to their nursing values. The data also suggested that the ethos of the professional culture of mental health nursing, as well as nursing leadership, assisted the mental health nurses in facilitating spiritual care. Therefore, mental health nursing leaders could continue to develop a culture in which nurses are supported in their spiritual care by focusing on the cultural structures and processes of the organization that are either a barrier or an enabler of this care, and through the development of approaches that improve and evaluate spiritual care delivery. They can also continue to inspire nurses to articulate and develop spiritual care practices.

It is also crucial that the spiritual care needs of people with long-term mental illness and life-limiting illness are considered in organizational planning. Doing so opens the way for strategies to be put in place so that the voice of the individual who is facing death and has spiritual concerns, can be heard.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.