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This article is not for distribution

except for journal club use

Clinical Practice Keywords Spirituality/Faith/Religion/

Values/Meaning/Hope
Review
Assessment This article has been
double-blind peer reviewed

In this article...
● W
 hy it is important to assess older people’s spiritual needs
● Barriers to providing older people with spiritual care
● Tools, methods and approaches for spiritual care provision

Assessment of older people 6:

assessing the spiritual domain
Key points
Authors Hanneke Wiltjer is lecturer in nursing, HZ University of Applied Sciences,
Spirituality is not Vlissingen, the Netherlands; Nyree Kendall is senior lecturer and lead for district
just about religion nursing, University of Bolton, UK.
but also about
values, hope and Abstract The multidisciplinary and holistic assessment of older people allows health
meaning professionals to gain insight into their individual needs. The spiritual domain is one of
five key domains that need to be explored when assessing older people. All humans
Exploring the are spiritual beings with spiritual needs, whether or not they are religious or belong to
spiritual domain a church. Older people going through illness or faced with the proximity of death are
allows a deeper particularly at risk of a spiritual crisis. All older people cared for by health and social
understanding of care services should have the opportunity to access spiritual support. This last article
the person in a six-part series explores how to address the spiritual care needs of older people.

Spiritual care can Citation Wiltjer H, Kendall N (2019) Assessment of older people 6: assessing the
contribute to healing spiritual domain. Nursing Times [online]; 115: 10, 24-27.

S
The spiritual needs
of older people in pirituality is a much broader con-
care settings are not cept than religion and an integral
always addressed part of people’s health and well-
being. When assessing older
Barriers to spiritual people, their spiritual needs must not be
care include lack of forgotten or ignored. This article examines
time, lack of the spiritual care of older people. It dis-
knowledge and a cusses different forms of spirituality, the
reluctance to discuss principles of spiritual need assessment,
spiritual matters the impact of not addressing this care
domain, and tools and approaches that can
be used to assess older people’s spiritual
care needs.
What is spirituality?
Before discussing how to address older
people’s spiritual needs, we need to con-
textualise spirituality. For some, it is about
engagement in religious practices within
an organised group; for others, spirituality
can be mediated through a relationship, a
conversation, a landscape or a work of art
as well as through religious practice and
rituals (MacKinlay, 2017). Mowat and
O’Neill (2013) noted that there are two
schools of thought regarding the concept
of spirituality:
l I t pertains to religious belief
(Franciscan spirituality);
l I t pertains to people’s need for
meaning, which can be found in faith
in a divine entity but also in their
relationships with others.
Jewell (2011) argued that we are all spir-
itual beings, whether we realise it or not,
as we all have principles, beliefs and
values, and all need to find meaning and
purpose to our lives. The Royal College of
Nursing, in its pocket guide on spirituality
in nursing care (RCN, 2011a), explains that
spirituality is not just about religious
beliefs and values, but also about hope and
strength, trust, meaning and purpose, for-
giveness, love and relationships, morality,
creativity and self-expression.
Why spiritual care is important
In health and social care provision, spir-
itual care aims to respond to the needs of
the human spirit and provide meaning
during times of trauma and sadness; this
response could come through one’s faith

