Spirituality at the end of life: conceptualization of measurable aspects-a systematic review

Finnish Palliative Care Nurses' and Physicians' Perceptions of Spirituality and Spiritual Care Related to Their Attitudes toward End-of-Life Care

Background

Spiritual care constitutes an indispensable aspect of palliative care (PC). Health care professionals encounter challenges when addressing spiritual care at the end of life. Developing appropriate attitudes toward end-of-life care can facilitate the acquisition of competencies needed for effective delivery of spiritual care.

Aim

To explore the perceptions of spiritual care and attitudes toward end-of-life care among PC professionals.

Design

The Finnish version of the "Spirituality and Spiritual Care Rating Scale" (SSCRS-FIN) and a newly developed "Attitudes toward End-of-Life Issues" (AEOLI) questionnaire were validated and utilized.

Setting/Participants

Both questionnaires were distributed to PC professionals involved in PC through an online survey. Exploratory and confirmatory factor analyses were conducted. The newly derived factors were subsequently examined for their associations with age, gender, profession, affiliation with a religious community, personal interpretation of spirituality, and years of professional experience.

Results

A total of 204 participants took part in the study (163 nurses, 19 nursing students, and 22 physicians). Exploratory factor analysis demonstrated satisfactory internal consistency, as indicated by Cronbach's alpha coefficients, for the five factors of SSCRS-FIN: "Spirituality" (0.733), "Existential" (0.614), "Spiritual Needs" (0.599), "Passive Spiritual Care" (0.750), and "Active Spiritual Care" (0.665); and for the seven factors of AEOLI: "Anxiety" (0.823), "Discussion" (0.924), "End-of-Life" (0.573), "Education" (0.692), "Medically Induced Death" (0.859), "Suffering" (0.671), and "Knowledge" (0.444). Confirmatory factor analysis demonstrated satisfactory fit values for both questionnaires. Significant positive correlations were observed between end-of-life care and the factors "Existential," "Spiritual Needs," and spiritual care factors, whereas an inverse correlation was found among "Anxiety," "Medically Induced Death," and all factors of SSCRS-FIN.

Conclusions

Valid and reliable questionnaires for assessing spiritual care (SSCRS-FIN) and attitudes toward end-of-life care (AEOLI) were developed. Attitudes toward end-of-life care were positively correlated with perceptions of spiritual care.

Combined rehabilitation and palliative care interventions for patients with life-threatening diseases - PREGOAL. A scoping review of intervention programme goals

PURPOSE

WHO recommends integrating rehabilitation into palliative care when providing services for people with life-threatening conditions. Recently, there has been increasing interest in exploring how rehabilitation and palliative care approaches could be combined. The aim of this study was to map and discuss the goals of intervention programmes that combine rehabilitation and palliative care.

METHODS

A scoping review was performed. The electronic databases MEDLINE, EMBASE, and CINAHL were searched for papers published between January 2014 and September 2022. Papers were considered eligible if the participants in question had a life-threatening disease and if interventions included both rehabilitation and palliative care. All study types were included.

RESULTS

Ten papers describing five interventions were included. Qualitative goals were narratively described, and quantitative goals were analysed according to the International Classification of Functioning, Disability and Health, and the Total Pain framework. Findings showed an overall focus on functioning and quality of life. Further analysis indicated an emphasis on physical and psychological dimensions. Social participation, and the social and spiritual dimensions were rarely evaluated.

CONCLUSION

This review indicates that goals relative to social participation, the social and spiritual dimensions, and the patient's own goals may well be overlooked as points of orientation for interventions.

Spiritual Care Expectations Among Cancer and Noncancer Patients With Life-Threatening Illnesses

BACKGROUND

Spirituality is a core element in holistic nursing care. Therefore, it is necessary to understand the spiritual care expectations of cancer and noncancer patients with life-threatening illnesses.

OBJECTIVE

The aim of this study was to identify the spiritual care expectations of vulnerable patients with life-threatening illnesses.

INTERVENTIONS/METHODS

This study uses both quantitative and qualitative approaches, and data were collected from 232 patients. For quantitative data, we used the Nurse Spiritual Therapeutics Scale (NSTS), which comprises 20 items. Qualitative data were collected using an open-ended question. Quantitative data were analyzed using descriptive statistics, independent t tests, 1-way analysis of variance, and item and factor analysis. Qualitative data were analyzed using content analysis.

RESULTS

The mean score of spiritual care expectations ranged from 2.27 to 3.07. There was a significant difference in NSTS mean score between cancer and noncancer patients. In exploratory factor analysis, NSTS was extracted into 3 factors and items belonging to the 3 factors showed similarity between cancer and noncancer patients. Qualitative data using content analysis revealed the following 3 themes: "treat with respect," "religious support," and "comfort with presence." The 3 factors corresponded with 3 themes: factor I versus "treat with respect," factor II versus "religious ritual," and factor III versus "comfort with presence."

CONCLUSIONS

Spiritual care expectations of cancer and non-cancer patients with life-threatening illnesses were identified and the findings provide valuable data regarding the expectations of patients' spiritual care.

