Self-Determination (Magda Mother-in-law) Disscusion Question

Forum Article

The importance of spiritual assessment when caring for older adults

ANN HARRINGTON*

ABSTRACT There is a growing body of literature documenting the positive effects of both religiousness and spirituality on human health, particularly among those who are ageing or diagnosed with a life-limiting illness. These positive effects provide buffers to life’s stressors such as those associated with mental illness, care-giver burden, substance abuse and social disruption resulting from war. An important aspect of health care for individuals of all ages involves completion of a spiritual assessment. This paper explores the concept of spirituality and spiritual assessment, which has many definitions in the literature, and also provides examples of assessment tools from theology, nursing, social work and medicine.

KEY WORDS – piritual assessment, spiritual wellbeing, spiritual distress, spirituality, religion.

Introduction

An individual’s spiritual dimension is now universally accepted as an important aspect within health care. Some scholars argue that research in this area is well established and considered ‘mainstream’ (Cohen et al. ). Others, however, suggest it is still in its infancy (Moberg ). It is clear that research in the area of spirituality has burgeoned since , as shown by an exploration of abstracts using the PsycINFO and AgeLine databases from  to  that reveal the first article on spirituality was published in  and the second in  (Ribaudo and Takahashi ). The total number of research studies has subsequently increased from an average of . per year during the s to . per year by the early s (Ribaudo and Takahashi ). The number of articles published from  to 

* School of Nursing & Midwifery, Flinders University, Adelaide, Australia.

Ageing & Society , , –. f Cambridge University Press  doi:./SX



increased by over  per cent compared to the previous six-year period, – (Koenig ). Past research has identified the importance of spiritual wellbeing (Moberg

) and recognition of ‘spiritual distress’ (Gordon ). Consequently, an area that was once the domain of theology is now being addressed and discussed by nursing, medicine and mental health practitioners, as an area for both research and practice (Brennan and Heiser ; Harrington ). According to Puchalski (), spirituality is increasingly recognised as an essential element of health and a growing body of literature documents the positive effects of both religiousness and spirituality on human health (Brennan and Heiser ; Daaleman, Cobb and Frey ). Research by Baldacchino et al. () posits that a positive relationship exists between spirituality and wellbeing, even in times of distress and suffering (Baldacchino et al. : ). These positive effects provide ‘buffers’ to life’s stress during times of chronic or terminal illness, mental illness, care- giver burden, substance abuse and social disruption resulting from war (Brennan and Heiser ). Also as a resource for wellbeing; assisting individuals to transcend suffering, pain and despair; and coping with illness (Chiu et al. ; Harrington ; Picot et al. ). Within the practice of palliative care, the spiritual dimension is considered

a central component of care, together with physical, psychological and social support (World Health Organization (WHO) b). In palliative care, standards and/or guidelines have been developed to assist in care provision (McLeanHeitkemper et al. ). Research has shown that once patients are diagnosed with a life-limiting illness, a spiritual journey begins (Harrington ). Given the increase in the ageing population, a media release from Palliative Care Australia ( August ) noted that ‘palliative care should be the core business of aged care’. Examination of aged and palliative care literature has, however, shown that the terms ‘spiritual care’, ‘spirituality’ and ‘spiritual assessment’ still lack clarity. The interpretationof the term spirituality varies across disciplines, as raised

within a recent paper by social scientist David Moberg where he claims ‘even a casual survey of popular and professional literature reveals a wide range of labels . . . and types of spirituality’ (: ). He cites some  categories ranging from: active spirituality, embodied spirituality to Buddhist, Chinese religiosity/spirituality and Christian spirituality (Moberg : –). He states that the study of spirituality is rife with verbal definitions, commenting that even when scholars use the ‘same spirituality-related words [they] frequently have diverse interpretations and assumptions about their mean- ings’ (Moberg : ). Within the discipline of nursing there is limited agreement about the

concept of spirituality, including its definition, and there have been few

 Ann Harrington

empirical studies of spiritual interventions published (Kreitzer ). Tuck (: ) argues that there is an ‘overreliance on documenting religious preferences and faith practices’ rather than the implementation of spiritual care. A similar view has been raised within the discipline of medicine, with Koenig (: ) claiming approximately  per cent of physicians ‘often’ or ‘always’ take a spiritual history and nearly  per cent ‘never take one’. Puchalski (: ) reported on surveys showing patients ‘want their doctor to be sensitive to their spiritual needs and to integrate it in their treatment’. The importance of spiritual care is now reflected within government

