Assessing patients' spiritual needs: many nurses may not feel confident about assessing patients' spiritual needs but it is an important aspect of holistic care. Here a nurse offers some suggestions.

Religion and spirituality are important to the majority of New Zealanders. According to recent data, more than 60 percent of New Zealanders reported spirituality to be "rather" or "very important" in their lives (1) and nearly 60 percent reported being connected to a religious or spiritual tradition. (See Figure One.) (2)

Religion and spirituality have been shown to have a significant effect on the health and health outcomes of individuals. (3) Nurses are more likely than other health care providers to find themselves in a situation where spiritual needs are presented. The ability of a nurse to perform a spiritual assessment accurately, thereby meeting a patient's needs, may greatly enhance the health outcome. Despite numerous publications in foreign journals, there are a limited number of publications in New Zealand reviewing the provision of a spiritual assessment by a nurse. This article reviews the concepts of religion and spirituality, and provides spiritual assessment techniques that a nurse could incorporate into care.

Religious and spiritual conversation, debate, and lifestyles are frequently proclaimed and criticised through media, peers, and everyday acquaintances. For some faiths, the idea of religion will encompass the concept of spirituality, and will be a natural outflow of that idea. Others may view spirituality as a separate concept, possibly disconnected from any religious institution. People's understanding of spirituality has expanded greatly in recent years, and may vary immensely from one patient to the next.

'A search for the sacred'

Religion involves rituals, practices, and experiences, involving a search for the sacred (eg God, Allah, etc), that are shared within a group. It is most likely to be associated with formal, organised, group activities. Spirituality is defined as the search for meaning and purpose in life, which seeks to understand life's ultimate questions in relation to the sacred. Unlike religion, spirituality is informal, non-organised, and experiential. The concepts can be independent or interconnected with one another.

A spiritual assessment is an active and ongoing conversation that assesses the spiritual needs of the patient. It may be formal or informal, but should always be respectful and non-biased. There is no absolute in the timing of a spiritual assessment. Some have recommended incorporating it into the initial assessment, while others argue for a delayed assessment after the nurse and patient have an established relationship. The integration of both techniques may be the most relevant, as a spiritual assessment is not static, but an ongoing conversation between the nurse and patient. The questions in a spiritual assessment are asked to elicit beliefs that could affect patient care. The information divulged is then used to support, encourage, or lead the patient in harmonising their personal relationship between spirituality and health. However, collaboration with or referral to a chaplain may be the most appropriate step, if a nurse notes a situation that is deemed beyond the scope of available care.

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Nurses who have reviewed their personal beliefs are likely to be more comfortable discussing the spiritual needs of a patient. A thoughtful reflection on one's own beliefs and biases on the relationship between religion, spirituality and health can be undertaken through journaling, meditation, or discussions with interested persons. Reflective questions could include:

* How do I view the relationship between religion, spirituality, and health?

* If someone presents with spiritual needs, how would I respond?

* How can I provide spiritual care?

* Who could I collaborate with, if I feel I cannot provide the needed spiritual care?

These reflections can build the nurse's confidence in addressing spiritual issues.

While no spiritual assessment technique is universal, there are several methods that may provide insight into developing an individualised spiritual assessment. A few noteworthy examples of spiritual assessment techniques include the "FICA" and "HOPE" methods. These are easy to remember acronyms that could lead the nurse in performing a spiritual assessment. FICA denotes religious and spiritual attributes that include the faith tradition of patient, importance of faith, church involvement, and application of faith into health and/or addressing the patient's spiritual needs. (4)

The HOPE acronym includes sources of hope, eg meaning, comfort, strength, peace, Love and connection; organised religion; personal spirituality and practices, and the effects of religious or spiritual beliefs on medical care and end-of-life issues. (5) Using these methods will allow the nurse to address several areas of religion and spirituality that may affect health outcomes.

However, if a nurse is initially uncomfortable or unfamiliar with spiritual assessments, one or two simple questions could be presented to the patient, eg Do you consider yourself to be a religious or spiritual person? If so, how is this related to your health or health care decisions? Briefly addressing the patient's religion or spirituality can provide an area of open dialogue between the nurse and patient. Information gathered during a spiritual assessment can then be used throughout the patient's care.

While a nurse may not be fully comfortable in conducting a spiritual assessment, addressing this dimension of the patient can lead to an enhanced relationship between the nurse and patient, and potentially to better health outcomes. Spiritual assessment techniques among nurses are developed over a series of experiences. Initially, a nurse may need coaching from fellow colleagues or experienced caregivers. However, after becoming comfortable with the concepts and questions, a nurse can easily incorporate a spiritual assessment into regular nursing care, and provide an even greater degree of "holistic" nursing care.

Additional Resources

* The Center for Spirituality and Healing at the University of Minnesota: on-line modules for healthcare providers related to spiritual care and assessment, http://www.csh.umn.edu/modules/ index.html

* Spiritual Competency Resource Center: on-line resources for spiritual assessment (includes continuing education credits) http:// www.spiritualcompetency.com/index.asp

* Maori Health: on-line resource for information related to Maori health http://www.maorihealth.govt.nz/

This article was assessed by Kai Tiaki Nursing New Zealand's practice article review committee in March 2008.

References

1) Rose, E., Huakau, J., Sweetsur, P. &, Casswell, S. (2005) Social Values: A report from the New Zealand Values Study 2005. Auckland, New Zealand: Centre for Social and Health Outcomes Research and Evaluation & Te Ropu Whariki.

2) Statistics New Zealand. (2006) 2006 Census. Wellington, New Zealand: Statistics New Zealand, Tatauranga Aotearoa.

3) Koenig, H., McCullough, M. & Larson, D. (2001) Handbook of religion and health. New York: Oxford University Press.

4) Puchalski, C., & Romer, A. (2000) Taking a spiritual history allows clinicians to understand patients more fully. Journal of Palliative Medicine; 3, 129-137.

5) 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, 81-89.

Fleetwood Loustalot, RN, FNP, PhD, received a Rotary International Ambassadorial Scholarship and studied at Massey University's School of People, Environment and Planning from February 2007 to February 2008. He now works as an epidemic intelligence service officer in the National Centre for Chronic Disease Health Promotion and Prevention in Atlanta, Georgia and is an adjunct professor at the University of Mississippi Medical Center School of Nursing, Jackson, Mississippi.

Figure One: Distribution of religious traditions among New Zealanders

No Response            (13%)
Other Religion         (<1%)
Spiritualism           (<1%)
Maori Christ.          (1.6%)
Jewish/Judaism         (<1%)
Muslim/Islam           (<1%)
Hindu                  (1.6%)
Christian              (50%)
No Religion            (32%)
Buddhist               (1.3%)

Note: Table made from pie chart.