CHAPTER 4
Providing Spiritual Care
Using a Systematic Approach
Introduction
Chapter 2 explored the concept of spirituality, offering several explanations and definitions. These definitions were revisited in Chapter 3 when the concept of spirituality was discussed in relation to holism and conceptual models of care. This chapter covers the concept of spirituality in relation to ‘a systematic approach’ identifying how spiritual care may be provided within this framework. It is important to remember that individuals who are in need of health care will arrive with their own spirituality and spiritual needs that have developed across their lifespan.
It is wrong to imagine that a person’s spirituality, or indeed their spiritual needs, will be left at the entrance of the hospital or outside the care setting. In fact, Murray and Zentner’s (1989) definition of spirituality suggests that for some individuals illness or hospitalization may see a refocusing or questioning of their spirituality. An illness, or indeed any crisis, may act as a trigger that moves the individual to revisit, encounter, or ‘get in touch with’ their own spirituality (Narayanasamy 1996). Therefore, it is not unrealistic to assume that at some point during the course of a health care professional’s career they will encounter a patient in their area of practice or under their care who has a spiritual need(s). However, McSherry’s (2004) study suggests that not all patients will present with a spiritual need, or even raise any existential or spiritual issues as a result of their illness. Therefore, we cannot make assumptions within health care that all patients or service users will develop or present with spiritual needs(s), or that they will want to discuss matters of a spiritual nature with health care professionals.
Activity 4.1
Before reading the rest of this chapter, spend a few moments reflecting upon your understanding of what is meant by the phrase ‘a systematic approach’. Write down any thoughts or experiences that come to mind.
You may well have asked yourself what this exercise has to do with the provision of spiritual care. The answer is that an individual, who is experiencing a spiritual need, as described in Chapter 2, may require such a need to be systematically addressed by the health care professional. Once the need (problem) has been identified, or disclosed by the patient, a goal will need to be formulated. After a prescribed period of time, an evaluation should be undertaken to establish whether the intervention or actions taken by the nurse (team) have been effective. This summary is an oversimplification and there are many issues surrounding spirituality and a systematic approach that will be addressed during the rest of the chapter.
When undertaking Activity 4.1, several thoughts or experiences may have come to mind. First, you may have recalled that a systematic approach is a way of organizing nursing care for patients using a problem-solving approach. Second, you may know that, for example, the nursing process is systematic and cyclical, involving a series of steps or stages starting with assessment and ending with an evaluation of the effectiveness of the care provided (Figure 4.1).
A systematic approach to care, or in nursing the term ‘the nursing process’, provides a ‘safety’ mechanism for assessment and evaluation of care. In recent years within nursing (you might want to reflect upon the different innovations within your own profession), numerous types and variations of care plan have come into existence – for example, core care plans (Cowell and Swiers 1997), critical or care pathways (Currie and Harvey 1998) and multidisciplinary collaborative care plans (Scott and Bowen 1997). Despite the emergence of these new methods of recording care, it can be argued that the principles of a systematic approach still apply and are fundamental to their success.
Research undertaken by a host of researchers (see Chapter 7 – Table 7.1) indicates that health care professionals are encountering patients with spiritual needs during the course of their daily practice. Such research findings stress the importance of having some mechanism to ensure that patients’ spiritual needs will be effectively addressed and met in health care practice.
Figure 4.1: Cyclical processes: a systematic approach to care. Assessment: Conducting a spiritual assessment, recognizing a patient’s spiritual need(s). It is important to be aware that assessment does not end after initial admission but that it is a continuous ongoing process of observation and possible re-assessment. Planning: The identification of those factors that are important to the individual’s spirituality. This leads to the setting of goals, short- or long-term, that may be achievable by the individual in meeting his or her spiritual need(s). Implementation: The identification and, where appropriate, the documentation of those interventions that may be instrumental in meeting the spiritual need(s) or enabling the patient to maintain his or her own spiritual needs while ill. Evaluation: The identification of a criterion that may indicate that a patient’s spiritual need(s) has been sufficiently addressed. The patient may report a sense of spiritual well-being or a feeling of being at peace with himself or herself or the situation.
