Spiritual Care: Help in Distress


About This Course

N14. End of Life Care: Spiritual Care: Help in Distress, 3 CE-hours, $21

Course Description: Nursing acknowledges that the needs of the spirit are as important as physical needs for a person’s well being. Increased awareness and preparation, together with a united approach to this dimension of nursing practice, will be shown to enhance the quality of our care and strengthen our contribution to the ongoing development of our profession.

Objectives: At the end of this course, you will 1. diagnose spiritual distress, 2. treat spiritual distress,and 3. use the four languages of caring.

Course Format: Online linked resources and lectures that you can use anytime 24/7. One multi-choice test.

Course Developers and Instructors: R. Klimes, PhD, MPH (John Hopkins U), author of articles on Spiritual Care in distressful situations and overall physical and spiritual wellness.

Course Time: About thirty hours for online study, test taking with course evaluation feedback and certificate printing.

Course Instructor


Professor Rudolf Klimes, PhD, welcomes you to this online course. Keep going.

START the course here. TAKE the exam at the end. PAY after the exam.

N14  Spiritual Care
Help in Distress, 3 CE Hours


You meet Jane, age 45, just before surgery. “Jane, you appear concerned.”

“I’m scared. I might die,” she answers.

“What about death makes you afraid?”

With a sigh, she goes on, “I feel guilty. I really don’t measure up to God’s standards.”

What will you say? How will you care? You want to give compassionate service. You want to participate helpfully in the difficulties of others. You want to care.  How can we give spiritual care?


1. Help for Spiritual Distress, an Overview

Florence Nightingale wrote that, “The needs of the spirit are as critical to health as those individual organs which make up the body”, wrote Florence Nightingale.  Ever since then, spiritual care has been part of some nursing. Oldnall (1996) states that “each individual has spiritual needs regardless of whether the individual is religious or not.”  Spiritual Distress is an approved nursing diagnosis which McFarland and McFarlane (1997) define as “a disruption in the life principle that pervades a person’s entire being and that integrates and transcends one’s biological and psychological nature.” Govier (2000), has identified the five R’s of spiritual care:

  • Reason and Reflection – to find, meaning in life; the will live; to meditate on one’s existence (via art, music or literature)
  • Religion – to express spirituality through a framework of values and beliefs, often actively pursued in rituals and religious practices.
  • Relationships – to relate to one’s self, others and a deity (via service, love, trust, hope and/or creativity)
  • Restoration – to positively influence the physical aspect of care (life events can result in spiritual distress)

Govier (2000) cites a study by Amenta and Bohnet (1986) that suggests four tools to help nurses implement spiritual care:

  • Listening in an authentic manner
  • Being present
  • Accepting what the patient says
  • Using of self-disclosure

Spiritual care interventions:

  • Weekly nondenominational prayer services
  • A prayer corner in the family room, with increased availability of religious reading material
  • A monthly calendar placed in each patient’s room listing the holy days of many different religions
  • A spiritual well-being checklist added to the Trinity Cancer Center resource books, with patient instructions on contacting a chaplain if they have checked any spiritual concerns
  • A book of prayers and meditations placed at the bedside in each room
  • A monthly house-wide nursing newsletter that highlights spiritual-care nursing diagnoses and interventions

Margaret Hutchinson shares this thought:

Nursing today acknowledges that the needs of the spirit are as important as physical needs for a person’s well being. Increased awareness and preparation, together with a united approach to this dimension of nursing practice, will be shown to enhance the quality of our care and strengthen our contribution to the ongoing development of our profession. Recognizing and meeting the diversity of spiritual needs in our clients will call for a person centered, flexible approach. It will also require teamwork and unity in order to provide comprehensive, consistent and ongoing spiritual care. There is strength in a diverse yet united approach to the challenge of spiritual care in nursing practice.

1.1  Spiritual Pain

May Elizabeth O’Brien presents an insightful analysis of spiritual pain: “How, then, does one identify spiritual pain? What are the signs and symptoms? How is it recognized by the professional care giver? In order to answer these questions, a number of persons, including health care givers, pastoral care givers, and clients, were queried as to their interpretation of spiritual pain. The following are a few of the responses.

