I S S U E S A N D IN N O V A T I O N S IN N U R S I N G P R A C T I C E

Responses to the spiritual needs of older people

Aru Narayanasamy
UK
BA MSc PhD RN

Senior Health Lecturer, Faculty of Medicine and Health Sciences, School of Nursing, University of Nottingham, Nottingham,

Philip Clissett

BA MA RGN PGCE

Health Lecturer, Faculty of Medicine and Health Sciences, School of Nursing, University of Nottingham, Nottingham, UK

Logan Parumal

BEd MEd RNMH RNT

Health Lecturer, Faculty of Medicine and Health Sciences, School of Nursing, University of Nottingham, Nottingham, UK

Deborah Thompson

BA RMN RGN

Health Lecturer, Faculty of Medicine and Health Sciences, School of Nursing, University of Nottingham, Nottingham, UK

Sam Annasamy

MA BEd RN RNT

Health Lecturer, Faculty of Medicine and Health Sciences, School of Nursing, University of Nottingham, Nottingham, UK

Richard Edge

BA RN DipN RNT

Health Lecturer, Faculty of Medicine and Health Sciences, School of Nursing, University of Nottingham, Nottingham, UK

Submitted for publication 20 January 2003 Accepted for publication 19 January 2004

Correspondence: Aru Narayanasamy, Faculty of Medicine and Health Sciences, University of Nottingham, The Bearings Project Team, School of Nursing, A Floor, Queens Medical Centre, Nottingham NG7 2HA, UK. E-mail: aru.narayanasamy@ nottingham.ac.uk

NARAYANASAMY

A.,

CLISSETT

P.,

PARUMAL

L.,

THOMPSON

D.,

Journal of Advanced Nursing 48(1), 616 Responses to the spiritual needs of older people Background. The literature suggests that the notion of holistic health has gained popularity in the nursing of older persons. Holistic care, based on the premises that there is a balance between body, mind and spirit, is important for well-being, that each of these is interconnected, and that each affects the others. Human spirit is considered to be the essence of being and is what motivates and guides us to live a meaningful existence. However, there is little evidence in the nursing literature about how nurses caring for older people respond to their spiritual needs. Aim. The aim of this paper is to report a critical incident study to: (1) explore nurses perceptions of their role in addressing the spiritual needs of older people; (2) describe what constitutes spiritual care of old people in the light of the ndings. Methods. Descriptions of critical incidents were obtained from a convenience sample of 52 nurses working in the East Midlands Region of the United Kingdom (UK) and subjected to content analysis and construction of a data classication system. Findings. Respondents were prompted to identify patients spiritual needs by factors such as religious beliefs and practice (prayer); absolution; seeking connectedness, comfort and reassurance, healing or searching for meaning and purpose. The interventions initiated to meet patients spiritual needs included respect for privacy; helping patients to connect; helping patients to complete unnished business; listening to patients concerns; comforting and reassuring; using personal religious beliefs to assist patients and observation of religious beliefs and practices.
ANNASAMY S. & EDGE R. (2004)

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Responses to the spiritual needs of older people

Conclusion. The ndings provide empirical evidence of some practices related to spiritual care of older people. Further empirical research is needed to guide practice and education with regard to conceptual clarity and the delivery of spiritual care of older people. Keywords: critical incidents, spiritual needs, religious needs, spiritual care, nursing older people

Introduction
The nursing and health care literature suggests that the notion of holistic health has gained popularity, especially in the nursing of older people (Narayanasamy 1998, MacKinlay 2001). Holistic care entails the care of body, mind and spirit. It is based on the premise that each of these elements is interconnected and that one affects the other. A harmonious relationship between the three entities of the person is necessary for well-being. However, there is little evidence in the nursing literature that clearly shows how nurses caring for older people respond to their patients spiritual needs. The purpose of this study was to begin to open up this area of research and explore the ways in which nurses construct and respond to older patients spiritual needs. The study commenced in 2001 and completed at the end of 2002.

That which gives meaning, purpose, hope and value to peoples lives. This is part of a wide concept which may include but is not dened by religious faith and culture (Swinton 2001). For current purposes, a useful working denition is found in Narayanasamy (1999, p. 123):
Spirituality is rooted in an awareness which is part of the biological make up of the human species. Spirituality is potentially present in all individuals and it may manifest as inner peace and strength derived from perceived relationship with a transcendent God/an ultimate reality, or whatever an individual values as supreme. The spiritual dimension evokes feelings which demonstrate the existence of love, faith, hope, trust, awe, and inspirations; therein providing meaning and a reason for existence. It comes into focus particularly when an individual faces emotional stress, physical illness or death.