In summary, a systematic approach enables health care professionals to identify a patient’s health care problem(s) or needs, placing them in a systematic plan of care that is individualized and patient-centred, irrespective of the patient’s underlying condition. The diagram illustrates the cyclical nature of spiritual assessment. We are continuously re-assessing, implementing and re-evaluating care.
Kratz (1979 p.3) states:
The nursing process is a problem-solving approach to nursing that involves interaction with the patient, making decisions and carrying out nursing actions based on an assessment of an individual patient’s situation. It is followed by an evaluation of the effectiveness of our actions.
It is not unreasonable to suspect that this type of systematic approach is familiar to and utilized by many health care professionals in the organization and management of their care. A similar model of systematic assessment is provided by Govier (2000) who proposes that spiritual care can be summarized by the ‘Five Rs’ (Reason, Reflection, Religion, Relationships and Restoration) and delivered within a cyclical process, while Whipp (2001), when discussing the application of theological audit in health care organizations, presents an audit model that may lead to improvement in operational aspects of patient care. Therefore, it is not unreasonable or unrealistic to apply this systematic approach to an individual who presents with a spiritual need, nor is it unrealistic to suggest that the majority of health care professionals would feel comfortable and familiar with this form of care delivery. Ross (1996) suggests that spiritual care should be delivered to patients and taught to nurses, and this recommendation could be extended to include all health professions within the framework of the nursing process or a systematic approach. However, in recent times, the nursing process or a systematic approach has been the subject of much debate and criticism. Marks-Maran (1999) feels that it is now outdated.
Despite recent criticism, the four stages involved in the systematic approach – assessment, planning, implementation and evaluation (Figure 4.1) – can still be applied to problems of a spiritual nature (Harrison and Burnard 1993). Each of these stages will be addressed in detail during the rest of the chapter. However, it must be emphasized that the main principles of a systematic approach may need to be modified to meet an individual’s circumstances. Spiritual problems do not fit neatly into each stage of the cyclical process because these needs are usually complex. In fact, spiritual needs may go unrecognized during an initial assessment (McSherry 1996). These issues will be explored through the use of case studies and reflective exercises.
Another point that must be borne in mind when introducing a systematic approach is the issue of documentation. The importance of documentation or record-keeping within health care has generated much debate in relation to legal and ethical issues and who might have access to such information (Data Protection Act 1998). You are also encouraged to look at the implications of the Caldicott Report (DH 1997) which has led to the publications and guidance for NHS staff and, more recently, for people working in social care when dealing with issues of confidentiality and patient information (DH 2003). In stressing the importance of documentation, a simple principle applies. If a nurse’s, or indeed any health care professional’s, care or actions are disputed, bringing into question the quality or standard of the care provided, then if nothing is written there will be nothing in their defence – a ‘belt and braces mentality’. However, where a patient’s or service user’s problem originates from the spiritual dimension, owing to the sensitive and deeply personal nature of the issue identified, it may not be appropriate to document the concern or even devise a care plan. Patient confidentiality and consent is a very important issue when providing spiritual care. These legal and ethical issues will be addressed towards the end of the chapter.
Assessment
The first stage in a systematic approach is assessment of an individual’s care needs. Assessment involves the gathering of information, perhaps from a wide range of sources – i.e. patient, medical records or family – by various means such as questioning or observation, in order to identify the patient’s actual or potential problems. As you may recall, an assessment framework that is widely used in the UK involves the twelve activities of daily living based on or derived from the Roper, Logan and Tierney ‘model of living’ (1990), and this type of model or a similar one is used by many health care professionals. These activities are used as a checklist or template to provide some structure for the initial or admission assessment depending upon whether the context of care is primary, secondary or tertiary.
