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Type | Essay |
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Spiritual Assessment of Intervention and Ethical Decision Making Processes
Spiritual, Assessment, Intervention, Ethical, Decision, Making, Processes
Assessing the spiritual needs of patients Timmins F, Caldeira S (2017) Assessing the
spiritual needs of patients. Nursing Standard. 31, 29, 47-53. Date of submission: 18
October 2015; date of acceptance: 1 July 2016. doi: 10.7748/ns. 2017.e10312
Fiona Timmins Associate professor, School of Nursing and Midwifery, Trinity College,
Dublin, Ireland
Sílvia Caldeira Assistant professor, Universidade Católica Portuguesa, Instituto de
Ciências da Saúde, Lisbon, Portugal
Conflict of interest None declared
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Abstract Assessing spirituality and the spiritual needs of patients is fundamental to
providing effective spiritual care. This article, the second in a series of three, discusses
the assessment of patients’ spirituality and spiritual needs in healthcare settings.
Several formal spiritual assessment tools are available to assist nurses to identify
patients’ spiritual needs and to determine whether they are experiencing spiritual
distress.
However, it may be more appropriate to assess patients’ spirituality informally, by
asking open questions about their spiritual beliefs and needs. It is important for nurses
to be aware of the limits of their competence in undertaking spiritual assessment and
providing spiritual care, and to refer patients to the healthcare chaplain or other spiritual
support personnel where necessary. The third and final article in this series will discuss
spiritual care nursing interventions.
Keywords faith, holistic care, religion, spiritual assessment, spiritual care, spirituality
The First Article in this short series on spirituality, explored various definitions and
understandings of spirituality, and established that addressing the spiritual needs of
patients and their families is an increasingly important aspect of nursing care (Timmins
and Caldeira 2017).
Addressing spiritual needs can provide support for patients and families coping with
difficult or challenging situations (Weathers et al 2016). For example, parents might
have difficulty coping with their child’s diagnosis of cancer. Despite being aware that
many children make a full recovery, parents often fear the death of their child and will
attempt to make sense of the situation (Taylor et al 2015).
Parents in this situation will have to make significant psychological adjustments, and for
some, using spiritual resources will be an essential part of coping. Spiritual care may
also be particularly important in palliative care, serious or life-threatening illness, and for
older people recently admitted to nursing homes, where spiritual distress or needs might
be anticipated.
Nurses should first understand how to assess patients’ spiritual needs, so that they can
plan and provide appropriate spiritual care. This article, the second in a series of three,
will address four areas in relation to spiritual assessment: » How patients’ spiritual
needs might manifest in healthcare settings.
» What is required to conduct a spiritual assessment and whether nurses are well
placed to do this.
» What is involved in undertaking a spiritual assessment, including important questions
to ask.
» Whether it is better to use a formal assessment tool, or to assess spiritual needs
informally as part of developing a therapeutic relationship with the patient and their
family.
Spiritual needs in healthcare settings Many patients in hospital have spiritual needs and
will draw on their personal resources, as well as their family and healthcare chaplaincy
services, for spiritual
nursingstandard.com4 8 / 15 March 2017 / volume 31 number 29
evidence & practice / spirituality series: 2
support (Ellis et al 2013). However, nurses and other healthcare professionals should to
be able to identify and support patients’ spiritual distress as a component of providing
holistic care (Balboni et al 2014).
NANDA International defines spiritual distress as: ‘a state of suffering related to the
impaired ability to experience meaning in life through connections with self, others, the
world, or a superior being’ (Herdman and Kamitsuru 2014).
Spiritual distress occurs when an individual experiences suffering that undermines their
sense of purpose and personal identity; that which constitutes a meaningful life for them
(Caldeira et al 2017). Such distress raises questions for people about who they are and
why they are suffering, and is common in patients with cancer.
Caldeira et al (2017) found that patients with cancer undergoing chemotherapy who
expressed both suffering and a lack of meaning in life were most likely to be
experiencing spiritual distress. NANDA International recommends that nurses determine
at what point the patient’s suffering becomes spiritual distress (Herdman and Kamitsuru
2014).
In practice, it may not be straightforward to determine when patients are experiencing
spiritual distress, since their spiritual needs might be unclear, and nurses may lack
specific guidance about the spiritual care they should provide. In these circumstances, a
structured, formal spiritual assessment tool could be used to inform nurses and other
healthcare professionals of patients’ spiritual needs and indicate if they are experiencing
spiritual distress.
Patients may express their spiritual needs by: raising spiritual topics; showing a
reverence for religious items; celebrating a special spiritual season in their tradition; and
raising existential questions about the afterlife. It is important to consider that not
everyone has a spiritual or religious outlook on life. For some, even the suggestion of
spiritual distress or need may be considered offensive. Many societies, while historically
religious, are becoming increasingly secular, with fewer people subscribing to formal
religions.
There are also varying perspectives within religions and populations, and an increase in
personalised and selective approaches to spirituality, with new and alternative
‘spiritualities’ and beliefs arising. Even within religions, there may be nuances in beliefs;
therefore, it is increasingly complex to conduct a spiritual assessment, and determining
the patient’s spiritual needs may be challenging for nurses and other healthcare
professionals (Heelas and Woodhead 2005).