Literature review
There is a growing body of knowledge within health care that views spirituality as a signicant dimension of human wellbeing which is necessary for holistic care of body, mind and spirit (Montgomery 1991, Narayanasamy 2001). According to some scholars spirituality is an elusive concept, especially when nurse theorists attempt to dene it (Oldnall 1995, McSherry & Draper 1998, MacKinlay 2001, Narayanasamy 2001). This problem is further compounded by the common misperception that the word is necessarily equated with institutional religions such as Christianity and Judaism (Taylor et al. 1995, Swinton 2001). Several studies have conrmed that confusion exists amongst nurses where spirituality is conated with religion (Harrison & Burnard 1993, Narayanasamy 1993, Ross 1997a, Bruce 1998). Spirituality has been dened as: The essence or life principle of person (Colliton 1981). A sacred journey (Mische 1982). The experience of the radical truth of things (Legere 1984). Giving meaning and purpose (Bruce 1998). A belief that relates a person to the world (Soeken & Carson 1987). Being rooted in an awareness that is part of the biological make up of the human species (Narayanasamy 1999).

This understanding will guide the remainder of the paper. As the main aims of this study were to explore how nurses become aware of patients spiritual needs, the nature of these reported concerns and the action taken by the nurse, these aims will form the framework for the remainder of this literature review.

How nurses become aware of spiritual needs

The key means of gaining an awareness of spiritual needs is identied as assessment (Fry & Tan 1996). Heriot (1992) argues that the tradition of merely noting the religious afliation of the client fails to explore the full range of possible spiritual orientation. She argues for the inclusion of questions about the clients ideas about the meaning of life, how they express love for others, whether they feel loved, what gives them a sense of wonderment about life, their experiences with transcendence and their sources of forgiveness. Carr (1993) proposes a similarly structured assessment suggesting that, during this conversation, the nurse listen for statements that might indicate spiritual distress such as Why

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did God do this to me or Im afraid of being abandoned by my family and friends. However, Berggren-Thomas and Griggs (1995) argue that during such assessments many clients feel uncomfortable discussing their spiritual and religious orientations. They go on to propose that, only through time and on-going contact, would it be possible to discern areas of spiritual need in the lives of the clients. Hermann (2000) argues that this approach to identication of spiritual needs should be supported by the assessment of objective data obtained from patients. This relates to the presence or absence of religious/spiritual literature or artefacts and signs of depression or despair, recognizing that this might have a spiritual aspect.

Nature of spiritual concerns

There is marked variation in the understanding of spiritual needs among authors due to the inuence of their own belief systems and values (MacKinlay 2001, Narayanasamy 2001). The theoretical perspectives of the present study are derived from contemporary sources such as Bradshaw (1994), Narayanasamy (1999), Cohen et al. (2000), Sherwood (2000) and Reed (1992). Such literature espouses that in the main, spiritual needs are characterized by normal expressions of a persons inner being that motivates the search for meaning in all experiences and a dynamic relationship with others, self, and whatever the person values. However, authors such as Young (1993) argue that some of the life events associated with old age, such as retirement and chronic illness, inuence this search for meaning. Reed (1991) argues that these events challenge the persons usual approaches to nding consolation and meaning, particularly in the face of suffering. In the light of this, according to Sherwood (2000) spiritual needs may be attained through faith, hope, love, trust, meaning and purpose, relationships, forgiveness, creativity, and experiences that serve as catalysts of synthesis and meaning. Some people achieve these via religious beliefs and practices.

exclusively on spiritual problems. They argue that, such an approach ignores people who, although they have spiritual needs, have no major spiritual problems. According to Young (1993), the facilitation of expression involves the expression of religious/spiritual belief as well as expression of spiritual/emotional need. Bauer and Barron (1995) and Ross (1997b) both highlight the value of facilitating the expression of particular beliefs. The facilitation of the expression of emotional need might be achieved through active listening. This term is used by Carr (1993), Fry and Tan (1996), Hicks (1999) and Heriot (1992). Carr (1993) describes it as involvement with the client on his or her own terms. Heriot (1992) views the role of the listener as being to conrm rather than direct the client. Carr (1993) suggests that focus needs to be on exploring issues rather than nding the right words to make the client feel better. Religious approaches include the utilization of spiritual resources includes respecting religious articles (Bauer & Barron 1995), making artefacts visible and accessible and maintaining religious activities (Fry & Tan 1996) and facilitating access to a Chaplain for a chat, prayer or communion (Fitchett et al. 2000). Non-religious interventions include some form of reminiscence or life review (Heriot 1992), the use of television, music or the arts (Hermann 2000) or the development of opportunities for caring or feeling needed such as pet or plant therapy or intergenerational work (Touhy 2001). In addition, Fry and Tan (1996) recommend the fostering of on-going meaningful relationships with family and friends.