Spiritual pain is thinking about failing God by selfishness and sinfulness.  It occurs whenever one sees evil in the world.  Some may experience spiritual pain when they are not able to say what they have to say. Perhaps spiritual pain is the same as psychological pain except the source. Spiritual pain can occur when a person has fallen away from spirituality or religion and is not reconciled with God.  It is experienced by a person who is denied the blessings of his church. It is often felt when thinking about faults and failings before God. It’s a feeling of loss, a void; spiritual pain is a separation from God. It is suffering that results from a lack of spiritual fulfillment. Spiritual pain is an internal aching due to a disquieted self, an unsettled self. It is a sense of discomfort or unease that is very deep within oneself related to ones relationship to God or to others in a spiritual sense. Spiritual pain is a loneliness of spirit-a loneliness for God. It is when one’s sense of self as a person, that part of the person that is spirit, is violated.

“In attempting to explore the concept of spiritual pain by content analysis of the above comments and those of a number of other clients and professional health and spiritual care givers, the following dominant themes emerged from the data analysis. Spiritual pain is: (1) loss of or separation from God and/or institutionalized religion; (2) the experience of evil or disillusionment; (3) a sense of failing God-the recognition of one’s own sinfulness; (4) lack of reconciliation with God; (5) a perceived loneliness of spirit.

These comments and themes can provide clues for the nurse to use as she converses with the client who is experiencing spiritual pain. Through continued study of additional empiric data, the concept of spiritual pain may be formalized and redefined. For purposes of this discussion, spiritual pain is defined as an individual’s perception of hurt or suffering associated with that part of his person that seeks to transcend the realm of the material; it is manifested by a deep sense of hurt stemming from feelings of loss or separation from one’s God or deity, a sense of personal inadequacy or sinfulness before God and man, or a lasting condition of loneliness of spirit.” (O’Brien, pp. 104,105.)

Spiritual Assessment: a) Collect data on a person’s spiritual life, quality of major relationships with individuals and God, sense of the sacred and holy, faith, and personal desire to make changes in the spiritual life. b) Then assess the type of adaptation in each of the above six areas, whether it be positive or negative. c) Lastly, develop a diagnosis and treatment plan that includes the problem, the proposed intervention, short-term and long-term goals, evaluation of the implementation and proposed plan changes.

1.2 Nursing Diagnoses: Seven Manifestations of Spiritual Distress

Abstracted from data used for development of the Spiritual Assessment Guide, the following nursing diagnoses related to alterations in spiritual integrity are presented for consideration. These may be considered seven manifestations of spiritual distress.

+”Nursing diagnoses: spiritual pain, as evidenced by expressions of discomfort of suffering relative to one’s relationship with God, verbalization of feelings of having a void or lack of spiritual fulfillment, and/or a lack of peace in terms of one’s relationship to one’s creator.

+Nursing- diagnoses: spiritual alienation, as evidenced by expressions of loneliness or the feeling that God seems very far away and remote from one’s everyday life, verbalization that one has to depend upon one’s self in times of trial or need, and/or a negative attitude toward receiving any comfort or help from God.

+Nursing diagnoses: spiritual anxiety , as evidenced by expression of fear of God’s wrath and punishment; fear that God might not take care of one, either immediately or in the future; and/or worry that God is displeased with one’s behavior.

+Nursing diagnoses: spiritual guilt, as evidenced by expressions suggesting that one has failed to do the things which he should have done in life and/or done things which were not pleasing to God; articulation of concerns about the “kind” of life one has lived.

+Nursing diagnoses: spiritual anger, as evidenced by expression of frustration or outrage at God for having allowed illness or other trials, comments about the “unfairness” of God, and/or negative remarks about institutionalized religion and/or its ministers or spiritual care givers.

+Nursing diagnoses: spiritual loss, as evidenced by expression of feelings of having temporarily lost or terminated the love of God, fear that one’s relationship with God has been threatened, and/or a feeling of emptiness with regard to spiritual things.

+Nursing- diagnoses: spiritual despair, as evidenced by expressions suggesting that there is no hope of ever having a relationship with God or of pleasing Him and/or a feeling that God no longer can or does care for one.” (O’Brien, pp. 106,107.)

