Spotlight on Spiritual Care

Article by Keely Jennings, Content Developer

The care of older people, especially, but not exclusively, in palliative and end of life care, should focus on several essential aspects of what ‘being human’ is all about, alongside the perhaps more obvious consideration of their physical health.

Looking at the different aspects that should be assessed, one need which might not always be discussed, sometimes for important reasons such as lack of training, is ‘spiritual care’.

While it might be assumed that perceptions of ‘spirituality’ tend to focus on faith and organised religion, spirituality itself is in fact a broad concept and has a wide variety of meanings for different individuals.

We all have spiritual needs throughout our lives, and it’s widely acknowledged by key organisations involved in the care of older people – including the NHS and the National Institute of Health and Clinical Excellence (NICE) – that spirituality relates to religious and to non-religious principles, beliefs and values.

The Royal College of Nursing (RCN) – which conducted its own survey of spirituality in 2010 – has developed a useful and comprehensive summary to describe what spirituality is about and, crucially, what spiritual care is not about.

Thinking about these different elements of spirituality and how they can enrich and enhance human lives, it is clear that effective spiritual care and support are vital for older people in care settings and, if provided, can have huge benefits for those involved. Indeed, research has shown that there is a connection between meeting older people’s spiritual needs and positive health outcomes.

The RCN’s spiritual survey findings also showed that nurses acknowledged that if patients are supported in their spiritual needs, this can result in the possibility of improving the quality of nursing care overall.

If spiritual needs are not met, especially for people who are suffering with terminal illness, people can experience ‘spiritual distress’.

If someone is unable to gain a sense of essential feelings and emotions – such as hope, love, comfort and peace – due to the monumental changes in their lives that can result from ill health, their spiritual distress may cause them to question the meaning of life or turn away from their faith.

Spiritual distress can also increase stress and anxiety which can have a detrimental effect on the person’s ability to cope with their illness, so they will need ongoing assessment and support which recognises their specific spiritual needs.

This reinforces an important consideration in spiritual care for older people which is that it should be individualised to reflect the person’s own set of values and beliefs.

Spirituality Encompasses:

• People’s fundamental feelings and values such as hope and strength, trust and forgiveness, and a sense of morality

• Having a sense of meaning and purpose in life

• The value of love and relationships with other people

• A belief and faith in yourself and others which, for some people, will involve a belief in a deity or higher power

• Essential elements such as creativity and self-expression

Spiritual Care Doesn’t Mean:

• A focus on religious beliefs and practices only

• Assuming that a chaplain is the only person responsible for people’s spiritual needs and care

• Forcing the beliefs and values that you hold on other people

• Utilising your position or role to convert another person

How Can People’s Spiritual Needs Be Assessed?

Several important themes emerge when looking at how relevant organisations and care givers, such as the RCN and those involved in delivering care for those who are terminally ill or at the end of their life, approach the assessment of older people’s spiritual needs.

An essential starting point is to encourage older people in care to talk about their thoughts, needs and wishes. Staff and volunteers should listen carefully and sensitively, without passing judgement or dismissing individual concerns, and allow enough time for each person to express their feelings. Good communication skills, including an aptitude for active listening, are extremely important.

Observation is also a key skill in terms of assessing and identifying unmet spiritual needs – for example, paying attention to the person in care’s personal possessions, such as objects or books that might relate to religion or a potentially spiritual activity such as meditation, or if someone being cared for is becoming more withdrawn, appears isolated, sad or worried, or is refusing care.

Looking at palliative care for the terminally ill specifically, Marie Curie Cancer Care has developed an instructive assessment tool for staff and volunteers. It outlines four levels of competency that should be reached by those working in all areas of care who have contact with people in their care and their families.

To reinforce the initial need to recognise people’s spiritual needs, Level 1 requires staff and volunteers to appreciate that every person has a ‘spiritual dimension’ and also that, for some people, their spirituality will have a religious element.