The study
Aim
The aims of the study were to explore nurses perceptions of their role in addressing the spiritual needs of older people and how they construct spiritual care of old people.

Design
A qualitative approach was used, incorporating the critical incident technique as described by Flannagan (1954), Cormack (2000) and Narayanasamy and Owens (2001). A cross-sectional design with a convenience sample of Registered Nurses working with older people.

Nursing interventions
The interventions for spiritual care needs available to nurses include respecting the older person as a spiritual being, facilitation of expression, active listening and religious and non-religious interventions. Reed (1991) highlights the need to recognize and respect older people as spiritual beings. Berggren-Thomas and Griggs (1995) express concern that older clients might be viewed as being spiritually challenged, with assessment focusing
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Critical incident technique

The critical incident technique was popularized by Flannagen (1954) and is particularly useful for collecting data from

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indirect observation of human behaviour in order to facilitate problem solving (Cormack 2000). This method is used in preference to direct observation because of the practical difculties and constraints often experienced by researchers using observation, particularly in clinical settings (Narayanasamy & Owens 2001). The added advantage of this method is that it depends on descriptions of actual events, rather than descriptions of things, as they should be. According to Cormack, the critical incident technique recreates the authenticity of practice, because the technique is largely concerned with the real, rather than the abstract world, and at the same time it acknowledges the constraints and limitations that we encounter in the world in which we live and work.

information about the purpose of the study, the voluntary nature of participation, and assurances that anonymity and condentiality would be maintained.

Data analysis
The data were subjected to content analysis and construction of a data classication system, as suggested in Cormack (2000). Data were managed in an objective and systematic way that led to the construction of inferences (Narayanasamy & Owens 2001). The theoretical categories were identied in terms of the four main areas using Cormacks critical incident data classication system (Table 1), which were then subjected to review by a panel with particular expertise in the subject area, who conrmed the reliability and credibility of the analysis and classication system.

Participants
The critical incidents were obtained from 52 Registered Nurses working in the care of older people services who were attending post-registration courses in the care of older people. Their length of experience ranged from 1 to 30 years in nursing. Twenty-ve were educated to diploma level or beyond, i.e. their nursing qualication was equivalent to the rst 2 years of a 3 year bachelors degree. The others had certicate level qualications (equivalent to the rst year of a bachelors degree). Participation was voluntary and those who agreed to take part in the study were asked to complete the critical incident questionnaires in private and return them to the research team at the end of class session. Fifty-two questionnaires were returned.

Findings
The ndings in terms of the data classication system are described below, with quotes to illustrate the meaning of the categories (Table 1).

How nurses become aware of patients spiritual needs

Nurses became aware of older patients spiritual needs when the following were recognized: patients religious background, spiritual/religious loaded conversations, and the nature of patients diagnoses. Patients religious background acts as prompters In the course of their encounters with patients nurses became aware of their religious background. This awareness led to the acknowledgement that their patients had spiritual/ religious needs:
One lady admitted to the ward was a Mormon. Although religion is only a part of spirituality, for this lady it was a very essential part of her expression of her spirituality. (Nurse 19) She was a very religious ladyshe talked about her Christian beliefs often (Nurse 49)

Questionnaire
The critical incident questionnaire covered the following areas: Description of a nursing situation that demonstrated when and how informants recognized that clients had spiritual needs. How and why informants could identify specic spiritual needs. What informants did to try to help their clients meet their spiritual needs. Description of the effects of their actions on the clients or clients families, and the reasons why informants concluded that their actions had such effects. The questionnaire is shown in Appendix 1.

Spiritually/religiously loaded conversations In the course of interactions with patients and their families nurses picked up cues about their spiritual needs when conversations were loaded with spiritual/religious indicators:
they wanted to talk to someone. Got in touch with local priest, arranged a visit, but I was not able to follow through after the priests visit (Nurse 9)

Ethical considerations
Permission to carry out the study was obtained from the relevant local ethics committee. Participants were given

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A. Narayanasamy et al. Table 1 Data classication system

Areas A: How nurses become aware of patients spiritual needs B: Nature of patients reported concerns

Categories A1: Patients religious background act as prompters A2: Spiritually/religiously loaded conversations A3: Diagnosis prompts response B1: Religious beliefs and practices, e.g. prayer B2: Absolution B3: Connectedness B4: Comfort and reassurance B5: Healing B6: Meaning and purpose C1: Respect for privacy and dignity C2: Helping patient to connect C3: Helping patient complete unnished business C4: Listening to patients concerns C5: Comforting and reassuring C6: Using personal religious beliefs to assist patients C7: Observations of religious beliefs and practices D1: Positive effects on patients and their families D2: Positive effects on nurses