policies, particularly in regard to the care of older adults. Hodge et al. () argue that within the United States of America (USA), the Joint Commission (formerly known as the Joint Commission on Accreditation of Healthcare Organisations) requires spiritual assessments to be undertaken in hospitals as well as other health-care organisations where services to older adults exist. In Australia, the Aged Care Standards and Accreditation Agency has recognised the importance of spiritual care for older people through its Standard . Culture and Spiritual Life, highlighting that ‘Individual interests, customs, beliefs and cultural and ethnical back- grounds are valued and fostered’ (: ). The United Kingdom (UK) has been a pioneer in the implementation of spiritual care as the remit of palliative care, since the work of Cecily Saunders in the s (Thompson ). Ellis and Lloyd-Williams contend that spiritual care in the UK takes a ‘common humanity approach’ (: ) such as having hope, time to think, dealing with unresolved issues, preparing for death. This approach differs from those within the USA, ‘where studies tend to describe spi- ritual needs in more religious terms’ (: ). However, spiritual care services in the UK have become highly contested (Swinton and Pattison ), with recent debate on the cost of care through chaplaincy services among the National Health Service trusts (National Secular Society ). Set against this argument of cost is Kelvern (), who posits that spiritual

beliefs among the population of the West have grown increasingly eclectic. Consequently, spirituality can be constructed in different ways depending on religious traditions, belief systems, cultures and contexts (Swinton and Pattison ). This increased secularisation does not negate the need for spiritual care ‘even treated as a cultural construct, it clearly has a role to play in patient care’ (Kelvern : ). Further, Mowat (: ) found chaplaincy services in aged care beneficial, enabling older people to find meaning in ageing. The most recent study of Cowlishaw et al. () established that spirituality was a component of wellbeing in old age and was associated with positive psychological outcomes. They conclude that in terms

Importance of spiritual assessment

of beneficial impacts on older adults, ‘spiritual support services may be justified . . . and should remain’ (Cowlishaw : ). Given the link between spirituality and health, the variety of ‘spiritualties’

and their place within government policy, Hodge () contends that it is increasingly recognised that a spiritual assessment should be conducted by health-care providers as part of their service provision. Some confusion remains, however, in what is meant by spiritual assessment, and it should be noted that the terms ‘spiritual’ and ‘religion’ have often been used interchangeably, and some would argue that they overlap (Hodge ; Miller and Thoresen ). In addition, Hodge et al. () highlight that many gerontological practitioners have received little training in identifying spiritual needs; tools to assist with the assessment of spiritual needs are therefore warranted. In consideration of the need to clarify these concepts, this paper will:

. address the overlap between the terms ‘spirituality’ and ‘religion’;

. discuss the concepts of spiritual wellbeing, spiritual distress and spiritual assessment; and

. offer conceptual models that can be used to assess an individual’s spirituality as a guide to the practitioner in the determination of the administration of spiritual care.

Spirituality and religion

In spite of the burgeoning literature in the area of spirituality, Kreitzer has stated that ‘there is limited agreement regarding the concept and definition of spirituality and few empirical studies of spiritual interventions have been published’ (: ). While recognising that research in this area should continue, there are some common areas of agreement regarding the definitions of the key concepts in the research literature. Spirituality and religion are multi-dimensional constructs but they defy easy definition and quantitative assessment due to their subjectivity (Brennan andHeiser ). Burkhart and Hogan (: ) argue that although the terms spirituality and religion are often used interchangeably, the majority of the literature differentiates spirituality from religiosity. Hodge () asserts that although the two terms overlap, they are

distinct. Spirituality in its broadest sense reveals a predilection towards metaphysical concerns, where components include a sense of transcen- dence, inter-integration, connectedness to others, and purpose and meaning in life (Brennan and Heiser ; Burkhart and Hogan ; Harrington ; Pargament ; MacKinlay ). Components of