Nursing Times [online] October 2019 / Vol 115 Issue 10 24 www.nursingtimes.net

Clinical Practice
Review
or through discussion with a sensitive lis-
tener (NHS Education for Scotland, 2009).
In the context of illness, spiritual care may
be necessary to support recovery and
explore concerns about death and dying,
religious and non-religious convictions,
rituals and practices, relationships of sig-
nificance, a sense of the sacred, and beliefs
(NHS England, 2015).
There is evidence that spirituality and
physical health are linked. McCullough et
al (2000) suggested that people who par-
ticipate in spiritual activity as individuals
or in groups often live longer than those
who do not. Erichsen and Büssing (2013)
found a relationship between meeting the
spiritual needs of older people and positive
health outcomes. There is also evidence of
a link between spirituality and mental
wellbeing, as shown in Cornah’s (2006)
review of the literature.
Churches can be places of socialisation
and support, so older people who take part
in the life of a religious community will
often feel less isolated. They may also be
encouraged to follow healthier lifestyles,
as some faiths or religions condemn the
use of alcohol, tobacco and/or recreational
drugs (Zimmer et al, 2016).
According to the last UK census, which
took place in 2011, there has been a fall in
the number of people declaring they have a
religion. In 2011, 25.1% of the population in
England and Wales said that they had no
religion, versus 14.8% in the previous
census 10 years earlier (Office for National
Statistics, 2012). However, Noronha (2015)
has argued that, even though there may be
a decline in religious involvement, it is
essential that older people can continue
their spiritual development through
reflection and contemplation.
Meeting people’s spiritual needs
In the NHS Chaplaincy Guidelines, NHS Eng-
land (2015) stated that all patients, be they
religious or not, should have the opportu-
nity to access pastoral, spiritual and reli-
gious support when they need it. As out-
lined above, spirituality can express itself
through faith, so care providers need to
recognise and address people’s needs for
religious rituals and practices (Royal Col-
lege of Nursing, 2011a). However, there is
plenty of evidence that, in many health
and social care settings, the spiritual needs
of older people are not met. This may be
due a range of factors, including:
l L ack of time;
l L ack of training;
l L ack of awareness, knowledge or
ALAMY
understanding;
Nursing Times [online] October 2019 / Vol 115 Issue 10
“Historically, care
providers have been
reluctant to address the
spiritual domain of health
because a biomedical
model has been used to
frame care provision”
l R
 eluctance or fear;
l C
 oncerns about imposing one’s own
values and beliefs on others.
After all, the Nursing and Midwifery
Council’s (2018a) Code does ask nurses and
nursing associates to “make sure [they] do
not express [their] personal beliefs
(including political, religious or moral
beliefs) to people in an inappropriate way”.
In a survey on spiritual care in nursing
practice, RCN members expressed the
view that nurses did not receive enough
training on spiritual care provision and
felt that professional boundaries, when
dealing with patients’ spiritual needs,
should be clarified (RCN, 2011b).
Historically, care providers have been
reluctant to address the spiritual domain
of health because a biomedical model has
been used to frame care provision. This has
led to a narrow and directive approach to
care that, in turn, has led to a culture that
care providers are disinclined to move
away from (Brémault-Phillips et al, 2015).
There are clear links between spiritu-
ality, dignity and person-centredness, and
one cannot be considered without the
other two. Tailoring interventions to the
needs of patients can improve outcomes
but, as shown in Cornah’s (2006) literature
review, there are many barriers to good
spiritual care provision. NHS England
(2015) explains that insufficient training
and experience, poor communication,
insensitivity and lack of understanding of
25
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individuals’ belief systems can all have det-
rimental effects on the provision of good
spiritual care.
Cornah’s (2006) literature review on the
impact of spirituality on mental health
showed that spiritual care interventions
can have both detrimental and positive
effects on the individual. For Cornah, then,
it is particularly important to consider
mental health problems and coping styles
when addressing patients’ spiritual needs.
Tools, models and approaches
There are several ways to meet people’s
spiritual care needs and several tools,
models and approaches that can be used.
HOPE questions
Convinced that medical care service provi-
sion should cover people’s spiritual needs,
Anandarajah and Hight (2001) recom-
mended the HOPE questions to guide the
assessment these revolve around discus-
sion of:
H – s ources of hope, strength, comfort,
meaning, peace, love and connection;
O –r ole of organised religion for the
patient;
P – p ersonal spirituality and practices;
E – effects on medical care and end-of-life
care decisions.
The HOPE questions give practitioners
a basis for discussing spiritual needs with
patients and help them find out how to
address those needs. In the first step, prac-
titioners identify what spirituality means
to the patient and what may bring them
hope, strength, comfort, meaning and so
on. In the second and third steps, practi-
tioners identify the patient’s needs in rela-
tion to organised religion and to personal
spirituality and practices. Finally, practi-
tioner and patient discuss the impact of
medical care and interventions on the
patient’s spirituality.
It must be noted that, to be able to con-
duct useful and successful assessments
using the HOPE questions, practitioners
need to be aware of their own spiritual
beliefs and values.
FICA tool
Puchalski and Romer (2000) explored
another model of spiritual care provision.
Health and spirituality are interlinked, so
addressing a patient’s spiritual needs ena-
bles them to give meaning to their experi-
ence of illness. Puchalski and Romer rec-
ommended using a spiritual history tool