C: Nurses actions

D: Outcomes of nurses interventions

The patient had many unresolved issues with her deceased family. Since becoming ill she had not been able to attend churchShe felt that she needed to talk these issues through with a Catholic priest (Nurse 39)

Religious beliefs and practices Expressions of religious beliefs and practices led nurses to initiate actions, which could be broadly described as spiritual care:
Catholics follow structured spiritual pathways from birth to death. So as a non-Catholic I needed to alert the priest to ensure that the pathways were adhered to. (Nurse 3) Her need was to take communion as normally her religious beliefs and rituals were very important to her, and I believe would have aided her recovery. Particularly if her symptoms and problems werepsychological (Nurse 11)

Diagnosis prompted response The nature of patients diagnoses led nurses to form opinions about their spiritual needs:
[I] recently nursed a patient with advanced prostate cancer and bone metastasis. [He was] originally admitted with decreased mobility. Further tests revealed that he had ca prostate and bone metsand that his illness was terminal. I realised that [he]had spiritual needs, particularly at the time of nding out about illness and in the times when he began to deteriorate. (Nurse 10) Patient arrived on the ward very ill. I knew this patients death was imminent. Patient was still able to communicate minimally with non-verbal communicationOn one occasion when me and an auxiliary were bedbathing the patient, we started asking her questions[to] which she responded, her spiritual needs in this case[were] a religious oneafter the conversation I had to organize (Nurse 24)

Expressions of the need for prayer were cited as a spiritual need:

She wanted us to be sensitive to her wanting to pray before her meals, leave the light on when she was reading. This was sometimes difcult to accommodate as it distressed the others in the room. A lamp was provided for her to accommodate her needs. (Nurse 40)

Nature of patients reported concerns

Patients reported concerns provided nurses much information for the assessment of needs, which were perceived to be spiritual/religious needs. Such perceptions acted as prompters for nurses to initiate care interventions to meet patients spiritual needs.
10

Absolution The need to express thoughts and feelings of guilt and the need to absolute oneself was considered to be a spiritual need.
At the time the patient could not progress through treatment until her spiritual needs were met. She needed to express her thoughts and feelings, in a spiritual sense with her priest to absolute herself of some of her guilt feelings. (Nurse 39)

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Connectedness The critical incidents provided by nurses comprise accounts, which were categorized as patients needs for connectedness with their close relatives and signicant others.
We felt that she would need some emotional/psychological/spiritual support. We were aware that she lived on her own, with a daughter who lived some miles away. (Nurse 4) Patient expressed a desire to be close to his familyneeded privacy and opportunity to express his feelings about dying and be given choices about what would happen to him medically, in particular, when his health deteriorated further. I feel these were his needs from getting to know the patient and his family. (Nurse 10) The patient expressed that to be in communication with God gave her strength to bear her illness. (Nurse 13)

Nurses actions
The following categories emerged from the critical incidents with regard to nursing interventions to meet spiritual needs of their patients: respect for privacy and dignity, helping patients to connect, helping patients to complete unnished business, listening to patients concerns, comforting and reassuring, utilizing personal religious beliefs to assist patient, and being sensitive to observance of patients religious beliefs and practices. Respect for privacy and dignity Several incidents incorporated statements characterizing the importance of respecting patients privacy and dignity with regard to the patients spiritual beliefs. Nurses took practical steps to ensure that these needs are met.
Practically the patient was (after discussion with himself and his family) moved to cubical for privacy and dignity. (Nurse 16) I offered her the use of a quiet room or garden area for privacy. I also spent time talking to the lady about her beliefs and her thoughts on dying. (Nurse 7)

Comfort and reassurance Nurses accounts suggest that the need for comfort and reassurance were perceived as spiritual needs:
Facing death but patient and partner needed to talk about funeral arrangements. I felt this was not their main reason, they were seeking comfort and reassurance. (Nurse 9)

Healing Nurses perceived direct clues about the need for spiritual healing as spiritual need.
I thought she needed to be able to have a spiritual healer to see her without fear of others looking on or passing judgement on herher daughter-in-law was a spiritual healer. (Nurse 7)

Helping patients to connect The critical incidents comprised statements that suggest participants attempted to help patients to connect with their families and signicant others as part of the interventions to meet patients spiritual needs.
[We]encourage her family to visit and be around. (Nurse 6) Her behaviour and well being was much improved during the visits from her children. Subsequently, she began to show more trust towards her female carers. (Nurse 8)

Meaning and purpose Discourses about questions of life, the search for meaning and purpose and so on are perceived as spiritual needs according to some of the critical incidents:
She was angry about her disability, she was full of questions about her lifeat that time I did not know whether she would share or show her grief. I suspected she would see this [her disability] as another twist of injustice. (Nurse 31) The patient expressed a need to comprehend new circumstances and understand [questions such as] why me? and [requested] time to talk. (Nurse 22) The patient wanted to organise the remainder of his life and discuss various aspects of his life, things he had done in the past. He needed to come to terms with the diagnosis and his own mortality. He also needed to spend time talking with his family. The patient was given time to talk to express his needs and assisted through listening and counselling skills to be aware of his needs. (Nurse 16)