IMPLICATIONS FOR PRACTICE

Our findings emphasize integrating patient-reported outcomes with spiritual care to stimulate patient-centered care, thus promoting holistic palliative or end-of-life care.

Spirituality During the COVID-19 Pandemic: An Online Creative Arts Intervention With Photocollages for Older Adults in Italy and Israel

The present study aimed to examine how expressions of spirituality were stimulated and reflected in an online creative arts intervention for older adults during COVID-19 lockdowns. The online process focused on the creation of digital photocollages together with narrative elements of dignity therapy. Twenty-four Israeli and Italian community-dwelling older adults aged 78–92 participated in a three-session online intervention involving the production of three photocollages. The visual and verbal data (participants’ chosen photos and photocollages, and transcripts of the sessions) were qualitatively analyzed within an abductive framework. Four themes were generated, representing the four domains of spirituality that were stimulated by and expressed in the process: (1) Connectedness with the self, (2) connectedness with others, (3) connectedness with the environment, and (4) connectedness with the transcendent. The findings show how photographs can serve as projective visual stimuli which elicit personal content through spontaneous thinking, and they reveal the multifaceted nature of spirituality, wherein each domain nourishes the others. Overall, the findings illustrate how creative arts intervention guided by the tenets of dignity therapy can contribute to the spiritual care of older adults during periods of social isolation, or to the spiritual support provided in palliative care.

Spiritual Care in Palliative Care: A Physician’s Perspective

Palliative care is defined as ‘an approach that improves the quality of life of patients and their families who are facing problems associated with life-threatening illness. It prevents and relieves suffering through identification, assessment and treatment of pain and other problems, whether physical, psychosocial or spiritual’. As a palliative care physician, I aim to explore and meet the needs of my patients and their loved ones. As I am specifically trained as a specialist in assessing and treating ‘pain and other physical symptoms’, in psychological, social and spiritual issues, I am a generalist. Two approaches are described to assess spiritual needs in palliative care: The first is adjoining the analytic concept of the four dimensions of palliative care: using an instrument, measuring spiritual well-being or spiritual needs, and measuring the quality of life, with specific attention to spiritual issues. Second, a holistic approach is promoted, with openness to the patients’ narrative of their life, disease and suffering. In the integrity of the clinical encounter, medical, ethical and spiritual issues may be discussed. Broadening our clinical language with ethical, psychosocial, and spiritual vocabulary is mandatory, and self-reflection, interdisciplinary collaboration and specific interdisciplinary training may be supportive to develop such a clinical language.

Understanding Complexity in Care: Opportunities for Ethnographic Research in Palliative Care

Background: Ethnography has been used to address a broad range of research questions in health care. With ethnographic research methods it is possible to gain access to the complex realities of health care practice as it occurs, through interpreting the nuances of individual and team behaviours, the roles and dynamics of care provision, and the social impacts and influences of illness. The provision of clinical palliative care is complex, involving multidisciplinary collaboration across different health systems, and is subject to a multitude of personal, cultural and environmental influences. This complexity demands creative methodological approaches to research in palliative care, of which ethnography plays an important, if infrequently utilised, role. Aim: This article aims to explore potential opportunities of ethnographic methods for palliative care research. Findings: Ethnographic methods focuses on behaviour in the 'natural' setting of participants, to create theoretical descriptions of events, cultures, interactions and experiences. In palliative care these methods may provide nuanced understandings of illness, relationships and teams, communication, medical education, complex care provision, and novel or changing health practices. Of particular importance is the potential of these methods to understand complex practices and processes, and engage with under-represented population groups who may be excluded from interview research. Conclusion: Ethnography offers important opportunities for future research in palliative care and should be considered as part of the 'research toolbox' to improve understanding of the complex nature of care provision and the experiences of illness and loss.

Spirituality during COVID-19 in Northern Italy: The experience of participating in an online prayer group

Spirituality has ascendant value during times of adversity. Religious activities have beenfound to increase spirituality, and therefore might be considered a coping resource for the individual. The present research aims to explore participants' experience in an online Catholic prayer group in northern Italy that was held throughout the period of COVID-19 social restrictions. The group comprised 16 Catholic individuals aged 34 to 85, who were interviewed in writing following a protocol of four open-ended questions. The results reported four main thematic areas: (1) the benefits of the spiritual journey while coping with the pandemic; (2) the potential of the online setting; (3) the challenges of the online setting; and (4) the bond with God and how it evolved during the pandemic. The findings confirm the valuable contribution of the on-line group religious activity to the participants'    wellbeing, particularly during the time of social distancing.