 Ann Harrington

religion include adherence to a set of ideological beliefs, rituals and practices associated with particular creeds or denominations (Brennan and Heiser ). For some individuals, spirituality is expressed through religiousness. In particular, Hodge argues ‘religion can be seen as flowing from spirituality’, with expression demonstrated in particular beliefs, forms and practices that have been developed in community with other individuals who share similar understandings (: ). Furthermore, Brennan and Heiser contend that ‘religiousness is typically the outward manifestation of the inner spiritual life, spirituality can exist in the absence of religious affiliation, whereas religiousness in and of itself does not guarantee a developed spirituality’ (: ). Spiritual assessments can therefore clarify issues surrounding religion

and spirituality and are designed to help identify those who need assistance in expression of their spirituality. Such assessments may also identify those whose spiritual wellbeing may be at risk (Brennan and Heiser ).

Spiritual wellbeing

It has been shown that an individual’s spiritual wellbeing becomes more important when physical and psychological decline occurs, as in the ageing processor when a life-limiting illness has been diagnosed (Harrington ). For the health-care provider, such decline can be evident when individuals are admitted to a hospital, hospice or long-term care facility. MacKinlay () states that what is central to an individual’s life-meaning is critical to their sense of wellbeing, hope and a will to live that can flow out of this core. The origins of ‘spiritual wellbeing’ emerged from the ‘social indicators

or quality of life movement’ in the USA (Ellison : ). Following the  White House Conference of Aging, a seminal text on spirituality was published entitled Spiritual Well-being: Sociological Perspectives (Moberg ). Within this text, spiritual wellbeing was identified as the ‘totality of the inner resources of people . . . the meaning-giving center of human life’ (Moberg : ). Since these early beginnings, spirituality is now being included as an important component to consider in any assessment. Moberg’s () paper offered a two-faceted model that considered both the horizontal axis (sense of purpose and life satisfaction) and vertical axis (sense of wellbeing in relation to God) (Ellison : ). However, before the above conference, the National Interfaith Coalition

on Aging was formed in the USA and included the pioneering work of Don Clingan, Tom Cook and Roger Carstensen (Ellor and Kimble ). These three men posed questions to various leaders of denominations ‘as to the

Importance of spiritual assessment

need for a National Interfaith group that would involve more directly the variously religious traditions and their work with older adults’ (Ellor and Kimble : ). Until , theWhite House Conferences on Aging had alluded to a ‘religious section’ of the conference; following Clingan, Cook and Carstensen’s landmark work, the title ‘spiritual well-being’ becamemore prominent (Ellor and Kimble : ). This shift in title triggered some early differentiations of the term ‘spiritual’ from ‘religion’. Nevertheless, in its definition of health (which has not been amended since ), theWHO (a) identifies ‘social’ wellbeing but does not include spiritual wellbeing as a distinct component. Brennan and Heiser () suggest that the traditionalWestern perspective of health does not follow a holistic approach. They claim that this finding is in contrast to an Eastern world-view that considers spirituality an important constituent of a model of care that ‘integrates body, mind and spirit’ (Brennan and Heiser : ). It could be argued that the definition of health generated by the WHO in

 and prior to the Quality of Life movement of  has continued to maintain this Western world-view. Nevertheless, Goodloe and Arreola contend that the WHO definition in  ‘laid the foundation for this [spiritual] understanding by expanding its definition of health . . . to include the mental, physical and social dimensions’ (: ). The WHO thus considered ‘health’ as ‘notmerely the absence of disease or infirmity’ (WHO a). This expanded view of the definition of health is further supported by Banks, Poehler and Russell, who believe that ‘spiritual interaction’ is a dimension of total health and suggest that it includes the ‘social well-being’ that was ‘introduced by the [WHO] as an expansion of the concept of health in  (although this was never specifically defined)’ (: ). These authors believe, however, that spiritual interaction goes beyond mere social interaction and includes interaction between and among persons, God and nature (Banks, Poehler and Russell : ). Spiritual wellbeing is also discussed in the literature with the concept of spiritual distress, which will now be explored.