Helping patients complete unnished business As part of the interventions to meet patients spiritual needs participants helped patients to complete unnished business.
The patient requested a solicitor to formulate Will. He also asked if he could marry his partner (Nurse 16)

Listening to patients concerns Listening to patients and supporting them appeared to be features of nursing interventions related to their spiritual needs.
Staff were encouraged to listen to the patient and the family when the need aroseThe family were encouraged to talk to their brother, and staff supported them during their emotional crisis. (Nurse 16) We gave the lady the opportunity to talk whenever she wanted, and made it clear that all the staff were available for her as required. (Nurse 4)

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Comforting and reassuring As part of care interventions to meet patients spiritual needs evidence from the incidents indicate that nurses were engaged in interactions where they comforted and reassured them:
I reassured this gentleman that he was not to punish himself for his life style and not to feel that God was angry with him. (Nurse 1) [We]sat and talkedthey both knew the patient was dying and I think [they] had accepted this fact. They needed to talk about after the event had taken place. (Nurse 9) I tried to comfort her, reassuring that from what details I know of her friends death that her friend passed away quietly and not in pain. (Nurse 31)

I felt that this compromise helped the patient to full her religious needs to nearly normal basis. (Nurse 11)

Positive effects on nurses Apart from patients and relatives, statements from critical incidents suggest the nurses themselves derived positive effects from care interventions aimed to meet spiritual needs:
I felt happier that he found some inner peace through this. (Nurse 16) The situation felt right the patient seemed to be able to cope and accept (Nurse 42) The family was gratefulthey showed this by giving me a hug (Nurse 30)

Discussion
Nurses reported that patients religious background, spiritual/religiously loaded conversation and diagnosis acted as prompters for them to identify, plan and implement nursing interventions. Nurses perceived such interventions to be spiritual care. The ndings also indicate that there is a vocabulary in health care practice about patients spiritual needs. This includes such terms as respect for religious beliefs and practices, absolution, connectedness, comfort and reassurance, healing, and meaning and purpose. This aspect of the ndings is consistent with the results of other studies (Narayanasamy & Owens 2001, Narayanasamy et al. 2002) in which such factors acted as cues for spiritual care interventions. The need for respect for expression of religious beliefs and practices, including prayer, is also consistently identied in the literature (Bruce 1998, Narayanasamy 1998). Other studies suggest that that some patients pray as a way of connecting with God to seek reassurance and hope that through faith that they will be healed (Sherwood 2000, Narayanasamy et al. 2002). Furthermore, participants identied absolution as a signicant spiritual need. There is evidence that forgiveness may bring a feeling of joy, peace and elation, and a sense of renewed self-worth (McSherry 2000, Narayanasamy 2001, Macaskill 2002). According to Narayanasamy, confession of sin is one way in which some people achieve forgiveness from God. A recent study on forgiveness by Macaskill (2002) suggests that those who forgive also derive positive effects in terms of healing. The need for connectedness appears to be a spiritual need according to some participants. There is a body of literature to highlight the signicance of connectedness (Goldberg 1998). Others describe that striving for connectedness by seeking love and harmonious relationships is part of human

Using personal religious beliefs to assist patients A number of critical incidents indicate that some participants utilized personal religious beliefs to assist patients:
I also stated (she knew from previous conversations) thatas a Christian, I still had a rm belief that God was merciful and that we dont always have the answers why certain things are planned for us in the way they happen. That I believe in a God of love and mercy, and I recognise how hard is this challenge to any faithBy sharing faith, I had faith I hoped to encourage her in her faith and comforted her on a human level. (Nurse 31)

Observance of religious beliefs and practices As a strategy of nursing interventions to meet patients spiritual needs, participants suggested they made efforts to respect patients observance of religious beliefs and practices:
Although the patient could not take the bread for her communion, we agreed the wine could be put in a pot and taken in the form of mouth care. (Nurse 11) [A] Muslim familywho wished to stay with their elderly mother [during fasting] and drew the curtains round the bed at certain times of the day. (Nurse 32)

Outcomes of nurses interventions

Positive effects on patients and their families Participants provided certain examples, which suggested that they felt that their interventions met patients spiritual needs and resulted in positive outcomes:
She expressed her gratitude at our understanding in contacting the chaplain, and kept us informed about when her own minister was visiting. (Nurse 4) 12

