NURSING
PRACTICE &
SKILL
Authors
Carita Caple, RN, BSN, MSHS
Cinahl Information Systems, Glendale, CA
Tanja Schub, BS
Cinahl Information Systems, Glendale, CA
Reviewers
Eva Beliveau, RN, MSN, CNE
Professor of Nursing, Northern Essex
Community College
Sara Richards, MSN, RN
Cinahl Information Systems, Glendale, CA
Nursing Practice Council
Glendale Adventist Medical Center,
Glendale, CA
Editor
Diane Pravikoff, RN, PhD, FAAN
Cinahl Information Systems, Glendale, CA
May 8, 2020
Published by Cinahl Information Systems, a division of EBSCO Information Services. Copyright©2020, Cinahl Information Systems. All rights
reserved. No part of this may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by
any information storage and retrieval system, without permission in writing from the publisher. Cinahl Information Systems accepts no liability for advice
or information given herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthcare
professional. Cinahl Information Systems, 1509 Wilson Terrace, Glendale, CA 91206
Spiritual Care: Providing to Children and their Families
What is Involved in Providing Spiritual Care to Children and
their Families?
› Spiritual care is the provision of interventions that address the spiritual needs of patients
and their families. Spiritual care is recognized as a vital component of emotional and
physical health, and is important to the achievement of an overall sense of well-being
• What: Spirituality is highly individualized but is often defined as the core values of an
individual’s life, the nonphysical part of a person that forms the basis of character and
emotions, belief systems that sustain the individual through times of distress, or one’s
conception of the meaning of life that forms the core of his or her relationship with
others, nature, and/or God (i.e., as defined by the individual). Spiritual care is designed
to support spiritual beliefs and alleviate spiritual distress, which has been defined as
the impaired ability to experience and integrate meaning and purpose in life through
connectedness with self, others, art, music, literature, nature, or a power greater than
oneself. Spiritual distress is recognized by the North American Nursing Diagnosis
Association (NANDA) as a nursing diagnosis. Clinicians should be aware that the
elements of spiritual, pastoral, and culturally competent care often overlap
–Spiritual care is distinct from pastoral care, which focuses on the provision of religious
rituals and customs such as prayer, faith recommitment, blessings and sacraments,
and reading of holy books (e.g., Bible, Torah, Qur’an). In contrast, spiritual care
encourages expression of spirituality outside of the realm of religion, while facilitating
religious expression for those who desire it. While pastoral care is provided solely by
chaplains or specially designated laypersons, spiritual care can and should be provided
by all members of the healthcare team
–Spiritual care is distinct from culturally competent care, which is performed in
recognition of the historical and sociocultural factors, and values of an individual’s
community (for more information about providing culturally competent care, see the
series of relevant Nursing Practice & Skill papers)
• How: Spiritual care is provided by assessing the patient’s spirituality, encouraging
expression of spiritual beliefs, actively listening to spiritual concerns, maintaining
respect for the patient’s spiritual/religious preferences, and creating an environment
that promotes reflection, peace, meaning, and comfort. For children, spiritual health is
closely linked with strong support from parents and friends, rapport with hospital staff
members, and support in coping with invasive procedures. In providing spiritual care
to a child, the nurse clinician is responsible for assessing both the parents’ and child’s
spiritual health, and coping ability in order to implement interventions that bring comfort
to both the child and his/her family
• Where: Spiritual care can be provided in all healthcare settings, as well as in the home
• Who: Nurses are in a key position to provide spiritual care because of their extensive
interaction with patients; their focus on providing holistic care, or care of the whole
patient, including his or her physical, emotional, social, and spiritual needs; and because
they are in a position to facilitate additional support for the patient, with additional
support through collaboration with other members of the interdisciplinary healthcare
team, including chaplains, mental health clinicians, and social workers
What is the Desired Outcome of Providing Spiritual Care to Children and their
Families?
› The desired outcome of providing spiritual care to children and their families is spiritual health, improved emotional and
physiologic outcomes, and an overall sense of well-being

Why is Providing Spiritual Care to Children and their Families Important?