If the patient’s spiritual needs are personal, the assessment process might be more
complex and based on an established therapeutic relationship between the nurse and
patient. In these circumstances, it is less likely that beliefs codified in a religion can
guide the nurse in undertaking a spiritual assessment and planning suitable spiritual
care.
When considering whether patients and families would like or would benefit from
spiritual support in healthcare settings, the best approach is often for nurses or other
healthcare professionals to ask them. This not only demonstrates a person-centred
approach to care, but is also beneficial to nurses, because it means they can avoid
making assumptions about the patient’s spiritual needs and beliefs (McSherry 2006).
However, these assumptions are often made in healthcare settings (McSherry 2006),
with patients and families assumed to have particular spiritual needs, or none.
Assuming the individual requires spiritual support when they do not, or assuming they
are religious, when they are not, may cause offence. Moreover, providing spiritual
support that is inappropriate for patients may be deemed unprofessional behaviour
(BBC News 2009).
Not providing adequate religious or spiritual support to people who have strong religious
beliefs might be similarly offensive, particularly to those whose religious beliefs or
practices have been negatively affected by their hospital or healthcare experience
(Radford 2008). For example, Catholic patients who regularly attend church may feel
distressed that they are unable to do so while they are in hospital.
To address some of these issues in healthcare settings, it is suggested that
Key Point
Patients may express their spiritual needs by: raising spiritual topics; showing a
reverence for religious items; celebrating a special spiritual season in their tradition; and
raising existential questions about the afterlife. It is important to consider that not
everyone has a spiritual or religious outlook on life.
For some, even the suggestion of spiritual distress or need may be considered
offensive. Many societies, while historically religious, are becoming increasingly secular,
with fewer people subscribing to formal religions nurses and other healthcare
professionals engage in a preliminary assessment to identify whether patients and
families have spiritual needs, and whether they require spiritual support services, such
as healthcare chaplaincy (Royal College of Nursing (RCN) 2011, 2015).
Patients are usually asked whether they have a religious denomination on admission to
hospital, but this might not receive due attention. For example, during their admission,
the patient might state that they are ‘Church of England’, but not express whether they
practise the rituals and customs associated with this denomination of Christianity. It may
be suggested that patients answer this question only for the purpose of completing the
forms necessary as part of their admission to hospital.
Rather than only asking the patient about their religious denomination, it may be better if
the nurse or healthcare professional establishes whether the individual practises a faith
of some kind, by asking: ‘do you have a religious faith that you practise?’
However, even patients who express no religious faith during their hospital admission
may experience spiritual distress at a later time, for example during a difficult diagnosis
or prognosis, difficult treatment choices, and changes or challenges related to their
hospitalisation. Nevertheless, hospital admission questions can indicate potential
spiritual needs and may be crucial in planning individualised spiritual care.
To provide spiritual care, healthcare chaplains often rely on nurse referrals (Flannelly et
al 2005), which require some initial information or assessment of the patient’s spiritual
needs. Often, it is the patient or family who requests spiritual care or to see the
healthcare chaplain (Jennings 2013, Timmins 2013), but while patients’ religion is often
a question in hospital admission forms and nursing assessment paperwork, nurses
often do not complete this section (Swift et al 2007, Timmins 2013).
Requirements of a spiritual assessment by nurses' Formal spiritual assessment and the
use of spiritual assessment tools is a predominant theme in the literature on spirituality
(Narayanasamy 2004, Buswell et al 2006, Tanyi 2006, Timmins and Kelly 2008, Gomi
et al 2014, Bryson 2015, Hodge 2015). The primary purpose of a spiritual assessment is
to identify specific spiritual care needs and formulate a care plan for patients (Power
2006, Caldeira et al 2013). Nurses may use different methods and tools to do this,
although these have undergone limited testing (Draper 2012).
In the US, standards for spiritual care assessment and spiritual care delivery have been
requirements for accreditation with The Joint Commission since 2001 (National Center
for Cultural Competence 2015). This means spiritual assessment is required as the first
step in delivering spiritual care, and it is recognised as an important component of
healthcare delivery (La Pierre 2003).
While chaplains are employed in approximately half of all healthcare facilities in the US
(Cadge et al 2008), spiritual assessment is not the responsibility of the healthcare
chaplain alone, and may be conducted by other members of the healthcare team. For
example, Koenig (2014) supported the importance of spiritual assessment in the
medical profession, relating it to the desire of patients to have their religious and
spiritual needs acknowledged and addressed by healthcare professionals.
It is important to remember that nurses have a duty to work within the limits of their
competence (Nursing and Midwifery Council (NMC) 2015); therefore, they should not
undertake spiritual assessment and provide spiritual care unless they are competent
and confident to do so. Nurses should have an understanding of the importance of
referring patients to the healthcare chaplain or other spiritual support personnel where
necessary.
The assessment of spiritual distress and spiritual needs involves not only determining
whether nurses can answer patients’ questions and explore their concerns with them,
but also identifying when is an appropriate time to discuss spiritual matters. In practice,
patients often select particular members of staff with whom they will express their
concerns. For example, patients might express their key point.
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