Dilemmas of spiritual assessment: considerations for nursing practice

ISSUES AND INNOVATIONS IN NURSING PRACTICE

Dilemmas of spiritual assessment: considerations for nursing practice

Wilfred McSherry BSc MPhil RGN PGCRM RNT ILTM

Lecturer in Acute Care of the Adult, Department of Nursing and Applied Health Studies, University of Hull, Willerby, UK

and Linda Ross BA PhD RGN

Senior Lecturer, School of Care Sciences, University of Glamorgan, Pontypridd, UK

Submitted for publication 4 October 2001

Accepted for publication 4 March 2002

Background

There has been an increasing interest in the spiritual dimen-

sion of health care in the last two decades. Numerous articles

are appearing, that seek to explore and offer explanation into

this mysterious, complex, and subjective aspect of the human

being; some of these are anecdotal (Castledine 1998) whilst

others are research based (Narayanasamy 1993). Several

published and unpublished research studies have been

undertaken within the United Kingdom (UK) and elsewhere,

that suggest nurses are attempting to meet their patients

spiritual needs. The result of such research seems to have

generated an unfounded expectation that patients’ spiritual

needs must be assessed and attended to within health care.

There is a general assumption that nurses have the skills,

knowledge and expertise to undertake a spiritual assessment.

� 2002 Blackwell Science Ltd 479

Correspondence:

Wilfred McSherry,

Department of Nursing and Applied

Health Studies,

University of Hull,

Mary Seacole Building,

East Riding Campus,

Beverley Road,

Willerby HU10 6NS,

UK.

E-mail: [email protected]

M c S H E R R Y W. & R O S S L. ( 20 02 ) Journal of Advanced Nursing 38(5), 479–488M c S H E R R Y W. & R O S S L . ( 20 02 ) Journal of Advanced Nursing 38(5), 479–488

Dilemmas of spiritual assessment: considerations for nursing practice

Background. Interest in the spiritual dimension of nursing has resulted in a

proliferation of published research internationally that is very prescriptive, suggest-

ing that nurses should be providing spiritual care. However, little research has been

published that provides nurses with a potential framework for the assessment and

subsequent delivery of spiritual care. It would appear that there is a consensus of

opinion that nurses can and should be able to undertake an assessment of their

patients’ spiritual needs. However, such assumptions may be unfounded, inaccurate,

misguided and potentially detrimental to patient care.

Aim. This article explores the area of spiritual assessment, drawing on the

international literature, highlighting potential dilemmas in conducting a spiritual

assessment. A review of some of the currently available spiritual assessment tools is

also undertaken.

Design. A debate is presented based on the authors’ experiences and opinions with

regard to this aspect of care. The debate is informed by a review of the literature

specifically addressing spiritual assessment. The authors use United Kingdom policy

to illustrate drivers and provide a context for the debate. However the dilemmas

presented and issues raised are of significance to a wider international audience.

Conclusion. It is argued that the area of spiritual assessment needs careful

consideration, both nationally and internationally, by those professionals involved

in the provision of spiritual care so that potential dilemmas can be identified and

reviewed. Such consideration may prevent the construction and subsequent use of

inappropriate assessment tools within practice. The article incorporates some

considerations for practice.

Keywords: spirituality, spiritual care, spiritual assessment, nursing practice,

research, health care professionals

However the same research studies suggest the reverse might

be true.

The review

Aim

The aim of this article is to explore the area of spiritual

assessment drawing on a review of the literature and the

authors’ experiences. As such, the paper is a position paper.

Design

The data bases ‘Medline’, ‘CINAHL’, and ‘Embase’ were

searched from 1988 to the present using the search term

‘spiritual assessment’. Key papers were obtained following

scrutiny of the abstracts. This literature, together with the

authors’ experiences, informs the debate on spiritual assess-

ment presented in this paper. The debate is divided into four

sections. The first sections explore the apparent increase in

interest in the spiritual dimension in recent years, and the

possible drivers resulting in nurses’ involvement in spiritual

assessment and spiritual care. Some of the dilemmas of

spiritual assessment are discussed in the third section before

some specific assessment tools and ideas for spiritual assess-

ment are considered in the final section.

Findings

Increasing interest in the spiritual dimension

A decade ago little was published on the subject in the health-

related literature, now articles addressing some aspect of

spirituality are common place (Bradshaw 1996, McSherry

1996, Turner 1996, Emdon 1997, Hall 1997, Wright 1997,

Bush 1999). It could be argued that a triangular approach

(education, practice and research) is being adopted in the

investigation of spirituality.