1.3 Questions about the Seven Manifestations of Spiritual Distress

“Spiritual Pain: Do you ever feel hurt or pain associated with the spiritual or religious beliefs which you hold? Do you feel pain related to uncertainty or non-belief?

Spiritual alienation: Do you frequently feel “far away” from God? Does it seem that He is remote and far removed from your everyday life?

Spiritual anxiety: Are you afraid that God might not take care of your needs? That He might not “be there” when you need Him?

Spiritual guilt: Have you ever done things which God would be angry at you for? Are you feeling badly about things which you have done or failed to do in your life?

Spiritual anger: Are you angry at God for allowing you to be ill? Do you ever feel like blaming God for your illness? Do you think God is unfair to you?

Spiritual loss: Do you ever feel that you have lost God’s love? That you have broken or weakened your relationship with God? Has God turned His back on you?

Spiritual despair: Do you ever feel that there is no hope of having God’s love? Of pleasing Him? That God doesn’t love you anymore?” (OBrien, p. 102.)

1.4. Relationship Model

The relationship model highlights the various factors influencing all relationships, particularly those in the helping process with spiritual distress. Person A relates to person B in a particular way through language C. Each person has his/her self-concept and a concept of the other person. The content of that communication may be positive, neutral or negative.

Person A in Place X Language C in Time Z Person B in Place Y
Self-concept A and Concept of B Content +, 0, – Self-concept B and Concept of A



2. Treating Spiritual Distress

Ways of treating spiritual distress.

2.1 Who Really Cares

Select a problem case with four or five characters from your own experience or from the Bible and rank the characters from the best caring to the least caring.

2.2 Spiritual Questions

Consider the following spiritual questions and state under what circumstances each question would be most helpful.
What is the source of your strength?  What do you live for?  What are the most important things in your life?  What gives meaning to your life?  How are you progressing in your spiritual life?  How do your try to keep harmony with yourself ?

2.3. The Grief Process

Review a case of grief and state how the five steps are related to the experience: denial, bargaining, anger, depression, and acceptance.

2.4. Dealing With Guilt

James Dobson summarizes his discussion on guilt by drawing the following conclusions:

God is not the author of all feelings of guilt. The absence of guilt feelings does not necessarily mean we are blameless before God. Therefore, the conscience is not absolutely valid in its representation of divine approval and disapproval. However, Romans 9:1 teaches that the conscience is a tool of the Holy Spirit and is often enlightened by Him.  The conscience, then, is a valuable asset to the Christian rather than a defect to be overcome. We must interpret its messages with greater perceptiveness.  When feelings of guilt are reflective of God’s disapproval, they can be validated by the test of the intellect and the will. The conscience is largely a gift of one’s parents, which places a tremendous responsibility on mothers and fathers to handle that assignment judiciously. Regardless of what we feel, the ultimate test of one’s acceptability to our Lord is found in Romans 8:1: ‘There is therefore now no condemnation to them which are in Christ Jesus, who walk not after the flesh, but after the Spirit.’ (KJV).” (Dobson, 1980, p. 40-41.)

2.5. Corinthian Caring Test

After studying I Cor. 13:4-7, write a 1 (for weak), 2, 3, 4, or 5 (for strong) in the space after each word to indicate your present level of caring. I am patient I am kind I envy no one _, I am not boastful _, I am not conceited _, I am not rude _, I am not selfish _, I do not take offense _, I keep no score of wrong _, I do not gloat over others’ wrongs _, I delight in truth _. Add your score. If your total score is below 22, you can greatly improve your caring. If your score is above 44, you may be a very caring person.

2.6. Spiritual Entities

Clarify your personal relationship to death, terminal illness, suffering, forgiveness, material goods, God, the altruistic love of a friend/family member, and/or miracles, etc.

2.7. Questions About My Spiritual Life

Orally, or on a separate paper, answer the following questions:  How do I show care?  How do others see me? What holds me back? What are my weakest areas of service? What am I most selfish in? What am I most altruistic in?

2.8. Counseling Questions

Consider a specific case and answer the following questions. Who needs care?  What does the person need? When does the person need care? How can you meet the person’s needs?

2.9. Spiritual Resources

Describe 1) the spiritual resources you have available to you, 2) how your physical, mental, and social resources supplement and complete your spiritual resources, and 3) the adequacy or lack or adequacy of those resources.