called FICA, which stands for:
F – faith or beliefs;
I – importance and influence;
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Clinical Practice
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C – community;
A – address in care.
The FICA tool covers individuals’ faith
and beliefs, their role in the community and
what is important for them in their lives.
Spirituality of illness or crisis
In 2004, Van Leeuwen and Cusveller high-
lighted that addressing spiritual needs in
ill health is not a simple matter, as there
are two very different aspects involved:
l A ssessing day-to-day spiritual needs,
such as prayer and meditation, over
which people have some control even if
they are ill;
l A ssessing what they referred to as the
“spirituality of illness or crisis”, in
which people who are faced with major
changes in their lives due to ill health
(or any crisis situations) experience
spiritual distress that may lead them to
question the meaning of life or reject
their faith; their stress and anxiety
increase while their ability to cope with
illness decreases.
Van Leeuwen and Cusveller (2004) rec-
ommended that patients going through
spiritual distress receive regular and
ongoing holistic assessment and support
that uses a multidisciplinary approach
that is sympathetic to their spiritual needs
(which may be personal to them or linked
to their cultural background).
Spiritual Distress Assessment Tool
Monod et al (2010) developed the Spiritual
Distress Assessment Tool (SDAT), designed
to assess spiritual distress in hospitalised
older people. The authors felt such a tool
was needed because of evidence that spir-
itual needs were still under-assessed in
many settings specialising in care of older
people, and that many hospital chaplains
were unaware of the different dimensions
of spiritual care, but focused on religion.
The SDAT identifies four domains of spir-
ituality:
l M
 eaning;
l T
 ranscendence;
l V
 alues;
l P
 sychosocial identity.
To successfully ensure patients’ spir-
itual needs are met, it is important to con-
sider their values so their care can be indi-
vidualised and they can be referred on to
others as required (Monod et al, 2010).
Spiritual needs framework
Nelson-Becker et al (2007) created a frame-
work for clinicians to assess the spiritual
needs of older people. It encompasses 11
domains, as follows:
Nursing Times [online] October 2019 / Vol 115 Issue 10
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Box 1. Reflection exercise: spiritual domain assessment in a
care home
Joyce Simpson* is 93 years old. From childhood onwards and throughout her entire
life, she has attended her local Methodist church and been an active member of that
community. Five years ago, Ms Simpson had a sudden stroke, which left her with
limited mobility and dementia. On discharge, she moved into a nursing home, which
was some distance away from the community she knew and loved. The care home
arranged for a priest to come once a month to deliver a sermon to its residents.
You are a member of the nursing care team at the home and reflect on the
following questions:
l Are Ms Simpson’s spiritual needs being met at the care home?
l How would you assess Ms Simpson’s spiritual needs?
l Who could you involve in Ms Simpson’s care to meet her spiritual needs?
l What needs to feature in your action plan to address Ms Simpson’s spiritual needs?
*
The person’s name has been changed
l A
 ffiliation; spiritual needs”. The RCN (2011a) acknow-
l S
 piritual beliefs; ledged that, to meet the spiritual needs of
l S
 piritual behaviour; older people, nurses need to:
l E
 motions; l A
 dopt a caring attitude;
l S
 piritual experiences; l R
 ecognise an older person’s need to
l V
 alues; engage in spiritual care by using
l S
 piritual history; observation and effective listening skills;
l T
 herapeutic change; l R
 ecognise the individual’s preferences
l S
 ocial support; about spiritual care provision and not
l W
 ellbeing; redirect them inappropriately.
l E
 xtrinsic/intrinsic spiritual propensity. Marie Curie noted that all staff and vol-
This framework was developed to sup- unteers involved in spiritual care should
port the spiritual assessment of older have some level of competence in terms of
people from a social-work perspective, recognising people’s needs and offering
ensuring a holistic approach to care that adequate interventions. To help in that
goes beyond physical needs. respect, it has developed spiritual and reli-
gious care competencies for health profes-
Other approaches sionals working in specialist palliative care
There are many other approaches that can (Bit.ly/MarieCurieSpiritual).
be used to assess and address the spiritual Anyone involved in spiritual care provi-
needs of older people. One is reminiscence sion needs to acknowledge that this is not
therapy, which allows them not only to dis- just about meeting religious needs; those
cuss spiritual beliefs but also to establish a involved in assessing patients need to be
relationship, thereby allowing the discus- able to:
sion to evolve (Bender et al, 1998). Other
approaches include: Box 2. Reflection exercise:
l U
 sing music to develop bonds;
evaluate practice
l E
 ffective listening;
l R
 itualistic prayer or worship (Mowat Take a moment to reflect on practice –
and O’Neill, 2013). your own and/or that of other members
of staff – to identify whether the
Staff competencies spiritual needs of older people are met
Van Leeuwen and Cusveller (2004) sug- in your workplace. Consider the
gested that nurses need a number of com- following questions:
petencies to explore and address patients’ l How well is spiritual care assessed in
spiritual needs – first and foremost, the your workplace?
competency to conduct a holistic assess- l What barriers prevent you or your
ment – but the environment and circum- colleagues from assessing the
stances of care provision need to be favour- spiritual needs of the older people
able to such assessments. under your care?
The NMC (2018b) expects registered staff l What could be done to improve the
to “prioritise the needs of people when assessment process in terms of
assessing and reviewing their mental, phys- spiritual care provision?
ical, cognitive, behavioural, social and
26 www.nursingtimes.net

