A new simple spiritual assessment model for nurses
Dr Linda Ross, Reader in Spirituality & Healthcare, School of care Sciences, Faculty of Life Sciences & Education, University of South Wales & Visiting Fellow, Staffordshire University
Professor Wilfred McSherry,Professor in Nursing, Department of Nursing, School of Health and Social Care, Staffordshire University, University Hospitals of North Midlands NHS Trust, England, Part-time Professor VID University College (Haraldsplass) Bergen, Norway
1. Is it realistic to expect nurses to give spiritual care in today’s resource challenged health service?
Health care policy (e.g. NICE 2017), nursing guidelines (e.g. NMC 2010) and research evidence (e.g. Steinhauser et al 2017) all point to the importance of the spiritual dimension of life for health, wellbeing and coping. Patients also value spiritual care (e.g. Ross & Austin 2013, Selman et al 2017).
Nursing Codes of Ethics (ICN 2012) and regulatory bodies (NMC 2010) consider spiritual assessment, care planning and delivery to be part of what nurses do as part of their holistic care remit.
Nurses see spiritual care as a fundamental part of everyday nursing practice but they feel least prepared for it and want further education (Austin et al 2017, RCN 2011). In addition to feeling unprepared and unsure of what is expected of them, lack of time and focus on physical care in the workplace(with the prevalence of the medical model) are frequently cited reasons for nurses not assessing and delivering spiritual care (Eagan et al 2017, Ross 1994, RCN2011).
Picking up on the point of lack of time, can nurses really be expected to assess and respond to their patients’ deepest spiritual needs when they are already stretched to breaking point trying to meet patients’ essential physical and mental health needs? Already overwhelmed by paperwork and bureaucracy, how realistic is it to expect them to seek out and become familiar with an additional ‘tool’ for assessing spiritual needs? How many nurses working outside of palliative care (or within it for that matter), actually use any of the existing spiritual screening or assessment tools such as SPIRIT (Maugans (1996),HOPE (AnandarajahandHight 2001) or FICA (Puchalski andRomer2000). We suspect, not many. These combined reasons may partly explain why so few patients (15%) at end of life in the acute hospital setting in England were asked about their spiritual concerns (Royal College of Physicians [RCP] 2016), a situation which the RCP has said must change.
But, what if youcould conduct a spiritual assessment and give spiritual care without the need formore timeor an extra formal tool?What if in so doing you could improve patient care and maybe even save time? What if there were added benefits; care that isco-produced, person centred and prudent?
We believe the following simple two question model (2Q-SAM) might help in these ways and we invite you to try it out and tell us what you think.
2. The new model
Insert model here
3. The model explained
Looking at the first part of the model, there are many factors that come into play in the delivery of spiritual care such as the values/beliefs and spirituality of the people involved (patient and nurse), the environment where the care takes place (e.g. time, privacy, ethos) and the condition of the patient and their ability to communicate (Ross 1994). Getting the balance right between the science and art of nursing is also important, delivering high quality clinical care with sensitivity, compassion and personal warmth (Ross and McSherry 2010).
Let’stake a typical shift and see how the model and the two questions might work in practice. Let’s apply this to my (LR’s) mother (Margaret) who was diagnosed with terminal thyroid cancer and reflect on her needs and care in the last few days of her life.The following is a true account of some aspects of her care which I was aware of during regular but fleeting visits from Cardiff to Scotland. The 2Q-SAM is retrospectively and hypothetically applied to the care episodes described below (the model was not actually used by the staff). The two questions may seem rather mechanistic and repetitive in the way they are used below. This is for illustration purposes only. In reality they would be asked in different ways as a part of the normal conversation with a patient and would be embedded into the nurse’s practice throughout a shift.
7am: start of an early shift.
Margaret hasn’t slept well. Her mind has been working overtime throughout the night trying to take stock of her situation since being diagnosed with metastatic cancer.
Nurse: ‘What’s most important to you right now (Q1)’?
Margaret: ‘I really didn’t sleep well. I’m so tired now’ (physical need).
The nurse may not need to ask the ‘how can I help (Q2)’ question verbally, she may just ask this question in her mind. She knows a patient has just been discharged from one of the single rooms so she is able to offer Margaret the use of that room for a few hours, until the next admission comes in,to let her get some sleep.
Asking the ‘importance’ question here means that the nurse doesn’t need to waste time bringing breakfast or asking Margaret if she wants a wash (which would seem most relevant at that time of the morning) as her most important need (for sleep) is being taken care of (saving time?).Of course, the nurse may choose to ask a follow-on question ‘why were you unable to sleep?’whichwould allow Margaret to express her deeper concerns about how her elderly 89 year old husband will manage without her when she dies (spiritual, social needs).
10am: Margaret is awake. The nurse asks ‘What’s most important to you now (Q1)?’ to which Margaret responds ‘I could do with a wash, but I’ve got no energy’ (physical need). The ‘how can I help (Q2)’ question is obvious, she needs help with that task.
