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Journal of Religion, Spirituality & Aging

ISSN: 1552-8030 (Print) 1552-8049 (Online) Journal homepage: http://www.tandfonline.com/loi/wrsa20

Spirituality, spiritual need, and spiritual care inaged care: What the literature says

David Jackson, Colleen Doyle, Hannah Capon & Elizabeth Pringle

To cite this article: David Jackson, Colleen Doyle, Hannah Capon & Elizabeth Pringle (2016):Spirituality, spiritual need, and spiritual care in aged care: What the literature says, Journal ofReligion, Spirituality & Aging, DOI: 10.1080/15528030.2016.1193097

To link to this article: http://dx.doi.org/10.1080/15528030.2016.1193097

Published online: 14 Jul 2016.

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Spirituality, spiritual need, and spiritual care in aged care:What the literature saysDavid Jacksona, Colleen Doylea, Hannah Capona, and Elizabeth Pringleb

aNational Ageing Research Institute, Royal Melbourne Hospital Royal Park Campus, Parkville, Victoria,Australia; bImprovement Matters Pty Ltd, Galston, New South Wales, Australia

ABSTRACTThis article addressed the following questions: How arespirituality, spiritual need, and spiritual care in aged caredefined? What constitutes spiritual care for older people inaged care? From an organisational perspective, what arebarriers and enablers to providing spiritual care?Spirituality and spiritual care were defined in a variety ofways in the literature. The literature endorsed nurses andother aged care staff engaging in elements of spiritual careof older people as valuable. A whole-of-organisationapproach is required rather than leaving it to the individual.New guidelines are being developed specifically for spiritualcare in aged care.

KEYWORDSAged care; guidelines;organisational approach;spiritual care

Background

Existential or spiritual concerns are of fundamental importance and areespecially important for older people and those faced with their own mor-tality (Bruce, Schreiber, Petrovskaya, & Boston, 2011). Older people receivingaged care services in nursing homes or in the community may feel unable toexpress such existential or spiritual concerns during care, thereby creating aform of distress that can easily become a neglected component of theiroverall suffering and distress. For those providing care to older people,meeting spiritual needs can be considered lower priority than physicalneeds especially when health care resources are stretched or organisationaldemands are high.

Best practice increasingly identifies spiritual care as a component ofcare in general (International Council of Nurses, 2012; World HealthOrganization, 1998). However, up to now there has been little guidanceon the provision of spiritual care with specific reference to aged care andno specific guidelines exist as yet for these care settings. In preparationfor the development of Australian guidelines for use in aged care, we

CONTACT Colleen Doyle c.doyle@nari.unimelb.edu.au National Ageing Research Institute, 34–55 PoplarRoad, Parkville, VIC 3052, Australia.

JOURNAL OF RELIGION, SPIRITUALITY & AGINGhttp://dx.doi.org/10.1080/15528030.2016.1193097

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reviewed the literature on spirituality, spiritual need and spiritual carefor older people.

This article aimed to address the following questions through a descriptiveand analytical summary of the literature:

(1) How are spirituality, spiritual need, and spiritual care defined in thecontext of meeting the needs of older people receiving aged care?

(2) What constitutes spiritual care and its elements for older people inaged care?

(3) Within an organisational approach, what is needed in order to applythe elements of spiritual care?

Method

The literature on spirituality, spiritual need, and spiritual care covers a widerange of disciplines and approaches so in order to address the questionsposed, a literature search strategy involved a number of steps and a widerange of databases including nursing, allied health, psychology, medical,business, and sociological data bases (see Figure 1). This approach yieldeda large database of articles. After excluding papers not relevant to theresearch questions and duplications, a total of 335 relevant papers wereselected for review and added to EndNote software. Searches were performedon keywords and research terms within EndNote to address the researchquestions and to create groups for the relevant sections of this review.

Results

The results of the literature search were categorised into descriptive defini-tions of key terms, and a more analytical review of the topics that addressedour second and third research questions. Each of these descriptive andanalytical summaries are provided below.

Definitions

A significant gap was found in the literature for definitions of spirituality,spiritual need and spiritual care in the context of aged care. Neverthelessnumerous definitions of these terms were found, and of those the followingdefinitions appeared most relevant to aged care.