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spiritual nature (Narayanasamy 2001, Swinton 2001). The nding that nurses vocabulary embraced connectedness as a spiritual need is probably indicative of patients spiritual need for love and harmonious relationship. According to nurse participants, the need for comfort and reassurance is signicant. When patients are experiencing crisis as a consequence of ill health they are likely to become spiritually distressed, and this state is probably indicative of the need for reassurance and comfort. According to Teasdale (1995) reassurance is an enduring process involving extensive interpersonal communication strategies that help to reduce patients anxiety. However, participants appeared to have used the term comfort to mean giving physical attention to make patients feel comfortable by being present by their bedside. In contrast, Goldberg (1998) refers to this kind of intervention as presencing and points out its benets to patients. In developing a discourse on presencing derived from Roach (1991), Goldberg writes providing a presence which empowers and enables other to change, to accept, to grow, to die peacefully, is what nurses do each day (p. 838). Moreover, in a phenomenological study of nurses experiences, Dunniece and Slevin (2000, p. 614) suggest that presence or being there includes giving information, explaining, answering questions, listening and simply being present without speaking. These authors provide evidence from their own study and others that the phenomenon of presence or being there is important in the care of cancer patients, however, they note that being there is more than a physical presence. Furthermore, healing as a spiritual need was recognized by the nurses who participated in the current study. There is evidence that spiritual resources, in terms of support from carers and religious practices, are necessary for healing to take place (Montgomery 1991, Aldridge 2000). Our ndings indicate that participants believed that searching for meaning and purpose was a particular spiritual need. This aspect of the ndings is consistent with the literature in which the search for meaning and purpose is assumed to be an important dimension of human spirituality (Bruce 1998, Kendrick & Robinson 2000, Swinton 2001). According to Swinton (2001, p. 14), the spirit energizes human existence and lls it with meaning and purpose. However, Kendrick and Robinson (2000) claim that the notion of searching for meaning and purpose as used in the nursing literature implies that it is concerned with
esoteric images that place the realm of the contemplative, enigmatic, abstract and mystical, rather than being seen as something that is intrinsically woven into the everyday themes and concerns of being human. (p. 701)

According to Kendrick and Robinson, such view consigns spirituality to the images about sitting on a mountain thinking about nature and purpose and denies the entire essence of spirituality. However, Coyle (2002) acknowledges the therapeutic effects of spirituality and claims that this can benet health by providing meaning and purpose.

Spiritual interventions in the care of older people

The ndings demonstrate that the nurses in this study attempted to meet their spiritual needs, and put into action certain helping strategies which they perceive as spiritual care interventions. Respect for patients spiritual needs Nurses took practical measures to meet the needs related to patients spirituality. This aspect of the study is consistent with the literature where respect for religious beliefs and practices is identied as paramount (McSherry 2000, Narayanasamy 2001). Also, participants ensured that the respect for older peoples privacy and dignity was given priority as part of the nursing intervention. However, there is some concern in the literature that nurses tend to perceive spiritual needs as synonymous with religious needs. According to Swinton (2001, p. 12), this is view is limited in that one may not look beyond institutional religions and thus risk omission of some of the very signicant needs that are experienced by people with no formal religious interest on a daily basis. Helping strategies The ndings suggest that what could be described as helping strategies were designed to meet patients spiritual needs. The ndings on helping strategies are consistent with the literature that nurses in this study actually demonstrated how they help their patients to meet their need for connectedness (Bruce 1998, Goldberg 1998). As part of the helping strategy, nursing interventions included: helping patients to complete unnished business, listening to their concerns, comforting and giving reassurance. The participants perceived these interventions were necessary part of the spiritual dimension of nursing older people. Such interventions are consistent with the ndings of other studies (Montgomery 1991, Narayanasamy & Owens 2001) where such personal approaches that are seen as desirable model of spiritual of care. Furthermore, the potential for the therapeutic effects of such interventions is well documented in the literature (Montgomery 1991, Sherwood 2000, Swinton 2001). However, others dispute that such strategies are specic enough to

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What is already known about this topic

The human spirit has been said to constitute the essence of being and to give meaning to existence. Holistic care involves attention to body, mind and spirit and is important for wellbeing. Spiritual care interventions are perceived as having benecial effects for patients.

construed as a healing force of spirituality (Coyle 2002). According to Montgomery (1991) caring for others can promote empowerment and self-esteem in the carers.

Limitations of the study

The study sample was small, which limited the number of incidents for analysis. The most that can be claimed is that the study is indicative of an emerging care pattern related to spiritual care interventions in the care of older people, but there is a need for further research in this area.

