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evidence & practice / spirituality series: 2

SPIRITUAL ASSESSMENT

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

Correspondence [email protected]

@timminsf

Conflict of interest None declared

Peer review This article has been subject to external double-blind peer review and checked for plagiarism using automated software

Online For related articles visit the archive and search using the keywords. Guidelines on writing for publication are available at: journals.rcni.com/r/ author-guidelines

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

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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

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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

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

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evidence & practice / spirituality series: 2

difficulties to night staff, because they may have more time available than day staff, and the environment is often less busy at this time. The nurse should provide spiritual support where they feel able to, and consult with others, such as the healthcare chaplain, about further spiritual care where necessary.

Nurses in the UK are required to provide spiritual care to patients (NMC 2010), but this requirement can seem vague (Nursing and Midwifery Board of Ireland 2005) and inconsistent. For example, the Standards for Pre-Registration Nursing Education (NMC 2010) state that nurses should carry out a ‘systematic nursing assessment’ that considers patients’ spiritual needs, but little other guidance is provided. The Code: Professional Standards of Practice and Behaviour for Nurses and Midwives (NMC 2015) does not mention spirituality or patients’ spiritual needs, although cultural sensitivity is recommended. The RCN (2011) developed guidance in response to concerns about inappropriate spiritual care delivery by nurses. Spirituality in Nursing Care: A Pocket Guide (RCN 2011) outlines definitions of spirituality and spiritual care, and provides information about spiritual care delivery. Questions to use as a basis for spiritual assessment in healthcare settings are also provided.

Formal spiritual assessment tools In healthcare settings, most patient care plans are based on standardised assessment tools. An assessment is a statement of perception, and a process of gathering and interpreting patient information (McSherry and Ross 2010). Therefore, care plans should be based on a variety of assessments that cover the range of patient care that may be delivered (Pierce and Koning 2004, Draper 2012), and assessing or screening spiritual needs could be incorporated in other standardised assessments. An effective spiritual assessment enables nurses and other healthcare professionals to identify the religious and spiritual needs, resources and coping strategies of the patient (Pierce and Koning 2004, McSherry and Ross 2010, Draper 2012).

Another approach to formal spiritual assessment is the use of the Spiritual Health and Life-Orientation Measure (SHALOM) (Fisher 2010). This is a 20-item survey that can be used in research and practice. It is one of the most widely-used scales, and is suitable for many contexts (Fisher, 2008, 2009, 2010, Gomez and Fisher 2003, 2005a, 2005b). The SHALOM has four domains: personal, communal, environmental and transcendental, each of which contains five short statements (Fisher 2010). Each statement is scored on a Likert scale from 1 (very low) to 5 (very high). The tool may be completed by the patient alone or with a healthcare professional asking these questions.

A range of mnemonic tools for formal spiritual assessment is also available (Table 1), many of which are also used by healthcare chaplains. Guidance on the use of these tools is available (National Center for Cultural Competence 2015). These tools are shorter than SHALOM, ranging from four to seven questions, and can be used by any healthcare professional, including nurses. Most of these assessment tools involve asking the patient questions about their personal spirituality and rituals, faith and beliefs, resources and expectations. They consist of open questions; this enables the assessment of specific aspects of the patient’s beliefs and promotes inclusion.

Given the importance of spiritual care in nursing, the use of these formal methods of documenting patients’ spiritual needs should be considered. It is also necessary to include spiritual care needs in nursing records, because they promote nursing visibility; if there is no record, then these needs and interventions are not visible. If spiritual assessment is included in nursing records, there is also a statement of commitment to deliver spiritual care, which can be measured and documented. It is essential that consideration is given to increasing nurses’ education and awareness regarding spiritual care, and that local guidelines for spiritual assessment are developed.

Assessing spiritual needs informally While formal spiritual assessment tools

KEY POINT

Given the importance of spiritual care in nursing, the use of these formal

methods of documenting patients’ spiritual needs should be considered. It is also necessary to include spiritual care

needs in nursing records, because they promote

nursing visibility; if there is no record, then these needs and interventions are not visible. If spiritual assessment is included in nursing records, there

is also a statement of commitment to deliver

spiritual care, which can be measured and

documented

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can help to focus attention and suggest questions that are important in identifying the patient’s spiritual needs, spiritual assessment should be an ongoing process; something that patients often explore with a chosen healthcare professional as part of developing a therapeutic relationship. The literature suggests that an open, qualitative approach to spiritual assessment may be appropriate (Hodge 2001, Draper 2012). Spiritual assessment should be based on the patient’s individual needs, rather than a tick-box exercise. The style and language used in spiritual assessments should be clear and straightforward to promote patient participation, and patient groups could be involved in developing such assessments by identifying important questions to include. Box 1 provides some examples of open questions that nurses could use to assess the patient’s spiritual needs informally. These questions can be asked when the patient is discussing their spiritual or religious beliefs, or while assessing other aspects of care.