All four competencies also highlight that those involved in providing care should be aware of their own “personal boundaries in spiritual care”.

This is also reflected in the RCN guide on spirituality which advises that those providing care should know their own strengths and limitations and also understand when it is appropriate to request help from their colleagues and the wider team, including chaplains, counsellors and psychologists.

Other recognised tools which can help to start a conversation about spiritual needs include the HOPE questionnaire which can assist in the discussion of the following key points:

H: identifying sources of hope, meaning, peace, comfort, strength, love and connection

O: finding out about the role organised religion plays in the person’s life

P: examining personal spirituality and practices – including the aspects of these that the person finds most useful, for example prayer, meditation, music or getting involved with nature

E: assessing the effects illness may have had on the person’s spirituality or how their own spirituality might affect their medical care and end-of-life care decisions.

These questions can enable those providing care to find out what spirituality means to those in their care – including factors that might bring them, for example, hope, strength, comfort and meaning.

Another tool that can aid effective and open conversations about spiritual care is the FICA Spiritual History Tool©. Within an environment where the person feels they can trust the healthcare professional, the F (Faith and belief) I (Importance) C (Community) A (Address in Care) tool can assist in creating a person-centred ‘spiritual history’ as part of an holistic approach to care.

Barriers to Providing Spiritual Care

So, while it seems that there is an appreciation of the importance of assessing the spiritual needs of older people in care and several tools are available to assist those providing this care, it is also evident when researching this topic that potential barriers to the delivery of effective spiritual care exist.

Those working in health and social care may find it difficult to address spirituality with the people they are caring for. The following factors might contribute to this:

• A lack of training which can lead to a lack of understanding and knowledge about the spiritual domain and related spiritual care

• Staff and volunteers might not know what to say to the person and this may lead to a sense of reluctance to discuss spirituality or spiritual care - this might also be coupled with a lack of time to have these discussions

• Concerns may be raised about the ‘sensitivity’ surrounding people’s spirituality, beliefs and principles and staff and volunteers may worry that they will say something unsuitable or they may be in a situation where they might force their own values on the people they are caring for.

Organisations such as the RCN and NHS which acknowledge the need for, and subsequent positive effects of, spiritual care, have also recognised the need for training in this area.

The results of the previously mentioned RCN Spiritual Survey showed that members thought nurses did not receive sufficient training on the provision of spiritual care and that the “professional boundaries” required when discussing the spiritual needs of those in their care needed to be fully explained.

In its Chaplaincy Guidelines published in 2015, the NHS also highlighted a lack of training as having a negative effect on the ability to deliver the best spiritual care.

Other issues mentioned in the guidelines include inadequate communication, not taking a sensitive approach, and a lack of insight into the different belief systems that people may have.

Delivering Spiritual Care

As definitions of ‘spirituality’ have become broader and now encompass a diverse range of beliefs, values and principles, it has become important for those caring for older people to take a universal approach and provide access to person-centred spiritual care.

But people have different spiritual needs: for some, spirituality might be related to prayer or attending a religious ceremony or meeting; for others, it might involve spending time with friends and family, taking part in a hobby or interest, or spending time outdoors in nature. To meet these different needs, every older person in care should have access to pastoral, spiritual or religious support.

Other interesting approaches to assessing and providing spiritual care include discussing and listening to music and, in particular for people with dementia, concepts such as reminiscence therapy (which is explored in more detail in this issue).

This brief look at the wide-ranging subject of spiritual care for older people has touched on several important issues. These include the fact that spiritual needs may be unmet or not assessed in some care settings, and staff and volunteers may also lack training in how to address these needs.

If spiritual needs are identified and the appropriate care is provided, those working with older people in care can gain a better understanding of the individual. This, in turn, has the potential to support a person’s wellbeing and assist with healing.

Spiritual care can also help people to examine their concerns about terminal illness and death, thus reducing the negative effects caused by ill health