Concerning education, study days and national confer-

ences are being held, providing insight into and debate

around the concept. There have also been attempts to set up

national steering groups for spiritual care, with varying

degrees of success, and websites are also appearing (Univer-

sity of Leeds – [email protected]

and Sacred Space in Cumbria – www.sacredspace.org.uk).

Within clinical practice, clinical audits are being undertaken

to assess how well practitioners are attending to this aspect

of care.

Research is also emerging, seeking to offer a deeper insight

into the spiritual dimension. When one of the author’s (LR)

undertook a literature search during the late 1980s and early

1990s, no UK nursing research studies could be identified as

having been published on spirituality, and only two unpub-

lished small scale studies were identified (Chomciz 1984,

Simsen 1985). Most of the North American research was also

unpublished (Kramer 1957, Lewis 1957, Chance 1967,

Kealey 1974, Piles 1986, Hitchens 1988). Only one full-

published paper was identified (Highfield & Cason 1983),

most being in summarized form (Stallwood-Hess 1969,

Chadwick 1973, Martin et al. 1976). Since then a number

of UK (Harrison & Burnard 1993, Narayanasamy 1993,

Ross 1994, 1997, McSherry 1997, Charters 1999, Govier

2000, Narayanasamy & Owens 2001) and North American

(Reed 1986, Ellis 1999) researchers have undertaken and

published their work on the topic. More recently other

countries have contributed to the debates underlining

the international recognition of the spiritual dimension

(Kuuppelomaki 2001, MacKinlay 2001, Shih et al. 2001)

while also displaying the diversity of investigation.

Others have added to the unpublished literature (Dunn

1993, Kearney 1994). The authors also know of several

doctoral students registered at UK universities undertaking

research on spirituality, as well as numerous undergraduate

students within nursing and the professions allied to medicine

who are conducting literature reviews or small scale research

studies on the subject as part of their degrees.

This activity points to an increasing interest in spirituality

within health care in recent years. Some of the drivers that

have been instrumental in nurses becoming involved in

spiritual care are identified in the following section.

Drivers for nurses’ involvement in spiritual care

First, Codes of Professional Conduct imply that nurses should

be aware of their patients’ spiritual concerns. The United

Kingdom Central Council for Nurses, Midwives and Health

Visitors (UKCC) Code of Professional Conduct (UKCC 1984,

p. 2) states that the nurse should:

Take account of the customs, values and spiritual beliefs of patients/

clients.

Spiritual care is implied in this statement but need not

necessarily involve action on the part of the nurse. The

updated version of the Code in 1992 remained similar, but in

the most recent consultation version 2001 the statement and

emphasis seem to have changed again. It will be interesting to

see if the statement changes as a result of the consultation

process.

The International Council of Nurses Code of Ethics for

Nurses (ICN 2000, p. 2) states that:

W. McSherry and L. Ross

480 � 2002 Blackwell Science Ltd, Journal of Advanced Nursing, 38(5), 479–488

In providing care, the nurse promotes an environment in which the

human rights, values, customs and spiritual beliefs of the individual,

family and community are respected.

The Code then goes on to ‘assist nurses to translate the

standards into action’ (p. 4). However, it is noteworthy that

in this section the word ‘spiritual’ is dropped. Practitioners

and managers are advised to:

Provide care that respects human rights and is sensitive to the values,

customs and beliefs of people (p. 5).

Guidelines for educators, researchers and national nurses’

associations emphasize human rights and ethics, with no

mention of spiritual beliefs.

Second, in their review of the place of spirituality within

nursing theories and models, Marstolf and Mickley (1998)

consider that spirituality is either implicit (Rogers 1980, Roy

1980) or explicit (Parse 1981, Watson 1985, Neuman 1995).

This aspect has been discussed more fully elsewhere (Ross

1997, McSherry 2000a).

Third, British nurse education guidelines state that nurses

should be taught to:

Undertake and document a comprehensive, systematic and accurate

nursing assessment of physical, psychological, social and spiritual

needs of patients, clients and communities (UKCC 2000, p. 13).

However, the UKCC gives no guidelines as to how this might

be achieved for spiritual care, drawing attention to the

educational debate surrounding the teaching of spirituality

(Narayanasamy 1993, 1999a, 1999b, Ross 1996, Bradshaw

1997, Bush 1999, McSherry 2000b).

The American Association of Colleges of Nursing (1986,

p. 5) recommends that nurse education should ensure the

nurse’s ability to:

Comprehend the meaning of human spirituality in order to recognize

the relationships of beliefs to culture, behaviour, health and healing.

and to plan and implement this care.