Is There a Connection Between Spiritual Transcendence and Quality of Life? A Cross-Sectional Survey Study in Patients Under the End-of-Life Care

Background: There is limited data available on the spiritual dimension of palliative care in Eastern Europe. In countries such as Poland, investigating spirituality and its essential aspects is further complicated because in a predominantly Catholic country, spirituality is mistakenly thought to be identical to religiousness. Aim: This study investigated the connection between spiritual transcendence, meaning in life, altruism, and the quality of life of cancer patients in end-of-life care in an Eastern Europe Country (Poland). Design: This cross-sectional study was based on 4 surveys. The Quality of Life Questionnaire MQOL-R, the Scale of Spiritual Transcendence, the Purpose in Life Questionnaire PIL-6, and the Altruism Scale were used. Setting/Participants: Data from 41 oncology patients receiving end-of-life care at home and in a stationary hospice was obtained. Results: Results indicate that there is a significant positive correlation between transcendence, spiritual growth, and global quality of life. There is also a positive correlation between altruism and the meaning of life, as well as between the meaning of life, spirituality and quality of life, while altruism is positively associated exclusively with spirituality. Conclusion: This study revealed that spiritual transcendence can be understood, according to Piedmont's theory, as a personality trait that allows the patients to cross the boundaries of their existence and identify subjectively important values in their life. It can be examined and developed not only in the context of the need but also as a predisposition and a resource of personhood.

Exploring the Meaning of Spirituality and Spiritual Care with Help From Viktor Frankl

Problem: A difficult concept to understand, spirituality is not often addressed in healthcare. Purpose: This paper will explore the concept of spirituality and spiritual care using the theory of meaning by Viktor Frankl. Implications: Authors will provide ways for nurses to think about spiritual needs and spiritual care for patients and identify barriers to spiritual care implementation. Suggestions are made for spiritual inquiry, resources are provided for spiritual care education and training, and recommendations are made for nursing education curricula and health care policy change. Conclusions: With a greater understanding of spirituality, nurses practicing holistic care can increase their spiritual care competence and implement spiritual care into practice.

Toward a socio-spiritual approach? A mixed-methods systematic review on the social and spiritual needs of patients in the palliative phase of their illness

BACKGROUND

Patients express a variety of needs, some of which are labeled social and spiritual. Without an in-depth exploration of patients' expressions of these needs, it is difficult to differentiate between them and allocate appropriate healthcare interventions.

AIM

To gain insight into the social and spiritual needs of patients with a life-limiting illness and the distinction between these needs, as found in the research literature.

DESIGN

A mixed-methods systematic review and meta-aggregation were conducted following the Joanna Briggs Institute (JBI) approach to qualitative synthesis and the PALETTE framework and were reported according to the PRISMA statement. This review was registered in PROSPERO (CRD42019133571).

DATA SOURCES

The search was conducted in PubMed, EMBASE, CINAHL, Scopus, and PsycInfo. Eligible studies reported social and spiritual needs from the patients' perspective and were published between January 1st 2008 and October 2020. The quality of evidence was assessed using JBI Critical Appraisal Tools.

RESULTS

Thirty-four studies (19 qualitative, 1 mixed-methods, and 14 quantitative) were included. The five synthesized findings encompassing social and spiritual needs were: being autonomous, being connected, finding and having meaning, having a positive outlook, and dealing with dying and death.

CONCLUSION

What literature labels as social and spiritual needs shows great similarities and overlap. Instead of distinguishing social from spiritual needs based on patients' linguistic expressions, needs should always be explored in-depth. We propose a socio-spiritual approach that honors and preserves the multidimensionality of patients' needs and enables interdisciplinary teamwork to allocate patient-tailored care.

Coordinating assessment of spiritual needs: a cross-walk of narrative and psychometric assessment tools used in palliative care

Addressing spiritual needs of patients in healthcare settings improves patient experiences and clinical outcomes; however, non-chaplain providers typically assess spiritual needs differently (quantitative psychometric) than healthcare chaplains (long form narrative) and thus there is little shared language or cross-disciplinary evaluation frameworks across disciplines. This discrepancy impedes the provision of both team-based and patient-centered care. This paper used scoping review methodology to illustrate the overlap between narrative and psychometric assessment tools, comparing four narrative tools against eight psychometric tools. The SpNQ-120 and Brief RCOPE demonstrated consistent domain coverage across the four chaplain narrative tools. This work provides preliminary resources to aid clinicians and researchers in choosing an appropriate tool. Additionally, for those who do not work closely with chaplains, it provides a sense of what domains chaplains prioritize, from their professional and lived experience, in assessing the spiritual life of the patient. This improves interdisciplinary communication, and therefore, patient care.

Spirituality and Caring for the Older Person: A Discussion Paper

Holistic healthcare to the older person is important. Spirituality is considered to be the very essence of being and for some is what motivates and guides us to live a meaningful existence. Nurses caring for the older person need support in responding to their spiritual needs in order to ensure that they are appropriately and successfully met. The aim of this paper is to explore these needs and highlight some evidence indicating how this care can be implemented and therefore ultimately influence nursing practice.

Spiritual care provided by nursing home physicians: a nationwide survey

Objective

To examine perceptions and experiences regarding providing spiritual care at the end of life of elderly care physicians practising in nursing homes in the Netherlands, and factors associated with spiritual care provision.