› Most patients, including children, perceive a greater spiritual need during times of illness. Spiritual care is designed to
address and alleviate symptoms of spiritual distress that can arise during times of illness, including feelings of anxiety,
uncertainty, fear, confusion, despair, and loneliness. Children frequently express spiritual distress as increased fear and
anxiety related to separation from family, uncertainty concerning pending medical interventions, anger and sadness at being
“different” from other children, and guilt related to the increased stress their illness causes family members

Facts and Figures

› Spiritual care has long been recognized as an important component of nursing care; early nursing leaders, including Florence
Nightingale of the 19th century, Jean Mance of the 17th century, and Hildegard of Bingen of the 12th century, stressed the
need for nurses to promote the spiritual well-being of their patients ( Wu et al., 2011)
› Researchers who surveyed 55 nurses about the spiritual needs of families of seriously ill children identified four main
themes: anger with God for their situation, blame/regret about what they might have done wrong to cause the child’s illness,
seeking forgiveness (including the parents seeking forgiveness from the child and vice versa), and the importance of ritual
and cultural traditions (Ferrell et al., 2016)
› Up to 65% of nurses report that they received insufficient education on providing spiritual care during their nurse training
(Vance, 2001). This perceived lack of education has led to a lack of self-awareness about spirituality and discomfort with
providing spiritual care to children and families. Investigators found that participation in an educational session aimed at
clarifying spiritual care and incorporating it into the nursing process of assessment, diagnosis, planning, intervention, and
evaluation resulted in pediatric and neonatal nurses having a more positive perspective toward providing spiritual care to
their patients. The researchers also found that nurses who clearly identify and become comfortable with their own spiritual
beliefs are better able to provide spiritual care to their patients (O’Shea et al., 2011)
› In a survey study of 349 nurses in Taiwan, researchers found that perception of spirituality and spiritual care was positively
associated with higher education level and having had training in spiritual care in nursing school or after graduation (Wu et
al., 2011)
› Researchers who studied the effects of spiritual care education provided to nurses in The Netherlands concluded that the
training resulted in improvement in several areas, including receptiveness and support by the nurses with regard to patient
questions about the meaning of their lives and their illness, documentation of spiritual needs, and referrals to chaplaincy
(Vlasblom et al., 2011)
› Authors of a literature review found a lack of published evidence to allow generalizations about effectiveness of approaches
to teaching nurses about providing spiritual care (Timmins et al., 2013)

What You Need to Know Before Providing Spiritual Care to Children and their Families
› Understanding of the concepts of spirituality, spiritual distress, and spiritual care, and knowledge of the differences between
spiritual care and pastoral care are essential
• Understanding that the concept of spirituality is highly individualized and defined by patients in a variety of ways
• For more information, see What is Involved in Providing Spiritual Care to Children and their Families?, above
› Knowledge of ways to provide spiritual care to children is important
• Deviation from the normal family routine, painful or uncomfortable medical treatments, uncertainty, and separation from
parents/family members increase the child’s risk for spiritual distress
• Spiritual care should be adapted to the child’s developmental and cognitive level, and can be provided in the form of
promoting increased communication with, and reassurance from parents; building rapport with healthcare providers;
engaging in play and other “normal” activities (e.g., hobbies or schoolwork); and preserving the family routine (e.g., eating
dinner together)
• An adolescent patient might have developed his/her own set of spiritual beliefs independent from his/her parents but still
values normalcy, family support, and reassurance
• For more information, see Why is Providing Spiritual Care to Children and their Families Important?, above
› Understanding that the spiritual health of the child is linked with the spiritual health of his/her parents and their ability to
comfort their child
• Parent/guardians with diminished coping ability will be less able to provide reassurance and comfort to their sick child
› The ability to respectfully understand and care for the spiritual needs of individuals with different belief systems or religious
faiths is essential
• Spirituality does not always entail structured participation in religious practices or institutions. In providing spiritual
care, the nurse should never prescribe a certain religious practice or belief, but rather encourage a patient’s individualized
expression
› Preliminary steps that should be performed before providing spiritual care to children and their families include the
following:
• Review the facility/unit-specific protocol for providing spiritual care to children and their families, if one is available
• Review the patient’s chart to determine if information regarding the patient’s spiritual/religious preferences has been
documented. This might be included as part of the admission assessment form or might be a separate form
› There are usually no designated supplies used when providing spiritual care; however, facility documentation might include
a tool for spiritual assessment