A fourth driver for health care professionals’ involvement

in spiritual care in the UK is the publication of the Revised

Version of the Patients’ Charter entitled ‘Your Guide to The

NHS’ [Department of Health (DOH) 2001, p. 29], which

states that:

NHS staff will respect your privacy and dignity. They will be sensitive

to, and respect, your religious, spiritual and cultural needs at all times.

Of course ‘respecting’ a patient’s religious/spiritual needs

does not necessarily mean taking action to meet these needs.

Having identified some of the drivers for nurses’ involve-

ment in spiritual care, some of the dilemmas associated

with spiritual assessment are discussed in the following

section.

Dilemmas of spiritual assessment

Issues of definition

Perhaps the greatest dilemma associated with spiritual

assessment concerns the definition of spirituality. The word

is not bound by a common set of defining characteristics: it

can mean different things to different people. Recently there

has been an Anglo-American debate within nursing in an

attempt to achieve a consensus of opinion or an authoritative

definition of the term (Markham 1998). Despite such articu-

lation and debate the concept is still surrounded in miscon-

ception, ambiguity and subjectivity possibly more so now

than at any other time in the history of nursing.

It is recognized that we are living in a pluralistic, material-

istic, and, some may argue, a secular society. The UK is no

longer mono-cultural. There is considerable religious diver-

sity and there are many geographical regions that have to

provide health care to multifaith users. This cultural and

religious diversity may account for the variety of ways in

which spirituality has been viewed. With reference to faith

communities the concept of spirituality may be associated

with a philosophical or religious tradition. Markham (1998)

warns that not all multifaith traditions may identify with the

term or share the same definition of spirituality. The

language or set of defining characteristics may be alien to

their own philosophical position. Markham (1998) suggests

that the manner in which spirituality is being developed

within health care is a secular version of Judeo-Christian

spirituality. Therefore there is the potential for some faith

traditions to be offended by the term ‘spirituality’ as applied

to health care.

However, for others the term spirituality may take on a

more humanistic, existential meaning. For these individuals,

for example, atheists and agnostics, the word is void of any

religious connotation. For others, such as secular humanists,

who do not believe in the existence of any spiritual dimen-

sion, the term is irrelevant.

The concept of spirituality is therefore deeply subjective.

Given its diversity of definition how can a spiritual assess-

ment be undertaken? What happens if the assessor and

assessed have differing views of what constitutes spiritual

need and care? Arguably for those whose spirituality is

founded on a religious belief then this should be taken into

account if they are admitted into health care and appropriate

provision should be made to enable them to maintain their

religious practices. This also means that all health care

workers need accurate information and insight into the

Issues and innovations in nursing practice Dilemmas of spiritual assessment

� 2002 Blackwell Science Ltd, Journal of Advanced Nursing, 38(5), 479–488 481

different multifaith communities and their beliefs and prac-

tices. It seems that nurses are among key stakeholders being

delegated the task of addressing and co-ordinating this

sensitive area.

Motives for undertaking assessment

The motive for undertaking a spiritual assessment will be

fundamental in determining how such assessments are con-

structed, used, and perceived in practice.

A recent development within health care in the UK is the

desire for clinical excellence and accountability, in the form

of Clinical Governance (DOH 1999, UKCC 2001) and

Evidence Based Practice (Sackett et al. 1997). There is a

growing desire to quantify and measure aspects of care in

order to raise standards and reduce risk, thereby making

practitioners more accountable for their practice. An example

is the Waterlow Score in predicting which patients are at risk

of developing pressure sores (Waterlow 1985). Such assess-

ments are undertaken in the knowledge that a practitioner

has the required skills, knowledge and resources either to

prevent, reduce, or resolve any risk to the patient. The danger

is that spiritual assessment tools may also end up being used

in a similar way. To do so would clearly be inappropriate, as

the spiritual dimension does not easily lend itself to predicting

cause and effect.

The Patient’s Charter, discussed earlier, and the ensuing

standards seem to have resulted in providers of health care

conducting audits and satisfaction surveys asking patients to

comment upon how well the standards have been met. This

has infiltrated nursing care, where audits and patient satis-

faction surveys are now common-place (Bond & Thomas

1992, McColl et al. 1996). Whilst the rationale behind such

initiatives (the drive to score, quantify and identify potential

risk) is understandable, its application to spiritual care is of

concern as this dimension is not easy to quantify or measure.