Methods

A cross-sectional survey was sent to a representative sample of 642 elderly care physicians requesting information about their last patient who died and the spiritual care they provided. We compared their general perception of spiritual care with spiritual and other items abstracted from the literature and variables associated with the physicians’ provision of spiritual care. Self-reported reasons for providing spiritual care were analysed with qualitative content analysis.

Results

The response rate was 47.2%. Almost half (48.4%) provided spiritual end-of-life care to the last resident they cared for. Half (51.8%) identified all 15 spiritual items, but 95.4% also included psychosocial items in their perception of spirituality and 49.1% included other items. Physicians who included more non-spiritual items reported more often that they provided spiritual care, as did more religious physicians and those with additional training in palliative care. Reasons for providing spiritual care included a request by the resident or the relatives, resident’s religiousness, fear of dying and involvement of a healthcare chaplain.

Conclusion

Most physicians perceived spirituality as a broad concept and this increased self-reported spiritual caregiving. Religious physicians and those trained in palliative care may experience fewer barriers to providing spiritual care. Additional training in reflecting upon the physician’s own perception of spirituality and training in multidisciplinary spiritual caregiving may contribute to the quality of end-of-life care for nursing home residents.

Patient Perspectives about Spirituality and Spiritual Care

Objective:

This study was undertaken to explore the perspectives regarding spirituality and spiritual care held by individuals with advanced disease. The aim was to gain a deeper understanding about their viewpoints surrounding spiritual care and the role of health-care professionals in providing such care.

Methods:

Sixteen individuals with advanced disease and a prognosis of <12 months underwent an in-depth interview. Transcripts were subjected to a qualitative descriptive analysis to identify salient content and themes.

Results:

Four overall themes were identified: Spirituality is personal, spiritual distress is about separation, spiritual care is about connecting, and conversations about spirituality must align with the patient's beliefs. Subthemes emphasized the individuality of spiritual expression, the potential for illness impacting spiritual beliefs, and the value of connections to one's spiritual community. Participants thought healthcare providers needed to be able to identify individuals who were experiencing a spiritual struggle, acknowledge the reality of that struggle, and connect the individual with the appropriate resource or person.

Conclusions:

Patients with advanced disease are likely to express their spirituality in unique ways. Being able to talk about their spiritual beliefs and doubts during illness without judgment was seen as a benefit to them. Healthcare providers ought to be able to identify those patients who require assistance in connecting to appropriate spiritual care resources.

Cross-cultural validation of the Brazilian version of the spiritual care competence scale

OBJECTIVE

This study describes the cross-cultural validation and psychometric evaluation of the Spiritual Care Competence Scale - Brazilian Portuguese version. This reliable and valid instrument is recommended in the literature to measure the outcomes of the education process in the development of spiritual care competences.

METHOD

This is a cross-sectional validation study following the stages proposed by Beaton et al.: translation into Portuguese, back translation into English, expert committee review for semantic equivalence, assessment of the clarity of the pre-final version, and evaluation of the psychometric properties of the final version in Portuguese. Health professionals working at a public hospital in South Brazil participated in the different stages of this study.ResultRegarding internal consistency, total Cronbach's alpha was 0.92 and the mean inter-item correlation was 0.29. The test-retest procedure showed no statistically significant differences in the six subscales. The intraclass correlation coefficient ranged from 0.67 to 0.84, demonstrating the stability of the scale.Significance of resultsThe results support the psychometric quality of the scale and indicate that the adapted instrument is a valid and reliable scale with good internal consistency for measuring spiritual care competencies of health professionals in Brazilian healthcare settings.

Investigating the relationship between the quality of life and religious coping in mothers of children with recurrence leukemia

Background:

Leukemia is a life-threatening chronic disease for children. The recurrence of the disease causes tension and reduces the quality of life for the family, especially for mothers. Religion is an important humanitarian aspect of holistic care that can be very effective in determining the health level of the patient and the family members. The present study aims at investigating the role of religious coping (RCOPE) in the quality of life for mothers of children with recurrent leukemia.

Methods:

This is a cross-sectional study of the descriptive-correlational type. Two-hundred mothers with children aging 1–15 years suffering from leukemia were selected using a continuous sampling method. The data were collected using questionnaires eliciting information about personal information, Persian version of the Caregiver Quality of Life Index-Cancer, and RCOPE. The collected data were analyzed in SPSS using descriptive tests and independent samples t-test.

Results:

The result of examining the relation between life quality and demographic features of mothers showed that education level, income, and occupation had a significant statistical relationship with general quality of life mothers. The results of examining the relationship between quality of life and RCOPE of mothers showed that RCOPE was positively correlated only with the positive coping dimension quality of life (P < 0/001). Negative RCOPE had a significant reverse statistical correlation with general quality of life and all its aspects.

Conclusion:

The quality of life for the participants in this study was significantly related to RCOPE. Mothers with negative RCOPE faced low scores for quality of life, and religious support can improve their life quality. Further longitudinal studies are required to investigate the effects of establishing support communities.