Spiritual distress

One of the first articles on spiritual distress appeared in the North American Nursing Diagnosis Association’s handbook of diagnostic categories (Gordon ). At this time, spiritual distress was defined as ‘a disruption in the life principle which pervades a person’s entire being and which integrates and transcends biopsychosocial nature’ (Gordon : ). Over time this definition has been modified and is now more reflective of common definitions of spirituality, recently defined as an ‘Impaired ability to

 Ann Harrington

experience and integrate meaning and purpose in life through connected- ness with self, others, art, music, literature, nature and/or a power greater than oneself’ (Carpenito : ). Puchalski () suggests that spiritual distress can be manifested in

different ways, for example, an inability to find meaning and purpose in life that leads to depression and anxiety. She argues that people find meaning and purpose throughout their lives through their jobs, relationships, accomplishments and financial success, all of which may be transient. She proposes that ‘the challenge for all people is to find meaning and purpose even in the midst of failed jobs, relationships, accomplishment and unattained success’ (Puchalski : ). At times of life’s challenges, spiritual and religious beliefs pay a significant role in how people transcend their suffering and try to find such ultimate meaning (Puchalski ). In offering a tool to measure spiritual distress in hospitalised elderly

persons, Monod et al. claim that ‘religious struggle, defined as negative feelings toward God, feeling punished by God . . . has been associated with increased mortality in elderly patients’ (: ). These authors further highlight that spiritual distress might have a harmful effect on a patients’ quality of life and hence a spiritual assessment is an important step to determine spiritual wellbeing and spiritual distress.

Spiritual assessment

A review of the literature reveals that the term ‘spiritual assessment’ has been used in a variety of ways. Puchalski includes three aspects, namely a ‘spiritual history, screening or assessment’ (: ). In her view, a screening is a triage or a quick determination of whether a person is experiencing a serious spiritual crisis, indicating that a referral to a chaplain should immediately follow. She argues that the spiritual history is the process of interviewing a patient and asking questions with a view to understanding their needs and resources. The goal of the spiritual history is to allow the health-care provider (her term used is ‘clinician’) to incorporate spiritual care into the patient’s overall care plan. The information obtained from the history taking allows the clinician to understand how spiritual concerns could complement or complicate the patient’s overall care (Puchalski : ). For those conducting a spiritual history, Puchalski offers the FICA Spiritual History Tool. Puchalski’s () final aspect, a spiritual assessment, involves a more

extensive in-depth and ongoing process of active listening to a patient’s story that should be undertaken by a professional chaplain who then summarises the patient’s needs and this information should then be communicated to the treatment team. In this case, she argues, the major models are not built

Importance of spiritual assessment

on a set of questions employed in an interview but rather via the use of ‘interpretive frameworks’ based on listening to the patient’s story. An alternative view from the discipline of social work under the rubric

of ‘spiritual assessment in marital and family therapy’ aims to ‘acquaint therapists with a variety of assessment tools and how to select from among them’ (Hodge : ). He uses the term ‘spiritual assessment’ to describe five tools to help gather information regarding an individual’s spiritual needs. Firstly, Hodge offers spiritual histories where this method is ‘analogous

to conducting a family history’ (: ). Initially, a brief spiritual assessment is used to clarify issues of religion and/or spirituality, then he presents two question sets to guide the conversation and to provide some prompts to help clients tell their stories. His second tool is a spiritual lifemap, described as a ‘diagrammatic alternative to verbally based spiritual histories’ (Hodge : ). These are used to sketch significant life events on paper that identify the path travelled and to help to plan for the future. The third tool offered is spiritual genograms that illustrate the ‘flow of spiritual patterns across at least three generations’ (Hodge : ), used to designate which individuals have played major spiritual roles. Spiritual ecomaps are the fourth tool offered by Hodge, and these are similar to the former genograms but ‘focus on that portion of a family’s spiritual story that exists in space (: ). Hodge’s fifth tool is identified as spiritual ecograms that depict the connections between past and present functioning; these ‘combine the assessment strengths of spiritual ecomaps and genograms in a single assessment approach’ (: ). Regardless of the tool used, the purpose of making a spiritual assessment

is to recognise possible spiritual needs. According to Brennan and Heiser (), assessment tools may include a variety of modalities that obtain information about a person’s spiritual wellbeing, history, crises or dilemmas. They also provide a base to assist in determining any spiritual distress. Such assessments are used to guide pastoral care and/or interventions and to determine whether or not spiritual beliefs may be enlisted as an additional personal resource for dealing with issues at hand (Brennan and Heiser ). In addition, Higginbotham and Marcy suggest it ‘is the first step in addressing a patient’s spiritual needs’ (: ). The literature on spiritual assessments can be drawn from the practice

bases of psychology (Fowler ), social work (Hodge ), pharmacy (Higginbotham and Marcy ), medicine (Puchalski and Romer ), with one of the first articles coming from the discipline of nursing (Stoll ). Many of these research studies followed the publication of a landmark volume within theology (Pruyser ). When used correctly, these tools should be followed by an integration of that information into the