SpiritualityThe following definition captures the main concepts used in the literature todefine spirituality:

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Spirituality is the aspect of humanity that refers to the way individuals seek andexpress meaning and purpose and the way they experience their connectedness tothe moment, to self, to others, to nature, and to the significant or sacred.(Puchalski, Vitillo, Hull, & Reller, 2014, p. 643)

PsycINFO

Figure 1. Development of search strategy used to collect literature on spiritual care andspirituality in aged care.

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Within various disciplines there was a documented lack of consistency ofdefinition of what was spirituality, what were the needs of variousgroups, e.g., older people and people from different cultural back-grounds, and what were the methods of providing spiritual assessmentsand care (Timmins, Murphy, Neill, Begley, & Sheaf, 2015).

The following view of spirituality was offered by National Health ServiceScotland (2009):

Spirituality provides the higher level intelligence and wisdom which integratesthe emotional with the moral. It acts as a guide in integrating different aspectsof personality and ways of being and living. It is found in the integration ofseveral deep connections: the connection with one’s true and higher self; theconnection with society and especially with the poor, the deprived and under-privileged; the connection with the world of nature and other life forms; andfor some, a connectedness with the transcendent. (p. 19)

Spiritual needNo papers were found that addressed a definition of spiritual need in olderpeople living in residential aged care or receiving home care.

Narayanasamy (1991) defined spiritual need in the following terms, whichseemed relevant to aged care settings:

The need to give and receive love; the need to be understood; the need tobe valued as a human being; the need for forgiveness, hope and trust; theneed to explore beliefs and values; the need to express feelings honestly;the need to express faith or belief; the need to find meaning and purpose inlife.

Spiritual careSpiritual care occurs in a compassionate relationship and responds to aperson’s search for meaning, self-worth, and their need to express themselvesto a sensitive listener.

National Health Service Scotland (2009) offered the following definition ofspiritual care:

. . . that care which recognises and responds to the needs of the human spirit whenfaced with trauma, ill health or sadness and can include the need for meaning, forself-worth, to express oneself, for faith support, perhaps for rites or prayer orsacrament, or simply for a sensitive listener. Spiritual care begins with encouraginghuman contact in compassionate relationship, and moves in whatever directionneed requires. (p. 6)

The National Health Service Scotland (2002) differentiated between spiritualcare and religious care suggesting that “spiritual care is usually given in a oneto one relationship, is completely person-centred and makes no assumptions

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about personal conviction or life orientation,” while in contrast, “religiouscare is given in the context of shared religious beliefs, values, liturgies andlifestyle of a faith community” (NHS Scotland, 2002, p. 6).

Spiritual care was not characterised in the literature as being just aboutreligious beliefs and practices or about imposing one’s own beliefs and valueson another, using one’s position to convert. Nor was spiritual care a specialistactivity or the sole responsibility of the chaplain (Royal College of Nursing,2011).

According to the National Health Service Scotland, spiritual care could beprovided by all health care staff, by carers, families, and other patients.

The elements of spiritual care in aged care

In order to address the second research question, papers on spiritualcare were categorised into the components or elements of spiritual care.In the literature a number of elements of spiritual care were described.The literature supported that it was important to provide an environ-ment in which a person’s religious, spiritual, and cultural beliefsand values were safeguarded (Ramezani, Ahmadi, Mohammadi, &Kazemnejad, 2014).

Spiritual assessmentAssessment was a key element. The importance of spiritual assessment waswidely affirmed in the literature (Baldacchino, 2010; Fitchett, 2012;MacKinlay, 2006). However, there was no agreement regarding definition,methodology, or domains to be assessed. One article identified sixapproaches to spiritual assessment (McSherry & Ross, 2010): direct method,indicator-based assessment, use of audit tools, value clarification, indirectmethods, and acronym-based methods.

A number of tools for spiritual care assessment both for patients andfamilies were identified (Oliver, Galiana, & Benito, 2015), including bothquantitative and qualitative tools (Hodge & Horvath, 2011; Hodge,Horvath, Larkin, & Curl, 2012). There was general consensus that spiritualassessment should be carried out using a two-stage approach: initial spiri-tual screening and an in-depth spiritual assessment (Fitchett, 2012;MacKinlay, 2006; McSherry & Ross, 2013; Puchalski, 2012). The explora-tion of a person’s spirituality or their perspective would help to understandtheir sources of strength and hope and their spiritual needs (Ramezaniet al., 2014).