1pm: After lunch the nurse asks again ‘what’s most important to you right now (Q1)?’ to which Margaret replies ‘I don’t suppose there’s a wheelchair I could use for when my husband comes please?’ (physical). Again the ‘how can I help (Q2)’ question does not need to be asked as it is obvious what is needed.Unbeknown to the nurse however, Margaret actually wants her husband to wheel her to a quiet place in the corner of the canteen to tell him her wishes for her funeral: pink flowers from family only;which undertaker, caterer and venue to book;the music she wants; her wish for a minister to read the eulogies from the family. So, the nurse is actually unknowingly meeting a spiritual need as well as a physicalneed by providing a wheelchair. Gentle enquiry from the nurse on Margaret’s return to the ward might provide opportunity for Margaret to say what’s on her mind if she wishes.
5pm: After visiting time is over the nurse asks again ‘What’s most important to you right now? (Q1)’. Margaret tells the nurses about her concerns. They have a cry together (emotional/psychological need). The nurse asks ‘how can I help? (Q2)’ to which Margaret asks if there is a chaplain in the hospital. The nurse makes the referral and the chaplain calls the next day (and regularly thereafter until her death). Conversation turns to her most pressing need, which is to be transferred to the palliative care unit (preferred place of death, physical, psychological and spiritual needs). I discovered later that the chaplaincy team worked hard with the ward to fulfil that wish. Margaret made it to the palliative care unit 12 hours before she died.
In the above example, the 2Q-SAM ensured that what was most important to Margaret at any point in time wasaddressed through a process of continuous assessment.The care she receivedwas person centred, needs led, dynamic and holistic. It was also prudent (it only did what was necessary at any point in time).
The 2Q-SAM could be a realistic solution to delivering spiritual care (or care that is spiritual, [Clarke 2013]) in a resource (money, staff and time) challenged health service.
The 2Q-SAM model is more fully described, explained and is applied to different care settings in a chapter on spiritual assessment in the book ‘Spirituality in Healthcare: Quality and Performance‘ to be published by Springer later this year edited by Fiona Timmins and Silvia Caldeira.
4. An invitation to try out the model
Of course care is delivered in the way described above happens every day, but we would like to know if the 2Q-SAM makes any difference to the care you give; does it for example make it more needs led, patient centred and prudent?We invite you to try it out with one patient during one shift, asking the 2 questions (or variants of them) at key points throughout that shift and to consider the following questions:
Did it made any difference to the care you were able to give, and if so how?
Did it take more or less time?
What did your patient think (if you feel able to ask them)?
Did you modify the model in any way? E.g. did you word the questions any differently?
To give us feedback on the 2Q-SAM please email ……
References
Anandarajah G., Hight E 2001 Spirituality and Medical Practice: using the HOPE questions as a Practical Tool for Spiritual Assessment American Family Physician 63 (1) 81 – 88
Austin, P., MacLeod, R., Siddall, P, McSherry, W and Egan, R (2017) Spiritual care training is needed for clinical and non-clinical staff to manage patients’ spiritual needs. Journal for the study of spirituality, 7 (1). 50 -3
Clarke J (2013) Spiritual care in everyday nursing practice. Palgrave Macmillan, Basingstoke
Egan, R., Llewellyn, R., Cox, B., MacLeod, R., McSherry, W and Austin, P. (2017) New Zealand Nurses’ Perceptions of Spirituality and Spiritual Care: Qualitative Findings from a National Survey Religions 2017, 8, 79; doi:10.3390/rel8050079
International Council of Nurses (2012) The ICN Code of Ethics for Nurses. ICN, Geneva
Maugans, T.A. (1996). The SPIRITual history. Archives of Family Medicine, 5(1), 11-16.
NICE (2017) Care of dying adults in the last days of life. NICE Quality Standard (draft) Available at Accessed 1/5/18
NMC (2010) Standards for pre-registration nursing education. NMC, London
Puchalski, C., Romer, A.L. (2000) Taking a spiritual history allows clinicians to understand patients more fully. Journal of Palliative Medicine, 3(1), 129-137.
Ross L A (1994) Spiritual aspects of nursing. Journal of Advanced Nursing, 19, pp 439-447.
Ross L and McSherry W (2010) Considerations for the future of spiritual assessment. In McSherry W and Ross L (eds) (2010) Spiritual assessment in healthcare practice. Chapter 9. M&K Publishing, Keswick.
Royal College of Nursing (2011) RCN spirituality survey 2010. Accessed 10/8/17
Royal College of Physicians (2016) End of Life Care Audit – Dying in Hospital: National report for England 2016 (Accessed 10 August 2017)
Steinhauser KE, Fitchett G, Handzo GF, Johnson KS, Koenig HG, Pargament KI, Puchalski CM, Sinclair S, Taylor EJ, Balboni TA (2017) State of the science of spirituality and palliative care research part I: definitions, measurement, and outcomes. Journal of Pain and Symptom Management, 54, 3, 428-440