Spiritual Therapy in Coping with Cancer as a Complementary Medical Preventive Practice

There are many of methods of treating cancer. However, the concept of curing the cancer is beyond our current knowledge. Some patients who have the cancer may seek an alternative manner of curing their disease. Alternative medicines, such as spiritual and complementary therapy, are able to cure the cancer and, at the least, are safe. Research on the importance of spirituality in cancer care has mainly been performed in geographically heterogeneous populations. The results are limited to these specific religious-cultural contexts and enlightened by contributions from ethnicity and religion. This article focused on the religiousness and spiritual support of cancer patients from diverse and heterogeneous groups around the globe. An electronic search of peer-reviewed articles was systematically performed to obtain the relevant literature with the CINAHL, PsycINFO, and PubMed databases. The keywords included religion, cancer, illness, psychotherapy, and spiritual and alternative treatment/therapies. The inclusion criteria for the reviews were that the documents were original quantitative research and published in English. Articles that were not directly relevant to the present objective were excluded. The present outcome of these review resources suggest that it may be helpful for clinicians to address spirituality, particularly with regard to prevention, healing, and survival of cancer patients. This article indicates that it may be useful for clinical oncologists to be informed of the prevalence of the use of spiritual medicine in their specialized field. In addition, patients should routinely be asked about the use of spiritual medicine as part of every cancer patient's evaluation.

The role of ICU nurses in the spiritual aspects of end-of-life care in the ICU: an explorative study

AIM

The aim of this study was to examine the role and responsibilities of intensive care unit (ICU) nurses regarding the spiritual aspects of end-of-life care in the ICU, from the chaplains' perspectives.

METHOD

An explorative study including inductive thematic analysis was used. Two focus group interviews with in total eleven chaplains working in several Dutch ICUs were performed.

RESULTS

The focus group interviews resulted in five themes: (i) awareness of ICU nurses, (ii) communication, (iii) nursing interventions, (iv) multidisciplinary care and (v) education. In total, twenty recommendations were formulated.

CONCLUSIONS

This explorative study provides an overview of the perspectives of chaplains about the role of ICU nurses during end-of-life care, specified to spiritual care. Chaplains mentioned different roles, responsibilities and competences which are needed for ICU nurses to give spiritual care. These roles, responsibilities and competences included giving spiritual care to patients and families as standard care. Chaplains agreed that ICU nurses should start and maintain a dialogue with patient and families, but that it is also important to be aware of one's own spiritual background. However, education about spiritual care is needed to establish this. It could be recommended to educate ICU nurses during their ICU training or retraining about spiritual care and reflection.

Where is God in my dying? A qualitative investigation of faith reflections among hospice patients in a secularized society

Despite increased focus on the role of spiritual care in palliative care, there is limited knowledge about spirituality/religiosity among dying patients in secularized cultures such as Denmark. This study aims through semi-structured interviews with Danish hospice patients and participant observation to elucidate how hospice patients reflect and act upon their potential faith. The results demonstrate three dimensions of faith: (1) "Knowing" (cognition), (2) "doing" (praxis) and (3) "being" (meaning). The article concludes that most patients had a hesitant, but according to their situation, important faith although it was not something they knew much about, let alone discussed or practiced much.

Tools to Assess Pain or Lack of Comfort in Dementia: A Content Analysis

CONTEXT

There is need for tools to help detect pain or lack of comfort in persons unable to communicate. However, pain and (dis)comfort tools have not been compared, and it is unclear to what extent they discriminate between pain and other possible sources of discomfort, or even if items differ.

OBJECTIVES

To map and compare items in tools that assess pain and the broader notion of discomfort or comfort in people with severe dementia or at the end of life.

METHODS

Using qualitative content analysis with six classifications, we categorized each item of four thoroughly tested observational pain tools (Pain Assessment in Advanced Dementia [PAINAD], Pain Assessment Checklist for Seniors with Limited Ability to Communicate [PACSLAC], Doloplus-2, and draft Pain Assessment in Impaired Cognition [PAIC]), and four discomfort tools (including distress, comfort, and quality of life in severe dementia or at the end of life; Discomfort Scale-Dementia Alzheimer Type [DS-DAT], Disability Distress Assessment Tool [DisDAT], End-of-Life in Dementia-Comfort Assessment in Dying with Dementia [EOLD-CAD], and Quality of Life in Late-Stage Dementia [QUALID] scale). We calculated median proportions to compare distributions of categories of pain and discomfort tools.

RESULTS

We found that, despite variable content across tools, items from pain and discomfort tools overlapped considerably. For example, positive elements such as smiling and spiritual items were more often included in discomfort tools but were not unique to these. Pain tools comprised more "mostly descriptive" (median 0.63 vs. 0.44) and fewer "highly subjective" items (0.06 vs. 0.18); some used time inconsistently, mixing present and past observations.

CONCLUSION

This analysis may inform a more rigorous theoretical underpinning and (re)development of pain and discomfort tools and calls for empirical testing of a broad item pool for sensitivity and specificity in detecting and discriminating pain from other sources of discomfort.

Discerning the healing path--how nurses assist patient spirituality in diverse health care settings

AIMS AND OBJECTIVES

To examine nurses' experiences in spiritual care in diverse clinical settings, preferably not palliative care.