2.10. Discussion

Discuss the appropriateness and use of various tools of mental, social, and spiritual health therapies: role playing, communication exercises, behavior modification, contracting, values clarification, reality therapy, family therapy, group therapy,
recreational therapy, stress management, and conflict management. People who really trust me: People whom I can fully trust: The “wrongs” others did to me that I have never forgiven: My “wrongs” others have not forgiven me: I am: My three great hopes are: My strong areas of service are:

2.11. Case Presentation And Analysis

Present an experience you have had in meeting a spiritual need of a person. Give the appropriate background. After the presentation, identify a) the parts that suggested spiritual needs, b) the spiritual need(s) you tried to meet, c) the tools you used, d) the appropriateness of the tools, and e) planning for further spiritual care.

2.12. Consider this Person

Select a person-biblical or other. Consider his/her needs of spiritual care and describe a) his or her history including physical, emotional, social, and spiritual needs; b) his/her personal states apparent in each of the four areas; c) tools appropriate for meeting each of his/her needs; d) ways you would use those tools in each area; and e) the evaluation of the case.

2.13. Interview With Chaplain/Pastor

Interview a chaplain /pastor, asking about his ministry, services, role, referrals, relationship with other helpers, and ways the relationship with other helpers can be improved.

2.14. Use Of Care-Scriptures

a) Read the following texts, b) select cases from your own experience for each text, and c) discover how you would use these scriptures to provide spiritual care. Matt. 28:18-20 (Disciple-making) Peter 1:1-11 (Self-perception) Philip. 4 (Understanding People) Romans 4:10-13 ( Helping ) Job 1:1-2, 11 (Emergencies) I Cor. 7:2-5, 26 (Counseling) Exodus 18 (Finding Help) Ephesians 4 (Fitting Together) Ephesians 5 (Helping Yourself) Matt. 5:1-6 (Caring Characteristics)

2.15. Care Scripture Cards

Prepare for reading, memorizing, and/or giving away. Colossians 3:16-17; Revelation 8:18; John 14:27; Isaiah 55:22; Joshua 1:9; Isaiah 40:11; Psalms 147:3; Deuteronomy 33:27; Proverbs 3:5-6; Psalms 27:14; Isaiah 26:7; Matthew 11:28-29.

2.16. Use of Prayer

Consider the use of prayer. First prayerfully listen to the needs of others. Then enjoy the love conversation with God, express feelings, express concerns/hopes, be brief, use the person’s names, express specifics, such as matters for praise and/or request, and feel free to use the Lord’s Prayer when appropriate. Worship is appropriate in the home, church, chapel, hospital, camp, or many other places. The Lord’s Supper can be a very meaningful, special type of caring.

2.17. Prayer

Describe a case and the spiritual needs involved. Then present a prayer appropriate for the situation. Each prayer ends with Amen. Blessed Lord, be very kind to Grant our friend courage of soul, peace of mind, and speedy recovery to health, if it pleases you. Amen.  Dear Lord, When I think of your love and patience, I just want to thank you and praise you and rest in your strong, protecting arms. I know that you will help me through these next few days. I know that you will look after me both on the mountaintops and in the valleys. Amen. Lord, In a world of turmoil and strife, in a life of fear and anger, there is no room for peace. Knowing you, I no longer fear Trusting you, I let go of my anger Loving you, I receive your gift of peace Amen. May the peace of God which passes all understanding keep your hearts and mind in the knowledge and love of God and of His Son Jesus Christ. Amen. Now unto Him that is able to guard you from stumbling and set you before the presence of glory without blemish in exceeding joy, to the only God our Savior, through Jesus Christ our Lord, be glory, majesty, dominion, and power, before all time, and now, and forever more. Amen. Almighty God, Make us conscious of your love that daily surrounds us, that continually supports us, and that now gives us hope. Overshadow our bodies, minds, and souls with Thy strengthening and healing presence. Amen. My Redeemer and my Lord, I beseech Thee, I entreat Thee, Guide me in each act and word, That hereafter I may meet Thee, Watching, waiting, hoping, yearning, With my lamp well trimmed and burning. Amen. (Henry Wadsworth Longfellow) Dear Lord, Take me just as I am and make something beautiful out of me. Recreate me not because I’m deserving, but because you’re forgiving and loving, and I fully trust your love. Amen. Lord, Walk with me into the unknown of tomorrow, and hold my hand tight. Because you are my Maker and God, I’m thankful for yesterday and today and confident of a blessed tomorrow. Amen. Lord, I stumbled again and fell flat on my face because I have rushed on, without listening to those around me and without looking up to you. I have been too busy with my poor hurt self. Now help me to notice and hear your sustaining love all around me. Amen.