Activity 4.2
Read Case study 4.1. Then write down on a piece of paper the types of questions that you might ask Mr Smith during the admission procedure.
Case study 4.1 Looking beyond the obvious
Mr Smith, a 75-year-old retired miner, is admitted onto your ward or under your care with a chest infection. Mr Smith has been unwell for several weeks. He has become extremely breathless upon exertion and has developed a productive cough. He reports that he has recently been bereaved, his wife dying from breast cancer.
The admitting nurse or health care professional might use the twelve activities of daily living as a mechanism for systematically enquiring into all aspects of the individual’s life – in principle, an individualized, patient-centred and holistic approach, providing a comprehensive and detailed assessment of the individual’s normal function and subsequent needs (Table 4.1). However, the assessment and identification of a patient’s spiritual needs may be problematic. Because of the sensitive nature of spirituality, an individual may not share or reveal such information during an initial assessment since spirituality is normally incorporated under the section ‘dying’. However, many care plans or admission records now incorporate a section entitled ‘spiritual needs’. With regards to spiritual assessment, a number of frameworks or assessment tools have been developed that may assist health care professionals in exploring the spiritual dimension of their patients or service users (Box 4.1).
Undertaking this exercise may have been easy in relation to several of the categories that address physical activities, such as eating, drinking or breathing. Similarly, we may feel comfortable with asking specific questions relating to our professional role – for example, a physiotherapist may enquire into the impact of the breathlessness upon mobility while a dietician may focus upon appetite, and the occupational therapist may explore personal activities such as washing and dressing. However, there may have been some areas of Mr Smith’s life that were difficult to assess – for example, his recent bereavement, his own attitudes towards death and dying, or even issues surrounding spiritual needs or sexuality. It has been recognized that there are several aspects of health care that are considered taboo; these include sexuality, death and dying, and matters concerning spirituality. Nurses and other health care practitioners may overlook these areas when assessing a patient (Burnard 1988).
Table 4.1 Admission assessment based on the activities of daily living
Box 4.1 Summary of published frameworks/models used in the advancement of spiritual issues
Highfield (1993)
Acronym PLAN
P: Permission
L: Limited information
A: Activating resources
N: Non-nursing assistance
Govier (2000)
Five ‘R’s of spirituality: Reasons
Reflection
Religion Relationships Restoration
Ross (1996)
McSherry (2000)
A systematic cyclical approach, incorporating the five phases:
Assessment
Planning
Implementation
Evaluation, and reassessment
Narayanasamy (1999, 2001)
ASSET Model (Actioning spirituality and spiritual care education and training in nursing)
ACCESS
A: Assessment
C: Communication
C: Cultural negotiation and compromise
E: Establishing respect and rapport
S: Sensitivity
S: Safety
Puchalski and Romer (2000)
Acronym FICA
F: Faith or beliefs
I: Importance and influence
C: Community
A: Address
Anandarajah and Hight (2001)
Acronym HOPE
H: sources of hope, meaning, comfort, strength, peace, love and connection
O: Organized religion
P: Personal spirituality and practices
E: Effects on medical care and end-of-life issues
Source: Nyatanga and Astley-Pepper (2005, p.115)
Activity 4.3
Reflecting upon your own clinical experience, can you recall the number of care plans you have encountered that have addressed or identified in detail a patient’s spirituality or spiritual needs?
Your reflections may reveal that you have encountered very few care plans or admission assessment forms that have identified a patient’s spiritual need(s) while in hospital or out in the community. You may have recalled that in the ‘spiritual needs’ section the patient’s religious beliefs had been written as C of E (Church of England) or RC (Roman Catholic). You may also have identified that on many occasions the section was left blank or empty. There are several reasons for the box remaining blank; these are listed in Box 4.2.
Box 4.2 Reasons for spiritual needs section being left empty
The subject of spiritual needs is too intrusive and personal to address on admission.
The admitting health care professional nurse did not feel comfortable in addressing such questions.
The patient did not want to answer the question or did not identify any spiritual needs at the time of admission.