How to Provide Spiritual Care to Children and their Families

› Identify the patient according to facility protocol
› Establish privacy by closing the door to the patient’s room and/or drawing the curtain surrounding the patient’s bed
› Introduce yourself to the patient and family member(s), if present; assess the coping ability of the patient and family and for
knowledge deficits and anxiety regarding the child’s medical condition and any pending procedures
• Determine if the patient/family requires special considerations regarding communication (e.g., because of illiteracy,
language barriers, or deafness); make arrangements to meet these needs if they are present
–Use professional certified medical interpreters, either in person or via phone, when language barriers exist
› Perform a spiritual assessment of the child’s parents/guardians:
• Use open-ended questions to encourage parents/guardians to express spiritual beliefs
• Demonstrate caring and concern as you actively listen to responses
• Explain that the spiritual assessment is a normal part of assessing overall health. The following questions can be asked if
the parent/guardian is comfortable with participating in the spiritual assessment:
–Ask how he or she expresses spirituality
–Ask whether or not he or she identifies with a religion and, if so, if there is a designated location where he/she worships
–Ask whether he or she has any specific spiritual needs
–Ask how you can be supportive of his or her spiritual or religious needs during the child’s hospitalization
• Observe for unspoken spiritual preferences
–Note whether the patient reads religious materials or holy books, prays, watches or listens to religious programs, wears or
displays religious symbols or objects, or speaks of spiritual matters with others
• Determine the risk of spiritual distress
–Identify parents/guardians of children who have a life-threatening illness, medical condition or end-oflife-care
–Ask the parents/guardians how they cope with illness
–Ask the parents/guardians whether they feel sad, lonely, anxious, or fearful
–Ask the parents/guardians whether they have adequate emotional support
› Perform the spiritual assessment of the child to elicit spiritual needs, if the parents are amenable. Tailor the assessment to
the child’s developmental stage and cognitive ability, and encourage parents to remain present when assessing young and
school-age children
• Ask the child if there is anything about being hospitalized that makes him or her fearful or uncomfortable
• Ask the child what would make him/her feel most at ease during hospitalization
• Ask what he or she misses most about being at home
• Ask the child what he or she thinks about to feel calm or peaceful and if those thoughts help him or her cope with illness
› Adapt medical care to accommodate the patient’s spiritual or cultural beliefs
• Defer to parents to determine whether there are religious or cultural objections to any diet or medical interventions
–Arrange for Kosher or vegetarian diet for those who have dietary restrictions based on spiritual/religious beliefs
–Document and communicate religious objections to medical interventions (e.g., to blood transfusion) to the treating
clinician
› Assist the child and his/her family members to express their spirituality in the way that they prefer
• Help parents/guardians make contact with a facility- or community-based religious leader of their faith
• When requested and if available, provide access to spiritual books, music, and videos
• Encourage the child/family members to recall experiences that enhanced their spirituality
• Provide privacy and quiet for prayer, meditation, and/or reflection
• Become aware of special days for spiritual/religious/cultural days of observance, and respect their significance for the child
and his/her family
› Communicate with the child and family
• Interact with the child and family members frequently and meaningfully to build trust and rapport
• Thoroughly discuss impending medical interventions with both the child and his/her parent to dispel uncertainty
• Be honest about interventions that are likely to cause the child pain or discomfort, and explain how you will help him or her
cope (e.g., pain medication will be given and parents can remain with their child/hold their child’s hand)
• Actively listen to the child’s and parents’ concerns
• Do not judge or offer criticism, but acknowledge and support the feelings and viewpoints of the child and his/her parents
› Encourage communication and quality time between the child and his/her family
• Encourage parents to promote a normal routine while their child is hospitalized. This can involve eating meals together,
communicating about the day’s activities, participating in hobbies, and playing games
• Encourage parents to reassure their child with love and support in order to dispel any worry, or guilt the child feels
› Update the patient’s plan of care, if appropriate, and document providing spiritual care in the patient’s medical record,
including the following information:
• Date and time of the spiritual assessment
• Spiritual needs expressed by the child/family
• Actions taken to provide spiritual support
• The patient’s response to spiritual care

Other Tests, Treatments, or Procedures That Might be Necessary Before or After

Providing Spiritual Care to Children and their Families
› When appropriate, request referrals to a mental health specialist, facility-based chaplain, or social worker for counseling,
assistance with coping, and for community resources
› Consult with a registered dietitian if special dietary needs should be addressed
› Changes in physical health or prognosis can create anxiety and spiritual distress. Remain alert for indications that the child
and his/her family would benefit from reassessment

What to Expect After Providing Spiritual Care to Children and their Families
› The spiritual assessment is conducted on all patients to identify their spiritual beliefs, needs, and symptoms of spiritual
distress
› Spiritual support is provided in order to encourage reflection and attainment of peace, meaning, and comfort

Red Flags
› Children with terminal illness and their families are at increased risk for spiritual distress and poor coping ability. These
patients and families benefit from additional interdisciplinary support (e.g., from mental health clinicians and chaplains)

What Do I Need to Tell the Patient/Patient’s Family?

› Discuss with the child and family the purpose of spiritual care, and ways in which it can be provided
› Encourage children and family to openly communicate their spiritual beliefs and needs with the healthcare team

References
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