 Ann Harrington

clinical care plan (Puchalski ) and act as a guide to what is considered important to an individual. McLean () and Harrington () argue that when making a

spiritual assessment it is crucial to take the cues from the patient and not impose one’s own spiritual or religious values, regardless of either individual’s religious tradition. This aspect should be considered important for health-care practitioners where a power differential between patients and providers often exists and it remains crucial to recognise ‘proselytizing is not ethical in the clinical encounter’ (Puchalski : ). In this case, Brennan and Heiser caution against ‘spiritual abuse’ highlighting that:

Spiritual assessments are designed to help identify individuals who need assistance in the expression of spirituality or who are having issues related to spiritual well- being . . . they are not used to impose values, beliefs or practices on another, rather spiritual is very personal and may or may not be connected with religious expression. (: )

Conceptual models for spiritual assessment

Rather than creating new instruments for spiritual assessment, it is prudent to build on prior work (Cohen et al. ). The following represent tools drawn from the disciplines of theology, nursing, chaplaincy, social work and medicine – all are qualitative assessment tools in that they are based on interview. Examples of quantitative tools also exist and these measure spiritual wellbeing (Paloutzian and Ellison ), spiritual beliefs (Holland et al. ), functional assessment of chronic illness therapy–spiritual wellbeing (Peterman et al. ), spiritual development (Hall and Edwards, ) and spiritual needs (Sharma et al. ). In an argument for the use of qualitative assessment tools, Hodge claims

‘quantitative instruments presuppose a certain construction of reality and in the process leave little room for clients to negotiate a shared understanding of individual experience’ (: ). McSherry (), in his review of international studies into spirituality, located  studies that included original research, dissertations and theses. His review identified  international studies that used qualitative methodologies, ten that used quantitative approaches, with three using a mixed-method approach. In asking the question as to why thereweremore qualitative studies, he suggests:

Perhaps one explanation for this disparity in research methods, might stem from the deeply subjective and personal nature of spirituality, which means that some form of rapport needs to be established between the research and the participant. This can be hard to achieve in several forms of quantitative research: for example, surveymethods that employ questionnaires. (McSherry : )

Importance of spiritual assessment

T A B L E . Spiritual assessment tools

Author and source Tool Components

Pruyser () The Minister as Diagnostician Seven Categories for Spiritual Assessment . An awareness of the holy . Providence . Faith . Grace or gratefulness . Repentance . Communion . Vocation

Discipline: Theology

Stoll () Guidelines for spiritual assessment Guidelines for Spiritual Assessment . Concept of god or deity . Sources of hope and strength . Religious practices . Relation between spiritual beliefs and health

. Obtaining spiritual data

Discipline: Nursing

MacKinlay () Spiritual Growth and Care in the Fourth Age of Life

Assessment of the Spiritual Needs of Older Adults: Level 

. Initial screening questions to identify any current and urgent spiritual needs

. Ultimate meaning in life

. Response to ultimate meaning

. Transcendence of loss and disabilities

. Moving from provisional to ultimate meanings

. Finding intimacy withGod and/or others

. Finding hope

Discipline: Nursing Assessment of the Spiritual Needs of Older Adults: Level 

McLean ()Onemore hat in the ring: a comparative synopsis and new tool for patient spiritual assessment Discipline: Chaplaincy

Spiritual Assessment . Providence . Religious practice . Relationships . Ethics . Purpose

 

A nn

H arrington

Hodge () Spiritual assessment in marital and family therapy: a methodological framework for selecting from among six qualitative assessment tools

Spiritual Assessment in Marital and Family Therapy

Table =Initial brief spiritual assessment Table =Framework for verbally based spiritual history

Discipline: Social Work Puchalski and Romer () Taking a spiritual history allows clinicians to understand patients more fully

FICA Spiritual History . Faith and belief . Importance and influence . Community . Addressed in care