The patient, and indeed the nurse, did not understand the term ‘spiritual needs’.
The patient identified a spiritual need considered too private and sensitive to write or disclose in his or her care plan.
In order to address the fears and apprehensions that health care professionals may experience when asked to address or assess matters of a spiritual nature, several authors have devised questions or guidelines that may make spiritual assessment easier.
Stoll (1979) presents some guidelines for undertaking a spiritual assessment:
Concept of God or deity. The types of questions that may be asked by the nurse addressing this aspect of spirituality are: Is religion or God significant to you? If yes, can you describe how? Is prayer helpful to you? What happens when you pray? (p.1572)
Sources of hope and strength. Who is the most important person to you? To whom do you turn when you need help? Are they available? (p.1575)
Religious practices. Do you feel that your faith (or religion) is helpful to you? If yes, would you tell me how? Are there any religious practices that are important to you? (p.1576)
Relationship between spiritual beliefs and health. What has bothered you most about being sick (or in what is happening to you)? What do you think is going to happen to you? (pp.1576–1577)
Activity 4.4
Spend several minutes reflecting upon these guidelines and write down your first impressions.
It is suggested that assessment in relation to the identification of spiritual needs must be an ‘ongoing’ exercise. Questioning an individual about his or her religious orientation or spiritual needs may be appropriate and helpful on admission to hospital, or when first meeting them in the community, in identifying those individuals for whom religious affiliation and practice are fundamental to their spiritual well-being. However, caution must be exercised as for the unbeliever, atheist or agnostic (Burnard 1988) this type of questioning may be threatening. Stoll’s guidelines do suggest the types of areas that may need to be addressed within a spiritual assessment. She herself, towards the end of her article (Stoll 1979, p.1577), writes:
Neither sexual nor spiritual values should be introduced at the beginning of the interview. I have found it beneficial to separate sexuality from spiritual concerns with questions pertaining to physical and social needs. The spiritual dimension lends itself to being a continuation of the psychosocial assessment toward the latter part of an interview.
This quotation highlights the sensitivity that has to be employed when discussing spiritual concerns. Two major questions must be considered before nurses, chaplains and academics ‘steam roll’ ahead in designing complex assessment criteria:
1.Can spiritual needs be identified by the use of assessment tools – for example, those used to predict or identify those individuals at risk of developing a pressure sore, i.e. Waterlow score? Or using visual analogue scales to identify the amount and type of spiritual pain an individual may be experiencing?
2.Can spiritual needs be predicted by such mechanistic interventions and calculations? The definitions of spirituality presented in Chapter 2 demonstrate that it is a very subjective, complex and individually determined aspect of life.
CAUTION
There is a danger in making spiritual assessment mechanistic, reducing it to a tick box exercise that may negate the use of other modes of continuous assessment (Catterall et al. 1998). This can be illustrated by the following question: What if a patient is assessed on admission by one nurse or health care professional who, at that time, felt the patient did not have any spiritual needs? Does this mean that such an individual may not develop a spiritual need(s) during the course of their illness or hospitalization? If you can recall Murray and Zentner’s (1989) definition, this seems to support the principle of continuous assessment because during their period of illness or hospitalization individuals may begin to question the meaning of life or the implications of illness (Simsen 1985), perhaps facing the prospect of death. Such existential questions may not be raised, or identified, when a patient is first admitted into hospital. The dangers or problems that can arise when even the crudest of spiritual assessments is not undertaken during admission to hospital are raised in Case study 4.2. informed by Peter of his admission into hospital and she was intending to visit as soon as possible. In the afternoon on the following day Peter was due to be discharged when he developed sudden severe central chest pain, collapsing with a cardiac arrest – resuscitation was initiated. During the resuscitation, Peter’s wife arrived on the ward. Unfortunately, she did not see Peter before he died. After Peter’s death, his wife asked if the Catholic priest had been. Inspection of the nursing notes showed that nothing in relation to religion had been entered.
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