The use of formal spiritual assessment tools has limitations; for example, they may not be suitable for this area, given the sensitivity of the topic. It may be that assessing patients’ spiritual needs should be a more explorative, less standardised process; perhaps a simple enquiry when the patient volunteers relevant information. Indeed, in many cases, healthcare chaplains use an informal and discreet approach in assessing spiritual needs (Nuzum et al 2014). In addition, where nurses are not already using formal spiritual assessment tools, the prospect of including additional documentation to support this can be daunting.

Spiritual assessment may be an ongoing process, rather than a specific event or checklist; however, in some cases there may not be opportunities for nurses or other healthcare professionals to develop therapeutic relationships or trust with patients, for continuity of care or time to explore patients’ concerns. If appropriate, and a therapeutic relationship and trust

TABLE 1. Mnemonic tools used for formal spiritual assessment

Assessment tool Components

SPIRIT (Maugans 1996)

» Spiritual belief system » Personal spirituality » Integration with a spiritual community » Ritualised practices and restrictions » Implications for medical care » Terminal events planning

FICA (Puchalski and Romer 2000)

» Faith or belief: do you consider yourself religious? » Importance/influence: what importance does your faith or belief have in your life? » Community: religious or spiritual: are you part of a religious or spiritual community? » Address: how would you like these issues to be addressed?

ETHNIC(S) (Kobylarz et al 2002)

» Explanation: why do you think you have this? » Treatment: what have you tried for this? » Healers: have you sought help for this? » Negotiate: how best to you think I can help? » Intervention: this is what could be done? » Collaborate: how can we work together on this? » Spirituality: what role does faith/religion/spirituality play in helping you?

HOPE (Anandarajah and Hight 2001)

» H: sources of hope, strength, comfort, meaning, peace, love and connection » O: the role of organised religion for patients » P: personal spirituality and practices » E: effects on medical care and end-of-life decisions

(Adapted from Timmins and Kelly 2008)

KEY POINT

The use of formal spiritual assessment

tools has limitations; for example, they may not

be suitable for this area, given the sensitivity

of the topic. It may be that assessing patients’

spiritual needs should be a more explorative, less standardised process;

perhaps a simple enquiry when the patient volunteers relevant information. Indeed,

in many cases, healthcare chaplains use an informal and discreet approach in assessing spiritual needs

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has been established with the patient, screening questions such as those suggested by Puchalski et al (2009), for example ‘are spirituality and religion important in your life?’, and ‘how well are those resources working for you at this time?’, or some of the questions in Box 1, may serve to guide an informal spiritual assessment. This can inform spiritual care interventions and referral to other support services and resources.

The Joint Commission (2015) suggests some informal screening questions in relation to spirituality, such as: » Who or what provides the patient with strength and hope?

» Does the patient use prayer in their life? » How does the patient express their spirituality?

» How would the patient describe their philosophy of life?

» What type of spiritual or religious support does the patient desire?

» What is the name of the patient’s clergy, ministers, chaplains, pastor, rabbi?

» What does suffering mean to the patient?

» What does dying mean to the patient? » What are the patient’s spiritual goals? » Is there a role of the church or synagogue in the patient’s life?

» How does faith help the patient cope with illness?

» How does the patient keep going day after day?

» What helps the patient get through this healthcare experience?

» How has illness affected the patient and their family?

The brief outline questions provided by the RCN (2011) in Box 1 are suitable for open-ended informal purposes, rather than using formal spiritual assessment tools such as those listed in Table 1 or the SHALOM (Fisher 2010). Overall, the type and format of questions used should be suitable for the healthcare setting and patient group, since it is unlikely that one spiritual assessment tool will be suitable for everyone. Performing a spiritual assessment is not necessarily a commitment to undertaking spiritual care interventions; it might indicate that referral to other spiritual support personnel is required. Spiritual care nursing interventions are discussed in detail in the third and final article in this series.

Conclusion As part of expressing respect for, and interest in the concerns of, patients, nurses should engage in assessing their spiritual needs. This is especially important in situations where spiritual distress or needs might be anticipated, for example in palliative care, serious or life-threatening illness and for older people. It is essential for nurses to understand the concepts of spirituality and spiritual care, and to be aware of the limits of their competence in undertaking spiritual assessment and providing spiritual care.

Nurses have an important role in the spiritual care of patients, and many nurses actively provide this care informally (Timmins 2013). The use of spiritual assessment and screening tools should be considered, but this is not necessarily the role of any one healthcare professional; rather, it is a role of nurses, doctors and allied healthcare professionals and based on a shared definition of spirituality and guidelines for spiritual assessment. These assessments should be based on the individual patient. The language used in spiritual assessment tools should be clear and open to promote patient participation, and patient groups should be involved in their development. The third and final article in this short series will discuss spiritual care interventions.

BOX 1. Informal questions for assessing the spiritual needs of patients

» What sources of help or support do you look to when life is difficult? » Do you have a way of making sense of the things that happen to you? » Would you like to see someone who can help you? » Would you like to see someone who can help you talk or think through the impact of this

illness or life event? (You don’t have to be religious to talk to them). » May we talk about things that I [nurse] can help you [patient] with? » What are your beliefs and where does your spirituality lie? » Where is your inner spirit, your soul, your being, the essence of what got you up and got you

here today? (Tanyi et al 2006, Royal College of Nursing 2011)

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