2.18. Care Cards For Spiritual Care

Care cards may be appropriate in many spiritual care situations. If their use is well considered and planned, they may serve a valuable purpose. If used indiscriminately and without proper design, at times some of the cards may be very inappropriate. They are here presented only as suggestions. Many other cards may be designed and presented in a printed or handwritten form. Examples:  I’m Jesus is actively helping me solve my problems. He wants to help you too.

2.19. Care Poem Cards

For reading, memorizing, and/or giving away. He prays well, who loves well both man and bird and beast. He prays best, who loves best All things both great and small; For the dear God who loves us, He made and loves all. (Samuel Taylor Coleridge) So stood of old the Holy Christ Amidst the suffering throng; With whom this lightest touch suffered To make the weakest strong. That healing gift He lends to them Who use it in His name; The power that filled His garment’s hem Is evermore the same. (John Greenleaf Whittier) God grant me the serenity to accept the things I cannot change, the courage to change the things I can, and the wisdom to know the difference.

2.20. Use the four languages of caring

2.21 An Outline of Spiritual Care Plan Options

Frustration Doubt Body Language, Listening, Speaking-
Joylessness Resentment, Hypocrisy Voice language, listening, emotional, understanding
Emptiness Lack of life-meaning, lack of love Action language. gifts, time, referral, self
Worry Lack of trust Touch language, hand contact
Guilt Unresolved guilt, blame Encouragement, testimony, grief process
Grief False trust Scripture, spoken, written
Distress Inappropriate life-meaning Prayer, worship, lord’s supper
Despair Sepf-destructive behavior, selfishness Spoken word, cards, music



3. The Four Languages of Caring 

We may not be saying much, but we talk much. We talk incessantly with our facial expressions, our words, our actions, the things we touch physically or symbolically. Not only do we talk through these media, we also listen with our eyes, our ears, our fingers. To care is to communicate. Communication takes place through the four languages of caring or the strange sounds and sights of carelessness. Everyone with good motives can learn to communicate through the four languages of caring.

The four languages, in order to communicate real caring, must present the same message through those four channels. If our action language violates our sound language, nobody will believe that we really care. As we speak the four languages of caring we incorporate our strengths, our weaknesses, our alternatives, our empathy, our vulnerability, our humility and our commitment.

3.1 Body Language

We communicate a great deal of information nonverbally, through our expressions and posture. There is much that others learn about us from our face, movements, clothing, hair styles, and other physical properties.  Sometimes these can be distancing and communicate that we are distracted or feel superior.

3.2 Sound Language

Normally we think of language as words and sounds. But it also includes the symbols that stand for sounds, such as numbers, letters, musical notes, etc. It also includes the songs we sing, the whistles, the groans, the clearing of the throat, the humming of a tune, or the playing of a musical instrument.

Sound communication and its symbols used in writing are our most common and accepted form of communication. We speak and we listen. It is not only the content, but also the style, form, and manner that count. All these can contribute to communicating caring or non-caring.

3.3 Action Language

Our actions speak louder than our words. The way we spend our time, our funds, our responses, our health tell much about us. It is in our visiting, in our helping, in our giving, in our working, in our struggling, that we demonstrate that the caring languages are real. Our actions speak louder than our words. The gifts we give, the letters we write, the kindness we render, the helping time we spend, the meals we share are all actions that can communicate spiritual care. Most acts are not caring or uncaring by themselves. They become so as they are invested with meaning by the care-giver. Thus most actions performed in the line of duty may be care-actions and communicate a caring attitude. Faithfulness and sensitivity are two important characteristics associated with caring action-language.