Trusting relationshipsIn the literature a trusting relationship was considered to be another elementof spiritual care. Such relationship develops slowly, taking months before

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older persons would be ready to open up and talk about deeper issuespresent in their life (Wilkes, Cioffi, Fleming, & LeMiere, 2011). For olderpeople, having someone other than a family member or a person living inthe residential facility (perhaps a person in similar circumstances to them-selves) was important to gain an outside perspective and to provide an outletto share what was going on inside. In a trusting relationship an olderperson would be able to open-up and honestly disclose deeper thoughtsand confide in the person providing spiritual care. From a practitioner’spoint of view, each individual relationship would be built on the premiseof being a companion on every step of a journey with an older person.It would incorporate spending time, being present, active listening,and passive responses and would see the practitioner contributing tothe person’s life not only in conversation but in practical and in physicalways.

An example of a trusting relationship is found in an analysis of a cha-plain’s journey with a terminally ill patient (Maddox, 2012). The chaplainsought to assess a person’s spiritual needs and over a period of time formed arelationship, built upon faithful companionship, that was essentially anintentional, authentic human relationship grounded in professional sacredintent (Schlauch, 1995).

From a nursing perspective, an important element of a trusting rela-tionship is the concept of patient-centeredness. That is, seeing theperson uniquely as an individual and having the ability to reflect uponthis. Developing meaningful therapeutic relationships that instilled hopeusing spiritual, religious, and complementary therapies formed anotherattribute of a trusting relationship in spiritual care (Ramezani et al.,2014).

Other aspects of a relationship that is trusting included responding ina non-judgemental way and active listening (Ramezani et al., 2014).

SupportSupport as an element of spiritual care could be on an individual or groupbasis. One paper that described supportive-affective group experiences forolder persons with life-threatening illness focussed on spiritual and religiousaspects of the illness experience and tested a psycho-sociospiritual interven-tion (Miller, Chibnall, Videen, & Duckro, 2005). Small groups of people withlife-threatening illness met for 75 minutes monthly for 12 months and werefacilitated by one or two staff with enabling, mediating, and motivating skills.Groups discussed immediate challenges, emotions, and spiritually challen-ging aspects of life-threatening illness. Therapy was more concerned with theprocess than about the content, offering people a chance to connect with self,others, and the transcendent. The study showed that supportive therapy

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reduced depression symptoms, increased spiritual well-being, and reducedfeelings of meaninglessness.

RitualsRituals are another element of spiritual care that could be beneficial forolder people living with cognitive impairment or with dementia (Carr,Hicks-Moore, & Montgomery, 2011). MacKinlay and Trevitt (2010) dis-cussed the importance of rituals in providing cues to older people andpeople living with dementia. Rituals provided patterns and symbols andcould be as simple as familiar sights, or spaces (e.g., a church interiorand/or the smell of wine or bread). For older people of a particular faithor community, the particular order of service and the materials used (e.g.,silverware, candle lighting, order of prayer, and reading of scripture) holdsignificant importance, drawing them into a sacred space and immersingthem in the deeper meaning of their faith and spirituality. To be effective,the ritual must be linked closely to the person’s own religious and orspiritual beliefs and needs.

CompassionFor some aged care staff another aspect of spiritual care involved engaging indeeply respectful, compassionate care that went beyond physical care aloneand involved an intentional connection with the other person (Pfeiffer,Gober, & Taylor, 2014). In this study nurses were guided by four principles:(1) awaiting invitation to discuss spiritual matters; (2) giving care with aspiritual part of oneself that provided a spiritual connection with the otherperson; (3) being attentive in care; and (4) allowing reciprocity in therelationship.