What this paper adds

Identication of gaps in previous studies of spiritual care. Ways in which nurses construct and respond to older patients spiritual needs. be conceptualized as spiritual care (Draper & McSherry 2002, McSherry & Ross 2002). Draper and McSherry are dismissive of the one size ts all approach to spirituality and argue that such intervention could be disrespectful and potentially harmful. However, participants in this study believed that their interventions in terms of the above personal approaches resulted in largely positive outcomes. Gestures of gratitude, being peaceful and relax states were perceived by the studys participants as indicators of positive outcomes. Swinton (2001) asserts that sensitivity and empathy on the part of nurses are central to effective spiritual care interventions. Furthermore, as part of the helping strategy, some participants utilized personal religious beliefs to assist patients. This would be desirable if patients request or consent to such approaches. However, there is the danger that an imposed strategy may actually be harmful in terms of compounding the spiritual distress, even if the intention was good. Narayanasamy and Owens (2001) raise ethical concerns about such an unsolicited approach in light of their ndings that some nurses were evangelical towards their patients.

Conclusion
This study provides empirical evidence of some practices related to spiritual care of older people. There is a vocabulary about spirituality in nursing which is confusingly and interchangeably used to refer to spiritual and religious needs. This ambiguity and confusion may mean that spiritual care is inconsistently applied to the care of older people. However, when spiritual care is given its benets are evident for both patients and staff. Further research is needed to explore whether nurses perceptions of spiritual needs and care converge with those of older patients. If they do, then we can condently articulate a clear strategy for spiritual care interventions in the care of this patient group.

Acknowledgements
This study is the larger part of a project on spiritual care sponsored by Trinity Care, part of the Southern Cross Healthcare Group.

References
Aldridge D. (2000) Spirituality, Healing and Medicine. Jessica Kingley, London. Bauer T. & Barron C. (1995) Nursing interventions for spiritual care: preferences of the community-based elderly. Journal of Holistic Nursing 13(3), 268279. Berggren-Thomas P. & Griggs M. (1995) Spirituality in aging: spiritual need or spiritual journey? Journal of Gerontological Nursing 21(3), 510. Bradshaw A. (1994) Lighting the Lamp: The Spiritual Dimension of Nursing Care. Scutari Press, London. Bruce E. (1998) How can we measure spiritual well-being? Journal of Dementia May/June, 1617. Carr K. (1993) Integration of spirituality of aging into a nursing curriculum. Gerontology & Geriatrics Education 13(3), 3346. Cohen Z., Headley J., Sherwood G. (2000) Spirituality and bone marrow transplantation: when faith is stronger than fear. International Journal for Human Caring Summer, 4046.

Outcomes
There appeared to be a consensus among our participants that these interventions were benecial to the patients, their families and the nurses themselves. Gestures of gratitude, satisfaction, being peaceful, and achieving relaxed states were interpreted as indicators of benecial outcomes. Nurses appeared to have derived satisfaction from personal involvement in spiritual care interventions. This is consistent with the results of Narayanasamy et al. (2002) and Narayanasamy and Owens (2001), where similar indicators of satisfaction from spiritual care were evident. Others point out that carers nd healing by caring for patients, and such altruism can be
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Issues and innovations in nursing practice Colliton M. (1981) The spiritual dimension of nursing. In Clinical Nursing (Belland E. & Passos J., eds), Macmillan, New York. Cormack D. (2000) The Research Process in Nursing, 4th edn. Blackwell, Oxford. Coyle J (2002) Spirituality and health: towards a framework for exploring the relationship between spirituality and health. Journal of Advanced Nursing 37(6), 589597. Draper P. & McSherry W. (2002) A critical view of spirituality and spiritual assessment. Journal of Advanced Nursing 39, 12. Dunniece U. & Slevin E. (2000) Nurses experience of being present with a patient receiving a diagnosis of cancer. Journal of Advanced Nursing 32(3), 611618. Fitchett G., Meyer P. & Burton L. (2000) Spiritual care in the hospital: who requests it? Who needs it? Journal of Pastoral Care 54(2), 173186. Flannagan J. (1954) The critical incident technique. Psychological Bulletin 51(4), 327358. Fry A. & Tan L. (1996) The spiritual dimension: its importance to the nursing care of older people. Geriaction 14(4), 1417. Goldberg B. (1998) Connection: an exploration of spirituality in nursing care. Journal of Advanced Nursing 27, 836842. Harrison J. & Burnard P. (1993) Spirituality and Nursing Practice. Avebury, Aldershot. Heriot C. (1992) Spirituality and aging. Holistic Nursing Practice 7(1), 2231. Hermann C. (2000) A guide to the spiritual needs of elderly cancer patients. Geriatric Nursing 21(6), 324325. Hicks T. (1999) Spirituality and the elderly: nursing implications with nursing home residents. Geriatric Nursing 20(3), 144146. Kendrick K.D. & Robinson S. (2000) Spirituality: its relevance and purpose for clinical nursing in a new millennium. Journal of Clinical Nursing 9(5), 701705. Legere T. (1984) A spirituality for today. Studies in Formative Spirituality 5(3), 514520. Macaskill A. (2002) Heal the Hurt. How to Forgive and Move on. Sheldon Press, London. MacKinlay E. (2001) The Spiritual Dimension of Ageing. Jessica Kingsley, London. McSherry W. (2000) Making Sense of Spirituality in Nursing Practice. Churchill Livingstone, Edinburgh. McSherry W. & Draper P. (1998) The debates emerging from the literature surrounding the concept of spirituality as applied to nursing. Journal of Advanced Nursing 27(4), 683691. McSherry W. & Ross L. (2002) Dilemmas of spiritual assessment: considerations for nursing practice. Journal of Advanced Nursing 38(5), 479488. Mische P. (1982) Toward a global spirituality. In The Whole Earth Papers (Mische P., ed.), Global Education Association, East Oroange, NJ. Montgomery C. (1991) The care-giving relationships: paradoxical and transcendent aspects. Journal of Transpersonal Psychology 23, 91105.