BACKGROUND

Spirituality is part of holistic nursing care. The concept of spiritual literacy is introduced as the nurse's ability to read the spiritual signs of the human experience.

DESIGN

Classical grounded theory methodology with open and selective coding was used to identify the participants' main concern and the strategies they used to resolve it, and to develop a substantive grounded theory.

METHOD

Data were collected in 2008 and 2014 during eight focus group interviews with a total of 22 nurses recruited from a master's programme, postgraduate programmes and a local hospital. Data were analysed through constant comparison until the grounded theory emerged.

RESULTS

The participants' main concern was how to assist the patient to alleviation. The participants resolved this by Discerning the healing path, which comprises three stages: Tuning in on spirituality, Uncovering deep concerns and Facilitating the healing process. These three stages are accompanied all the way by the participants' Willingness to overcome own comfort zone and Building a trusting relationship.

CONCLUSION

Spirituality is of relevance for all areas of nursing care, not just dying patients or those in palliative care. Spirituality relates to the deep and important things in life and affects how patients face health issues. Nurses attend to spirituality in patients because the pain of the soul touches them and the calmness of spiritual peace amazes them.

RELEVANCE TO CLINICAL PRACTICE

The professional culture in the health care team socialises nurses into the workplace, and leaders need to pay close attention to how they can foster openness to spiritual matters. The personal and professional maturity of the nurse is fundamental to his or her willingness and ability to overcome own comfort zone.

Predictors of spiritual care provision for patients with dementia at the end of life as perceived by physicians: a prospective study

BACKGROUND

Spiritual caregiving is part of palliative care and may contribute to well being at the end of life. However, it is a neglected area in the care and treatment of patients with dementia. We aimed to examine predictors of the provision of spiritual end-of-life care in dementia as perceived by physicians coordinating the care.

METHODS

We used data of the Dutch End of Life in Dementia study (DEOLD; 2007-2011), in which data were collected prospectively in 28 Dutch long-term care facilities. We enrolled newly admitted residents with dementia who died during the course of data collection, their families, and physicians. The outcome of Generalized Estimating Equations (GEE) regression analyses was whether spiritual care was provided shortly before death as perceived by the on-staff elderly care physician who was responsible for end-of-life care (last sacraments or rites or other spiritual care provided by a spiritual counselor or staff). Potential predictors were indicators of high-quality, person-centered, and palliative care, demographics, and some other factors supported by the literature. Resident-level potential predictors such as satisfaction with the physician's communication were measured 8 weeks after admission (baseline, by families and physicians), physician-level factors such as the physician's religious background midway through the study, and facility-level factors such as a palliative care unit applied throughout data collection.

RESULTS

According to the physicians, spiritual end-of-life care was provided shortly before death to 20.8% (43/207) of the residents. Independent predictors of spiritual end-of-life care were: families' satisfaction with physicians' communication at baseline (OR 1.6, CI 1.0; 2.5 per point on 0-3 scale), and faith or spirituality very important to resident whether (OR 19, CI 5.6; 63) or not (OR 15, CI 5.1; 47) of importance to the physician. Further, female family caregiving was an independent predictor (OR 2.7, CI 1.1; 6.6).

CONCLUSIONS

Palliative care indicators were not predictive of spiritual end-of-life care; palliative care in dementia may need better defining and implementation in practice. Physician-family communication upon admission may be important to optimize spiritual caregiving at the end of life.

Spirituality of chronic orofacial pain patients: case-control study

The objective of this study was to investigate spirituality and blood parameters associated with stress in patients with facial musculoskeletal pain. Twenty-four women with chronic facial musculoskeletal pain (CFMP) and 24 healthy women were evaluated with a protocol for orofacial characteristics, research diagnostic criteria for temporomandibular disorders and the Spiritual Perspective Scale. Blood samples were collected to analyze blood count, cortisol, ACTH, C3, C4, thyroid hormones, total immunoglobulin, C-reactive protein and rheumatoid factor. The study group was more spiritualized than control group. Individuals with a high score of spirituality had less myofascial pain, less bruxism and fewer complaints. They also had lower levels of ACTH and IgE. Spirituality was higher in the study group and can be considered an important tool for coping with CFMP.

Development and validation of a new tool for the assessment and spiritual care of palliative care patients

CONTEXT

Spiritual assessment tools and interventions based on holistic approaches are needed to promote healing. Such tools must be adapted to the wide cultural backgrounds of contemporary Western society.

OBJECTIVES

To develop and validate a new brief measure, simultaneously featuring clinical applicability and adequate psychometric properties. The tool uses six initial questions to establish a climate of trust with patients before they complete an eight-item, five-point Likert scale. The questionnaire is based on a model of spirituality generated by the Spanish Society of Palliative Care (SECPAL) Task Force on Spiritual Care (Grupo de Espiritualidad de la SECPAL), which aims to recognize, share, and assess the spiritual resources and needs of palliative care patients.