PrayerPrayer is an obvious element of spiritual care. To connect with faith and faithin God during spiritual care, prayer (e.g., group prayer, intercessory prayer)has been found to offer a sense of strength and comfort for older people livingwith dementia (Carr et al., 2011; MacKinlay & Trevitt, 2010). Evidence for theimpact of spiritual prayer-based interventions is inconclusive, but some practi-tioners and patients believed that prayer-based interventions by nurses mayproduce benefits for both nurses and those being cared for (Narayanasamy &Narayanasamy, 2008). The literature suggested that for practitioners—otherthan those religious and spiritual care professionals—engaging in prayer mayappear to have use in a health paradigm that incorporated religious andspiritual care (Christiansen, 2008). Caution was emphasised in interpretingthe results of numerous articles and studies that suggested that prayer had animpact on health.

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Reading scriptureAnother element of spiritual care identified was reading scripture. Throughreading scripture and the Bible (or equivalent), some older people remainconnected to their faith and faith in God and are given strength and comfort(Carr et al., 2011). For example, some older African American Christiansfound guidance in how to respond to stressful life events (such as seriousillness, death of loved ones, and mental illness) through reading the scrip-tures contained in The Bible (Hamilton, Moore, Johnson, & Koenig, 2013).Allowing aged care residents access to the scriptures or providing meaningfulpassages of scripture in older persons’ rooms could assist in managinganxiety, depression, stressful situations, and crisis situations and contributeto spiritual care. Prayer forms an important intervention for the chaplain andknowing when and how to pray with a person was considered in theliterature to often be more important than just engaging in prayer as aroutine (Maddox, 2012).

ReminiscenceSpiritual reminiscence was also considered an element of spiritual care andan important component of seeking meaning in later life and in navigatingthe latter stages of life’s journey (MacKinlay & Trevitt, 2010). Reminiscencewas considered to contribute to developing a greater sense of meaning inolder age and a sense of resilience rather than fear. Reminiscence could beincorporated as part of a group experience in an aged care facility (other thanattending church) or could become part of an individual’s later life journeythrough self-directed or facilitated exploration. Allowing people time toaccess and recount their narrative has potential to assist people towardfinding meaning in their lives. Adding a period of reminiscence to groupmeetings could provide avenues for group members to examine meaning intheir life and to discuss spiritual growth, strategies for spiritual growth, andto facilitate spiritual growth.

Story tellingTelling stories and the use of narrative was considered a possible elementof spiritual care in the literature to have the potential to affect individuals’well-being and their ability to navigate change in their lives. In contrast tothe act of making statements containing facts about one’s condition, theact of telling one’s story or replying to a question with a narrative has theability to allow the storyteller to impart a great deal of meaning andexpress fears in a safe way. The use of narrative was contingent uponthe listener allowing time and being intentional and present during thetelling. Through the story, both the narrator and the listener could poten-tially gain a greater understanding of the issues or situation surroundingthe storyteller (Southall, 2011).

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ConnectednessMaking connections with older people was considered in the literature to beanother component of spiritual care, by getting to know them, being presentwith them, understanding what was sacred to them, and helping them toconnect with what was sacred to them or important in terms their faith orreligion (Carr et al., 2011).

Generating a sense of hopeGenerating a “sense of hope” was another element of spiritual care. Chaplainsengage in a process of being accepted by individuals to accompany themthrough illness and at the end of life, becoming a companion prepared to staywith the person, sharing their experience and giving them strength and hopethrough their presence (Nolan, 2011). In this way, by being with people thepotential exists for people to generate a sense of hope in not what would betheir future but hope in the present and in their connectedness with others.In spiritual care, a hopeful presence can assist those in grief or in illness or atthe end of life to move from what might be a loss of hope, or a redundanthope and to reconfigure their hope. Stuart (2010) suggested that as a care-giver, holding another person’s hope in one’s hands during times when theperson was unwell or in difficulty and unable to find hope was an essentialingredient of caring for a person spiritually and assisting them towardrecovery.

Mindfulness and meditationMindfulness training with a skilled practitioner has been considered in theliterature to have the potential to enhance the experience of old age (Nilsson,2014). Engaging in mindfulness techniques, e.g., physical mindfulness (yoga,Tai Chi), mental mindfulness (meditation), existential mindfulness (resili-ence) and social mindfulness (cultivating empathy and compassion) has thepotential to transform the experience of the older person from an illnessexperience to a wellness experience. Aligned with Buddhist philosophy, thepractice of mindfulness techniques over the lifespan has been shown to havebeneficial health-giving effects (Gregory, 2012; Nilsson, 2014). For example,mindfulness meditation as part of a multicomponent spiritual care interven-tion has been shown to contribute to improved outcomes for community-dwelling adults with cardiac disease (Delaney, Barrere, & Helming, 2011).Mindfulness techniques mentored by a skilled practitioner are well within thereach and scope of learning for older people living in residential aged carefacilities and in the community.