Discipline: Medicine

Anandarajah and Hight () Spirituality and medical practice: using the HOPE questions as a practical tool for spiritual assessment

H=Sources of hope, meaning comfort and strength, peace, love and connection

Discipline: Medicine O=Organised religion P=Personal spiritual beliefs and practices independent from organised religion

E=Effects of medical care on spiritual practices

 

Im portance

ofspiritualassessm ent

A ‘one size fits all approach’ should not be considered for spiritual assessment as ‘some of the difficulties in applying a standardised approach to assessing spirituality include the idiosyncratic and personal nature of spirituality’ (Brennan and Heiser : ). Further, the majority of spiritual assessment tools available are based on a dialogue between health-care providers and patients. In the case of those unable to communicate (as in the case of palliative care patients at the end of life) or older adults with cognitive deficits, these tools have some limitations. They do, however, provide guidance for the novice (Harrington ). It is therefore of benefit that the health-care providers locate a tool that can be used in their particular setting. A simple search of an electronic database using the words ‘spiritual

assessment’ retrieved many tools. Given the variety of published tools, the following are by no means exhaustive and represent a small sample of those that can be used in practice. Table  offers only a brief synopsis of the entire assessment tool. The reader is encouraged to retrieve the citation in full to view the questions that are used in each tool. Once a spiritual assessment has been made using a designated tool,

‘spiritual interventions’ (also known as spiritual care) can be offered. These interventions can comprise any programmes, policies, procedures or protocols that address the spiritual needs of the individual. They can be described as any ‘activities that strengthen, reinforce or promote the spiritual and religious resources of individuals, or that utilise existing spiritual resources present in the individual to address wellbeing and needs regarding spirituality’ (Brennan and Heiser : ). Allowing consumers and patients to communicate their spiritual concerns

could be seen as a spiritual intervention (Brennan andHeiser ), but this may also have a therapeutic effect (Harrington ). Spiritual care within any setting can include giving the patient/consumer the opportunity to make their concerns known and these may be particularly evident prior to or following surgery, after the delivery of a poor diagnosis, whenever fear or discouragement appear, or when specifically requested (Brennan and Heiser ). The challenge for the health-care provider is to be alert to these cues.

Conclusion

It has been argued here that there is a growing body of literature highlighting the positive effects of religiousness and spirituality on human health. Government policy acknowledges this connection, as has palliative care, particularly when caring for older adults, and this

 Ann Harrington

acknowledgement directs health professionals to undertake a spiritual assessment. However, the professional literature of numerous disciplines is rife with verbal definitions surrounding the area of spirituality that may lead to confusion when considering a spiritual assessment. This paper clarifies a number of terms presented in the literature and

argues for the need to undertake a spiritual assessment. A variety of tools from various disciplines is offered to assist in this task and the use of these tools will assist health-care providers in their mandate to provide holistic care to all age groups.

References

Aged Care Standards and Accreditation Agency . Accreditation Standards. Available online at http://www.accreditation.org.au/accreditation/accreditation standards/ [Accessed  March ].

Anandarajah, G. and Hight, E. . Spirituality and medical practice: using the HOPE questions as a practical tool for spiritual assessment. American Family Physician, , , –.

Baldacchino, D. R., Borg, J., Muscat, C. and Sturgeon, C. . Psychology and theology meet: illness appraisal and spiritual coping. Western Journal of Nursing Research, , , –.

Banks, R., Poehler, D. and Russell, R. . Spirit and human–spiritual interaction as a factor in health and health education. Health Education, , , –.

Brennan, M. and Heiser, D. . Introduction: Spiritual assessment and intervention: current directions and applications. In Brennan, M. and Heiser, D. (eds), Spiritual Assessment and Intervention with Older Adults. Current Directions and Applications. Routledge, Taylor & Francis, New York, –.

Burkhart, L. and Hogan, N. . An experiential theory of spiritual care in nursing practice. Qualitative Health Research, , , –.

Carpenito, L. J. . Nursing Diagnosis. Application to Clinical Practice. Fourteenth edition, Wolters Kluwer/Lippicott Williams & Wilkins, Philadelphia.

Chiu, L., Emblem, J. D., Van Hofwegen, L., Sawatzky, R. and Meyerhoff, H. . An integrative review of the concept of spirituality in the health sciences. Western Journal of Nursing Research, , , –.