METHODS

Multidisciplinary professionals from 15 palliative care teams across Spain interviewed 108 patients using the Grupo de Espiritualidad de la SECPAL questionnaire. Confirmatory factor analysis techniques were used to study the new tool factor structure and reliability. Additionally, concurrent criterion validity coefficients were estimated considering spiritual well-being, anxiety, depression, resilience, and symptoms. Descriptive statistics on questionnaire applicability were reported.

RESULTS

Analyses supported a three-factor structure (intrapersonal, interpersonal, transpersonal) with an underlying second-order factor representing a spirituality construct. Adequate reliability results and evidence for construct validity were obtained.

CONCLUSION

The new questionnaire, based on empirical research and bedside experience, showed good psychometric properties and clinical applicability.

Describing Spirituality at the End of Life

Spirituality is salient to persons nearing the end of life (EOL). Unfortunately, researchers have not been able to agree on a universal definition of spirituality reducing the effectiveness of spiritual research. To advance spiritual knowledge and build an evidence base, researchers must develop creative ways to describe spirituality as it cannot be explicitly defined. A literature review was conducted to determine the common attributes that comprise the essence of spirituality, thereby creating a common ground on which to base spiritual research. Forty original research articles (2002 to 2012) focusing on EOL and including spiritual definitions/descriptions were reviewed. Analysis identified five attributes that most commonly described the essence of spirituality, including meaning, beliefs, connecting, self-transcendence, and value.

Development and preliminary testing of the quality of spiritual care scale

CONTEXT

The provision of spiritual care is considered a key element of hospice and palliative care, but there is a paucity of empirically developed quality-of-care measures in this domain.

OBJECTIVES

To describe the development and reliability and validity of the Quality of Spiritual Care (QSC) scale in family caregivers.

METHODS

We conducted analyses of interviews conducted that included the QSC scale with family members of residents who died in long-term care settings taken after the resident had died. To determine reliability and validity of the QSC scale, we examined internal consistency, concurrent construct validity, and factor analysis with promax rotation.

RESULTS

Of 165 family caregivers of decedents who were asked whether they received spiritual care, 91 (55%) responded yes, and 89 of these (98%) completed at least 80% of the QSC items. Two items (i.e., satisfaction with and value of spiritual care) were perfectly correlated so the latter item was dropped in scale development. Factor analysis identified two factors, personal spiritual enrichment (mean pattern matrix loading = 0.77) and relationship enrichment (mean pattern matrix loading = 0.72). Reliability analysis yielded a Cronbach's alpha of 0.87, and item-total correlations for all items were in excess of 0.55. Preliminary validity of the QSC was supported by significant and expected correlations in both direction and magnitude with items from validated instruments conceptually associated with the quality of spiritual care.

CONCLUSION

Preliminary testing of the QSC scale suggests that it is a valid and reliable outcome measure of the quality of spiritual care at the end of life.

The FACIT-Sp spiritual well-being scale: an investigation of the dimensionality, reliability and construct validity in a cognitively intact nursing home population

BACKGROUND

Spiritual well-being has been found to be a strong individual predictor of overall nursing home satisfaction and a fundamental dimension of global as well as health-related quality-in-life among nursing home patients. Therefore, access to a valid and reliable measure of spiritual well-being among nursing home patients is highly warranted.

OBJECTIVES

The aim of this study was to investigate the dimensionality, reliability and construct validity of the Functional Assessment of Chronic Illness Therapy Spiritual Wellbeing scale in a cognitively intact nursing home population.

DESIGN AND METHOD

A cross-sectional design was applied, selecting two counties in central Norway from which 20 municipalities representing 44 different nursing homes took part in this study. Long-term care was defined as 24-hour care with duration of 6 months or longer. Participants were 202 cognitively intact long-term nursing home patients fulfilling the inclusion criteria. Approval by all regulatory institutions dealing with research issues in Norway and the Management Unit at the 44 nursing homes was obtained. Explorative and confirmative factor analyses as well as correlation with selected construct were used.

RESULTS

Though three items loaded very low (λ = 0.22, 0.26, 0.32) indicating low reliability, the three-factor model for the FACIT-Sp spiritual well-being scale provided an acceptable fit (χ(2) = 101.15 (df = 50), p-value <0.001, RMSEA = 0.075 p = 0.030, NFI = 0.90, GFI = 0.91, AGFI = 0.85) for older nursing home patients, demonstrating acceptable measurement reliability. Construct validity was supported by significant correlations in the hypothesised direction with the selected constructs.

CONCLUSION

The three-factor model is an improvement over the original two-factor construct, based on these nursing home data. The measure yielded significantly factor loadings, good composite reliability and construct validity.

Assessing spiritual well-being in residents of nursing homes for older people using the FACIT-Sp-12: a cognitive interviewing study

PURPOSE

To detect any problems with completion of the Functional Assessment of Chronic Illness Therapy Spiritual Well-being Scale (FACIT-Sp-12), to analyse the causes of such problems and to propose solutions to overcome them.