Meditation was considered to be an element of spiritual care in somepapers. Two randomised controlled trials on adults with terminal diseasestudied the effects of meditation delivered by a qualified instructor anddefined as involving an induced state of consciousness and delving into

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self-realisation or meaning (Candy et al., 2012). The results found thatmeditation alone had no effect on well-being or quality of life. However,when combined with massage, reduced quality of life was prevented(Morgan, 2015).

A spirituality-based intervention piloted a combination of meditationtechniques (Mindfulness/Self-Discovery Meditation, RelationshipMeditation and Eco-Awareness Meditation) and led to a significant improve-ment on quality of life (Delaney et al., 2011).

Applying spiritual care and its elements in holistic aged care nursing

Considering the body of literature collected here, articles on spiritual care in agedcare often focussed specifically on the need for nurses to incorporate spiritualityand spiritual care into their practice, more-so than was found in other professions(apart from pastoral care specialists). The literature highlighted the need forspiritual care to be led by the staff member in a “person-centred”way emphasisingthe need to find the right balance in spiritual care between the “art” (self-aware-ness, sensitivity, communication, and person-centred) and the “science” (work inprocess, evidence, indicators, and outcomes;McSherry & Ross, 2010). A swing toofar in favour of the “art”would likely lack rigour; and if the balance swayed too farin favour of “science,” it would potentially lack humanity.

Enablers and barriers to applying spiritual care in aged careAn earlier review sought to understand the enablers and barriers for incor-porating spirituality into nursing practice in general and this review seemedparticularly relevant to aged care (Tiew & Creedy, 2010). The results demon-strated five recurring themes affecting nurses’ delivery of spiritual care: (1)organisational and cultural factors; (2) lack of emphasis on spirituality innursing education; (3) nurses understanding of spirituality; (4) attitudes; and(5) individuality.

Nursing literature also highlighted the impact that organisational cutbackshad created on nurses’ ability to provide spiritual care, including in aged care.As a result of nursing professional practice being embedded within a pre-valent reductionist paradigm, nurses contended that they are faced withincreasingly intensive and complex patient care situations and with signifi-cant workload increases (Carr, 2010). There is a large amount of literature onthe impact of workload on burnout, compassion fatigue, and nursing whichis relevant to the provision of complex spiritual care by aged care staff (Sansoet al., 2015).

The literature suggested that increased workloads lead to an inability tocomplete set tasks, leaving staff feeling that they are unable to meet the needsof their patients, therefore contributing to a sense of moral failure (Sansoet al., 2015). In a time-driven arena where staff are often faced with working

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overtime to meet expectations, there is little or no time to meet the spiritualor existential needs of the very sick older person experiencing loneliness,anxiety, or distress. Other factors that directly impacted staff ability toparticipate in spiritual care include growing expectations to do more withinthe time available.

Other issues affecting staff ability to contribute to spiritual care includednegative attitudes of peers toward spiritual care, suboptimal support fromcolleagues and executive officers, a lack of equipoise between effort andreward, limited access and support for professional development, increasedjob-related stress and strain, workplace abuse, and a general lack of respectwithin the health care system (Carr, 2010).

One review highlighted that it was essential for care-providers toattend to their own health and well-being and their own spiritual health(Tiew & Creedy, 2010). The literature identified a strong relationshipbetween staff’s own spirituality, spiritual well-being, and sense of selfand their ability to understand, practice, and provide effective sensitivespiritual care for others (Chang & Johnson, 2008). For example, nursesthat either followed a particular religion or those with no religiousaffiliation but who engaged in prayer, meditation, or who read religiousmaterials were more likely to have positive attitudes toward spiritualcare (Tiew & Creedy, 2010).