3.4 Touch Language

Of all the languages, the touch language can be the most intimate and also the most destructive; the most tender and the most cruel. Lovers speak it, football players speak it, nurses speak it, and so do murderers. We communicate by touch-language when we shake hands, grasp a book, scratch an itch, tag in a game, pinch or slap, push or hit, embrace or kiss. Backslapping, cheek-tweaking, hair-mussing, and the laying on of hands are other forms of touch-language.

In 1921, J.L. Taylor wrote that, “The greatest sense in our body is our touch sense. It is probably the chief sense in the processes of sleeping and waking; it gives us our knowledge of depth or thickness and form; we feel, we love and hate, are touchy and are touched, through the touch corpuscles of our skin.” (Taylor, 1921, p. 157.)

Besides communicating concern and affection, touch has important physiological dimensions. Ashley Montagu, in his book Touching: -The Human Significance of the Skin states: “The self-licking in which many mammals indulge, in the non-pregnant state, while having the effect of keeping the animal clean, is probably more specifically designed to keep the sustaining systems of the body-the gastrointestinal, genitourinary, respiratory, circulatory, reproductive, nervous, and endocrine systems-adequately stimulated. (Montagu, 1971,p. 20.)

The child’s first contact with the world is through touch-language with the mother. When this touch-language is not used, the breathing, nutritional, and other functions of the child are impaired and the child dies. When there is much positive and loving touch-language, the child’s physical, mental, and spiritual health is enhanced. Kabongo, a Kikiyu chief of East Africa, at the age of 80 described touch-language with his mother beautifully: “‘My early years are connected in my mind with my mother. At first she was always there; I can her body as she carried me on her back and the smell of her skin in the hot sun. Everything came from her. When I was hungry or thirsty she would swing me
round to where I could reach her full breasts; now when I shut my eyes I feel again with gratitude the sense of well- being that I had when I buried my head in their softness and drank the sweet milk that they gave. At night when there was no sun to warm me, her body took its place; and as I grew older and more interested in other things, from my safe place on her back I could watch without fear as I wanted and when sleep overcame me I had only to close my eyes.

‘Everything came from her.’ These are the key words. They imply warmth, support, security, satisfaction of thirst and hunger, comfort, well-being, the very satisfactions that every baby must experience at its mother’s breast.”

“It is through body contact with the mother that the child makes its first contact with the world, through which he is enfolded in a new dimension of experience, the experience of the world of the other. It is this bodily contact with the other that provides the essential source of comfort, security, warmth, and increasing aptitude for new experiences.” (Montaou, 1971, p. 91.)

The touch-language communicates emotions and interest with the feeling of the hand or other body parts. While it can be spoken with any part of. the body, touch is especially developed in the tips of the fingers and the lips. Braille, a special touch-language for blind individuals, is designed to take advantage of the finger-tip sensitivity.

Some cultures are characterized by a do not touch me attitude. Caretaking and nurturing, rather than love and affection, is the remember the comforting feel of general basis of the American mother-child touch-language. Other cultures use touch-language much more freely.

Americans have translated much of the touch-language into the sound language. “We speak of ‘rubbing’ people the wrong way, and ‘stroking’ them the right way. We say of someone that he has ‘a happy touch,’ of another that he is ?a soft touch,’ and of still another that he has ‘the human touch.’ We get into ‘touch’ or ‘contact’ with others. Some people have to be ‘handled’ carefully with kid gloves’). Some are ‘thick-skinned,’ others are ‘thin-skinned,’ some get ‘under one’s skin,’ while others remain only ‘skin-deep,’ and things are either ‘palpably’ or ‘tangibly’ so or not. Some people are ‘touchy,’ that is, oversensitive or easily given to anger. The ‘feel’ of a thing is important to us in more ways than one; and ‘feeling’ for another embodies much of the kind of experience which we have ourselves undergone through the skin. A deeply felt experience is ‘touching.’ We say of some people that they are ‘tactful’ and of others that they are ‘tactless,’ that is, either having or not having the delicate sense of what is fitting and proper in dealing with others.” (Montagu, 1971, p. 5.)

Caring can be communicated appropriately through touch-language. The general rules that guide all caring communication guide touch-language. It will be perceived negatively when too strong, too long, and too intimate for the occasion. It will be perceived as caring when performed with great sensitivity, honesty, and real caring.


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