Cohen, M., Holley, L., Wengel, S. and Katzman, M. A. . A platform for nursing research on spirituality and religiosity: definitions and measures. Western Journal of Nursing Research, , , –.

Cowlishaw, S., Niele, S., Teshuva, K., Browning, C. and Kendig, H. . Older adults’ spirituality and life satisfaction: a longitudinal test of social support and sense of coherence as mediating mechanisms. Ageing & Society, , , –.

Daaleman, T. P., Cobb, A. K. and Frey, B. B. . Spirituality and well-being: an exploratory study of the client-perspective. Social Science & Medicine, , , –.

Ellis, J. and Lloyd-Williams, M. . Palliative care. In Cobb, M. R., Puchalski, C. M. and Rumbold, B. (eds), Oxford Textbook of Spirituality in Healthcare. Oxford University Press, New York, –.

Ellison, C. . Spiritual well-being: conceptualization and measurement. Journal of Psychology and Theology, , , –.

Importance of spiritual assessment

Ellor, J. W. and Kimble, M. A. . The heritage of religion and spirituality in the field of gerontology: Don Clingan, Tom Cook, and the National Interfaith Coalition on Aging. Journal of Religious Gerontology, , /, –.

Fowler, J. . Stages of Faith. Harper & Row, New York. Goodloe, N. and Arreola, P. . Spiritual health: out of the closet. Journal of Health

Education, , , –. Gordon, M. . Manual of Nursing Diagnosis. McGraw-Hill Book Company,

New York. Hall, T. W. and Edwards, K. J. . The Spiritual Assessment Inventory: a theistic

model and measure for assessing spiritual development. Journal for the Scientific Study of Religion, , , –.

Harrington, A. . Hope rising out of despair: the spiritual journey of patients admitted to a hospice. Journal of Religious Gerontology, , /, –.

Harrington, A. . The connection health care providers make with dying patients. Journal of Religion, Spirituality & Aging, , /, –.

Harrington, A. . Spiritual well-being for older people. In MacKinlay, E. (ed.), Ageing and Spirituality Across Faiths and Cultures. Jessica Kingsley, London, –.

Harrington, A. . A beginning understanding of carers’ spiritual needs when relinquishing a loved one to a palliative care setting. Journal of Religion, Spirituality& Aging, , –, –.

Higginbotham, A. R. and Marcy, T. R. . Spiritual assessment: a new outlook on the pharmacist’s role. American Journal of Health-system Pharmacy, , , –.

Hodge, D. R. . Spiritual assessment: a review of major qualitative methods and a new framework for assessing spirituality. Social Work, , , –.

Hodge, D. . Spiritual assessment inmarital and family therapy: amethodological framework for selecting from among six qualitative assessment tools. Journal of Marital and Family Therapy, , , –.

Hodge, D., Horvath, V., Larkin, H. and Curl, A. . Older adults’ spiritual needs in health care settings: a qualitative meta-synthesis. Research on Aging, , , –.

Holland, J. C., Kash, K. M., Passik, S., Gronert, M. K., Sison, A., Lederberg, M. and Fox, B. . A brief Spiritual Beliefs Inventory for use in quality of life research in life-threatening illness. Psycho-Oncology, , , –.

Kelvern, P. . Who can give ‘spiritual care’? The management of spiritually sensitive interactins between nurses and patients. Journal of Nursing Mangement, , , –.

Koenig, H. G. . Spirituality in Patient Care: Why, How, When and What. Second edition, Templeton Foundation Press, Philadelphia.

Koenig, H. G. . Spirituality in Patient Care: Why, How, When and What. Third edition, Templeton Press, Philadelphia.

Kreitzer, M. J. . Spirituality and well-being: focusing on what matters. Western Journal of Nursing Research, , , –.

MacKinlay, E. B. . Spiritual Growth and Care in the Fourth Age of Life. Jessica Kingsley Publishers, London.

McLean, H. . One more hat in the ring: a comparative synopsis and new tool for patient spiritual assessment. Journal of Pastoral Counselling Annual, , –.

McLean Heitkemper, M., Ross Staats, C., Harrington, A. and Hegarty, M. . Palliative care. In Brown, D. and Edwards, H. (eds), Lewis’s Medical-surgical Nursing. Assessment and Management of Clinical Problems. Fourth edition, Mosby, Elsevier Australia, Chatswood, Australia, –.