Clinical Practice
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l R
 ecognise their own limitations;
l L
 iaise effectively with the
multidisciplinary team.
Spiritual care in dementia
An area in which spiritual care provision is
deemed particularly important is in the
management of people with dementia.
Ødbehr et al (2017) described spiritual care
for this group as:
l P
 erforming religious rituals that
provide a sense of comfort;
l C
 oming to know individuals with
dementia, which provides an
opportunity to understand what gives
meaning and purpose to their lives;
l A
 ttending to their basic spiritual
needs, which provides an opportunity
to appreciate their vulnerability and
humanness.
Discussions between the health profes-
sional and the individual allow the health
professional to create a trusting environ-
ment in which the relationship can
flourish and the individual can feel lis-
tened to and supported. Such discussions
allow the health professional to get to
know the individual and instigate inter-
ventions to address their needs.
For Wells (2017), addressing a person’s
spiritual needs – especially if that person
has dementia – creates connectivity;
Wells adds that some care environments
can be perceived as “inhumane”, so inter-
ventions allowing people to express their
individuality, values and beliefs should be
encouraged.
MacKinlay and Trevitt (2010) discussed
the use of reminiscence therapy and life
story telling to help people who have
dementia with their spiritual needs. These
activities foster an understanding of the
person’s life, thereby providing meaning,
and promote interaction with others,
thereby enhancing socialisation.
Conclusion
In many settings, health professionals are
reluctant to tackle the spiritual domain of
care. Some may lack the required under-
standing, awareness and knowledge;
although there are several tools and
models supporting the delivery of spiritual
care available, their implementation is
patchy. Care providers may consider that
discussing religious faith is sufficient to
meet older people’s spiritual needs, but
spirituality is not only about religion but
more broadly about individuals’ princi-
ples, beliefs and values.
The spiritual domain should be an inte-
gral part of the holistic assessment of older
Nursing Times [online] October 2019 / Vol 115 Issue 10
Box 3. Questions to assess the spiritual domain of health in
older people
l Do you consider yourself spiritual or religious?
l What kind of activities or viewpoints are important to you? Which activities or
viewpoints give value to your life?
l Would you like to receive spiritual support in any way?
l Do you attend a place of worship?
l Is there any religious or spiritual ritual that you would like to continue during your
stay in this facility?
l Is there any religious or spiritual ritual that you need support with?
l Would you like to discuss your spiritual needs with a professional?
l Would you like to stay in touch with your faith community in any possible way?
people. It allows a deeper understanding of
the person, thereby providing meaning,
building up a person’s ability to cope and
reducing the negative impact of disease
and ill health. Boxes 1, 2 and 3 offer reflec-
tion exercises and questions that can be
used to assess the spiritual domain of
health in older people. The fact that spir-
itual care can enhance people’s experience
of illness and contribute to the healing pro-
cess needs to be more widely recognised. NT
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CLINICAL
Assessment of older people
SERIES
series
Part 1: Definition, principles and tools May
Bit.ly/NTOldAssess1
Part 2: Physical domain Jun
Bit.ly/NTOldAssess2
Part 3: Functional domain Jul
Bit.ly/NTOldAssess3
Part 4: Psychological domain Aug
Bit.ly/NTOldAssess4
Part 5: Social domain Sep
Bit.ly/NTOldAssess5
Part 6: Spiritual domain Oct
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