METHODS

We audio-recorded face-to-face interviews with 17 older people living in one of three nursing homes in London, UK, while they completed FACIT-Sp-12. We used cognitive interviewing methods to explore residents' responses. Our analysis was based on the Framework approach to qualitative analysis. We developed the framework of themes a priori. These comprised: comprehension of the question; retrieval from memory of relevant information; decision processes; and response processes.

RESULTS

Ten residents completed the FACIT-Sp-12 with no missing data. Most problems involved comprehension and/or selecting response options. Twelve residents had problems with comprehension of at least one question, particularly with abstract concepts (e.g. harmony, productivity), or where there were assumptions inherent in the questions (e.g. they had an illness). When residents had problems comprehending the question, they also found it difficult to select a response. Thirteen residents had difficulties selecting responses (e.g. categories did not reflect their views or were not meaningful in the context of the statement). Some chose not to respond, others responded to the question as they understood it.

CONCLUSIONS

The FACIT-Sp-12 could provide valuable insights into the spiritual concerns of nursing home residents; however, data may be neither valid nor reliable if they do not comprehend the questions as intended and respond appropriately. Providing clear and detailed instructions, including definitions of abstract concepts, may improve the validity of this measure for this population.

Can the Communion of Saints Help the Search for Justice in Dying well (Enough), "In Abraham's Arms, Where Lazarus is Poor no Longer"?

How can we practice dying in community? What communal practices nourish positive acts that make dying well (enough)-more than prudent caution in avoiding causing death (killing)? What part of our common ecclesial life as Catholics enables us to accompany dying persons as a gracious return to God? We are twice haunted: most first world deaths result from foreseen end-stage illnesses; mortality is less feared than burdensomeness for caregivers from vulnerable dependence. Of those who die in the hospital, many deaths result from decisions to withhold and withdraw treatments. From ten kinds of desolation about dying, ten parallel consolations are discerned in hopes and outcomes-based best practices.

Evidence-based spiritual care: a literature review

PURPOSE OF REVIEW

As spiritual care has increasingly been considered an integral component of a healthcare treatment plan, spiritual care practitioners have been encouraged to adopt an evidence-based orientation, just as evidence-based practice is encouraged in every other aspect of healthcare. Though the notion of 'evidence-based spiritual care' is still developing, increasingly research is conducted in order to provide an evidence base to the practice of spiritual care. This article reviews spirituality and spiritual care literature from June 2010 to December 2011 that employ empirical research methods.

RECENT FINDINGS

The majority of patient-focused studies concentrate on oncology and palliative care patients. In the review period, studies of care giver perceptions and experience came from multiple disciplines, including medicine, nursing, and chaplaincy. A discrepancy exists between the provision of spiritual care and the theoretical commitment of practitioners to offer such care. Practitioners continue to view spiritual care as part of their role to a greater extent than they provide it. This is often attributed to the absence of consensus in the field regarding the definition of spirituality, a lack of clarity of disciplinary role, and inadequate education for nurses and doctors about spiritual care. Research has further indicated that care givers' explorations of their own spirituality correlate with the provision of spiritual care. Although historically spiritual care has been most integrated into the care of palliative and oncology patients, researchers are developing and testing spiritual care assessment tools with other medical populations. In addition, they are evaluating these tools in diverse religious, cultural and national contexts.

SUMMARY

Conceptual analysis combined with empirical study of care giver understandings of spiritual care will assist in developing clarity and consensus about the definition of spirituality and spiritual care. Investigation and conceptualization of interdisciplinary roles and provision of spiritual care is needed for optimizing collaborative care. More knowledge is needed about how to effectively teach spiritual care.

Effects of a spiritual care training for nurses

Despite the fact that spiritual care is an essential part of nursing care according to many nursing definitions, it appears to be quite different in practice. A spirituality training for nurses may be necessary to give spiritual care the attention it deserves. In a trial a pre-tested "spirituality and nursing care" training was provided to nurses from four different nursing wards in a non-academic, urban hospital. Prior to the training and six weeks after the training, nurses and all patients were asked to fill up a questionnaire. In addition, the number of referrals from nurses to the chaplaincy was examined. Compared to before (n=44 patients), after the training (n=31), the patients from the intervention wards experienced more receptiveness and support when asking questions about illness and meaning. There were also specific changes in nurses' attitudes and knowledge, changes in clinical practice such as documenting spiritual needs and the number of referrals to the chaplains was higher. The results indicate that a training in spiritual care for nurses may have positive effects on health care that patients can experience.

Spirituality in end-of-life care: attending the person on their journey

Spirituality is a fundamental element to the human experience of health and healing, illness and dying. Spiritual care is an essential component of palliative and end-of-life care provision and is the responsibility of all staff and carers involved in the care of patients and families. As end-of-life care is a significant element of community nursing, this article explores the relevancy of spirituality to end-of-life practice, the challenge of defining spirituality and the attributes and skills required for the practice of spiritual care. The aim of is to encourage self reflection and open dialogue about the subject, thus enhancing community nurses' understanding of spiritual care practice. By reflecting and generating talk about the practice of spiritual care, it may become more normalized, recognized, and practically meaningful, thereby retaining its significance in holistic nursing.