 Ann Harrington

McSherry, W. . The Meaning of Spirituality and Spiritual Care Within Nursing and Health Care Practice. Quay Books, London.

Miller, W. R. and Thoresen, C. E. . Spirituality, religion and health: an emerging research field. American Psychologist, , , –.

Moberg, D. O. . Spiritual Well-being: Sociological Perspectives. University Press of America, Lanham, Maryland.

Moberg, D. . Spiritualty and aging: research and implications. Journal of Religion, Spirituality & Aging, , –, –.

Moberg, D. . Expanding Horizons for Spirituality Research. Analytic Essay. Hartford Institute for Religion Research. Available online at http//hirr.hartsem.edu/ sociology/spirituality-research.html [Accessed  September ].

Monod, S. M., Rochat, E., Bula, C. J., Jobin, G., Martin, E. and Spencer, B. . The spiritual distress assessment tool: an instrument to assess spiritual distress in hospitalised elderly persons. BMC Geriatrics :. Available online at http://www. biomedcentral.com/- [Accessed  May ].

Mowat, H. . The promise of MHA chaplaincy: a journey towards reconciliation and restitution. A research report by Mowat Research for Methodist Homes Association, Derby, England.

National Secular Society . Costing the Heavens: Chaplaincy Services in English NHS Provider Trusts /. Available online at http://www.secularism.org.uk/ uploads/nss-chaplaincy-report-.pdf [Accessed  May ].

Paloutzian, R. and Ellison, C. . Loneliness, spiritual well-being and quality of life. In Paplau, L. A. and Perlman, D. (eds), Loneliness: A Source Book of Current Theory, Research and Therapy. Wiley Interscience, New York, –.

Pargament, K. I. . The Psychology of Religion and Coping. Guilford Press, New York. Peterman, A. H., Fitchett, G., Brady, M. J., Hernandez, L. and Cella, D. .

Measuring spiritual well-being in people with cancer: the functional assessment of chronic illness therapy – Spiritual Well-being Scale (FACIT-SP). Annals of Behavioral Medicine, , , –.

Picot, S. J., Debanne, S. M., Namazi, K. H. and Wykle, M. L. . Religiosity and perceived rewards of Black and White caregivers. The Gerontologist, , , –.

Pruyser, P. . The Minister as Diagnostician. Westminster John Knox Press, Louisville, Kentucky.

Puchalski, C. M. . Formal and informal spiritual assessment. Asian Pacific Journal of Cancer Prevention, , Supplement , –.

Puchalski, C. and Romer, A. L. . Taking a spiritual history allows clinicians to understand patients more fully. Journal of Palliative Medicine, , , –.

Ribaudo, A. and Takahashi, M. . Temporal trends in spirituality research: a meta-analysis of journal abstracts between  and . Journal of Religion, Spirituality & Aging, , –, –.

Sharma, R. K., Astrow, A. B., Texeira, K. and Sulmasy, D. P. . The Spiritual Needs Assessment for Patients (SNAP): development and validation of a comprehensive instrument to assess unmet spiritual needs. Journal of Pain and SymptomManagement, , , –.

Stoll, R. . Guidelines for spiritual assessment. American Journal of Nursing, , , –.

Swinton, J. and Pattison, S. . Moving beyond clarity: towards a thin, vague and useful understanding of spirituality in nursing care. Nursing Philosophy, , , –.

Thompson, P. K. . From Dark Night to Gentle Surrender. On the Ethics and Spirituality of Hospice Care. University of Scranton Press, Chicago.

Importance of spiritual assessment

Tuck, I. . A critical review of a spirituality intervention.Western Journal of Nursing Research, , , –.

World Health Organization a. WHO Definition of Health. Available online at http://www.who.int/about/definition/en/print.html [Accessed  March ].

World Health Organization b. WHO Definition of Palliative Care. Available online at http://who.int/cancer/palliative/definition/en/ [Accessed  March ].

Accepted  July ; first published online  September 

Address for correspondence : Ann Harrington, School of Nursing & Midwifery, Flinders University, GPO Box , Adelaide, SA , Australia.

E-mail: [email protected]

 Ann Harrington

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.