Numerous studies on nurses’ attitudes toward spirituality have revealed apositive relationship between spiritual education and nurses’ spiritual aware-ness and spiritual care practice (Tiew & Creedy, 2010). However, evidencesuggested that nursing textbooks and undergraduate nursing education didnot provide adequate guidance in this field (McSherry, 2006a).

Four internal barriers to the provision of spiritual care have been identi-fied: (1) the inability to communicate due to sensory loss, language problems,or cognitive impairments in patients; (2) lack of knowledge in assessingspiritual needs; (3) pluralism amongst nursing home staff, i.e., aligningspirituality with religiosity, resulting in reduced involvement or engagement;(4) emotional demand, particularly when staff repeatedly faced bereavementof residents (McSherry, 2006b). The provision of appropriate education forstaff to encourage and raise spiritual awareness and confidence in discussingspiritual matters could overcome many of these barriers.

From this same perspective, external or organisational barriers to theprovision of spiritual care were identified, which are particularly pertinentto aged care (McSherry, 2006b). The first barrier was the attitude of manage-ment and the organisation itself to spiritual care. It is very hard for staff whowant to participate in and provide spiritual care when this is not supportedby the organisation. The second external barrier identified was environmen-tal distractions resulting in loss of privacy. This is particularly the case withshared rooms. The third constraint was the economics of staff time. When

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there is a great deal of pressure to complete tasks within their shift, staff arereluctant to spend time with one resident because they are conscious of otherresidents wanting attention, and conscious of meeting task performanceexpectations. The fourth external barrier was the lack of recognition ofspiritual issues in vocational and tertiary education. In nursing, emphasison the scientific and technical would need to shift to a more holistic model ofcare. The fifth external barrier related to acute hospital episodes. Residentsadmitted to hospital for illness or surgery could potentially have increasedthoughts or concerns about spirituality and want to talk to someone whenreturning home or to care but there is not capacity to do so among staff.

Discussion

We collected and reviewed the literature on definitions of spirituality, spiri-tual need, and spiritual care in aged care settings, what elements can beidentified, and what organisational or external barriers mitigate againstspiritual care in aged care. We found many definitions of spiritual care andspirituality in the literature, but none specifically for aged care. The topics ofspirituality and spiritual care cross a number of disciplines and we found adiverse collection of literature. However, a large body of literature focused onhow nurses can help with spiritual care. The results showed that much of theliterature did not follow a standard scientific paradigm, but included both“art” and “science” perspectives. The literature summarised here indicatesthat although individual staff, including nurses, are responsible for incorpor-ating spiritual care in their practice, a whole-of-organisation approach maybe required to support and maintain good practice rather than expectingindividual staff to bear responsibility for incorporating spiritual care.

Although the need for effective spiritual support is recognised amongstmany providers of residential and home care services, strategic implementa-tion has remained elusive to date, suggesting that the aged care industryneeds more guidance on how to provide spiritual support. Numerous studieshave identified a lack of confidence in providing spiritual care within theworkforce (Baldacchino, 2008; Fenwick & Brayne, 2011). From these find-ings, we aim to fill a gap in practical guidance about spiritual care bydeveloping guidelines specifically designed for these settings.

Looking forward, an organisational approach may need to be adopted tomeet older people’s need for spiritual support in aged care. Spiritual care canbe provided well by team members with varying backgrounds (Daalman,Usher, Williams, Rawlings, & Hanson, 2008). In terms of a whole of organi-sation approach, Hudson and Richmond (2000) considered that the entireteam had a role in the spiritual care of residents, and argued that leavingspirituality to the chaplain (or the nurse) was not caring for the wholeperson.

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Spirituality may arise initially from experience then move on to cognitiveor more analytical thoughts although it is outside the scope of this literaturereview to expand on the origins of spirituality. Future guidelines for theprovision of spiritual care in aged care will assist aged care communities toattend to and explore their spirituality. It will require a holistic, organisa-tional approach that can support the needs of individuals receiving care aswell as facilitating spiritual awareness among health professionals.

Funding

Funding for this work was provided by Australian government Department of Health, AgedCare Service Improvement and Healthy Ageing Grant to Pastoral and Spiritual Care of OlderPeople (now Meaningful Ageing Australia).

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