Responses to the spiritual needs of older people Narayanasamy A. (1993) Nurses awareness and educational preparation in meeting their patients spiritual needs. Nurse Education Today 13, 196201. Narayanasamy A. (1998) The religious and spiritual needs of older people. In Promoting Positive Practice in Nursing Older People (Pickering S. & Thompson J., eds), Bailliere Tindall, London, pp. 128151. Narayanasamy A. (1999) A review of spirituality as applied to nursing. International Journal of Nursing Studies 36, 117 125. Narayanasamy A. (2001) Spiritual Care: A Practical Guide for Nurses and Health Care Practitioners, 2nd edn. Wiltshire, Quay. Narayanasamy A. & Owens J. (2001) A critical incident study of nurses responses to the spiritual needs of their patients. Journal of Advanced Nursing 33(4), 446455. Narayanasamy A., Gates B. & Swinton J. (2002) Spirituality and learning disabilities: a qualitative study. British Journal of Nursing 11(14), 948957. Oldnall A. (1995) On the absence of spirituality in nursing theories and models. Journal of Advanced Nursing 21(3), 417418. Reed P. (1991) Spirituality and mental health in older adults: extant knowledge for nursing. Family & Community Health 14(2), 1425. Reed P. (1992) An emerging paradigm for the investigation of spirituality in nursing. Research in Nursing and Health 15, 349 357. Roach M. (1991) The call to consciousness: compassion in todays health world. In In Caring: The Compassionate Healer (Gaul L. & Leininger M., eds), National League for Nursing, New York, pp. 718. Ross L. (1997a) Nurses Perceptions of Spiritual Care. Aldershot, Avebury. Ross L. (1997b) Elderly patients perceptions of their spiritual needs and care: a pilot study. Journal of Advanced Nursing 26(4), 710715. Sherwood G. (2000) The power of nurse-client encounters. Journal of Holistic Nursing 18(2), 159175. Soeken K. & Carson V. (1987) Responding to the Spiritual Needs of the Chronically Ill. Nursing Clinics of North America 22(3), 603611. Swinton J. (2001) Spirituality in Mental Health Care: Rediscovering a Forgotten Dimension. Jessica Kingsley, London. Taylor E., Amenta M. & Highfield M. (1995) Spiritual care practices of oncology nurses. Oncology Nursing Forum 22(1), 31 39. Teasdale K. (1995) Theoretical and practice considerations on the use of reassurance in the nursing management of anxious patients. Journal of Advanced Nursing 22(1), 7986. Touhy T. (2001) Nurturing hope and spirituality in the nursing home. Holistic Nursing Practice 15(4), 4556. Young C. (1993) Spirituality and the chronically ill Christian elderly. Geriatric Nursing 14(6), 298303.

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Appendix 1: spiritual care questionnaire

Please complete the following without mentioning the name of any member of staff or any patient. Speciality: Nursing qualications (including year): Number of years in nursing since qualications: Think of a past situation when you: nursed a patient (including family) who had spiritual needs. tried to help the patients/family to meet his/her spiritual needs. were able to observe or nd out the effects on the patient/family of what you did. 1. Try to describe the situation which led up to the event, including when and how you recognized that patient had spiritual needs and where was this? 2. At the time, (a) what did you think the patients spiritual needs were/(b) What led you to think this? (If you do not know, please say so). 3. Try to describe what you did to try to help the patient to meet his/her spiritual needs? Please be specic and include as much details as you can remember? 4. Please describe the effect on the patients/family what you did, and explain what led you to this conclusion? Thank you for completing the questionnaire.

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2004 Blackwell Publishing Ltd, Journal of Advanced Nursing, 48(1), 616