Whilst no published papers were identified on spiritual care

audit, the authors have copies of tools currently being used by

several Trusts.

‘One-off’ vs. continuous assessment

It is clear from the nurse education guidelines quoted earlier

that nurses are to undertake an assessment of their patients’

spiritual needs. How this should be done, however, is by no

means clear. The first dilemma concerns the timing and

comprehensiveness of the assessment.

There are those who would argue that a spiritual assessment

should not form part of the admission process, being too

sensitive and complex an area. Others, however, would take

the view that some sort of spiritual assessment needs to be

undertaken on admission, even if it is only a ‘one-off’ tick box

exercise. It could be argued that, with the time pressures on

nurses, this is all that can reasonably be achieved in short stay

acute settings. However, others hold the view that spiritual

assessment should be an on-going, continuous process. The

success of an on-going assessment, however, will depend upon

the degree of trust and rapport that has been established

between the patient and nurse. For this very reason, perhaps a

comprehensive on-going assessment is only realistic in longer

stay units, and where there is continuity of staff. Where there

is an over-reliance on bank and agency staff who are

constantly changing, the implication is that on-going assess-

ment may not be possible, even in longer stay units.

Direct questioning vs. observation

A further dilemma concerns the mechanisms used to gather

the information needed for the assessment. Spiritual needs

can be assessed both directly, through questioning, and

indirectly, through observation (Carson 1989, Ross 1994,

1997). If direct questions are used, care must be taken to

structure these in order to avoid offence. As will be shown in

the next section, some of the current North American

assessment tools contain questions that could be considered

intrusive to the UK public (see Table 1). If observation is

used, consensus must be reached concerning who observes,

what signs are looked for, how these signs are interpreted,

and if/how they are documented.

The practicalities of conducting an assessment

It is easy to be prescriptive and say that we should be

assessing spiritual needs without giving due consideration to

the practicalities of this for practice. It would appear that

there is a fundamental need for health care professionals to

stop and evaluate research findings that provide insight into

the practical implications of assessing the spiritual dimension.

Legislating and adopting a prescriptive stance will not resolve

many of the practical issues surrounding the provision of

spiritual care that seem to be emerging. By adopting a

practice approach we might go some way to achieving

evidence-based care. Oldnall (1996) suggests that the

spiritual agenda should be driven by practice – not a

managerial – top down approach. By adopting this approach

the voice and concerns of health care professionals will be

expressed and hopefully acted upon.

Who should assess?

It would seem that nursing cannot and should not go it alone

in the provision of spiritual care. Research suggests that not

one single professional group feel that they have a monopoly

in the provision of spiritual care and subsequently spiritual

assessment. Everyone within the health care team needs to be



involved, including traditional spiritual experts such as

hospital chaplains and religious ministers. It is our experience

from leading seminars with clergy and ministers that these

groups often feel neglected and not part of the health care

team. For example chaplains frequently mention that they are

not invited to participate in case conferences. Yet clergy have

a crucial and valuable contribution to make to the assessment

and provision of spiritual care. They should, thus, form an

integral part of the health care team. There is a need for

multidisciplinary involvement (between chaplains, nurses,

doctors and the professions allied to medicine) in the devising

of assessment tools so that all health care professionals feel a

sense of ownership. Perhaps one goal for health care profes-

sionals is for individual institutions to review and evaluate

their assessment criteria and procedures with a view to

disseminating and sharing best practice.

Ethical issues

Inevitably, seeking to assess such a sensitive and personal part

of an individual presents the nurse with ethical dilemmas.

First, it should not be assumed that everyone has spiritual

needs that require attention all of the time. As discussed

earlier, the types of need(s) patients’ encounter will depend

on their individual definition of spirituality. Furthermore, it

should not be assumed that patients will require help from

health care professionals with their spiritual needs. Patients

may be self sufficient, or may have called on friends and

family for help with their spiritual concerns. Hence the nurse

must make some judgement about the extent and appropri-

ateness of health care professionals’ involvement for specific

needs at different times. Such a judgement may not be easy to

make.

Second, there seems to be a great deal of postulating and

theorizing surrounding spiritual care without giving due

consideration to the inherent or potential implications of

health care practitioners being involved in such a sensitive

area. It is assumed that nurses have the skills and knowledge

to assess spiritual needs and to give spiritual care, but most of

the research points to nurses feeling inadequately prepared

to address the spiritual concerns of their patients/clients

(Ross 1994, 1996, 1997, McSherry 1998) and in need of

further education and training (Harrison & Burnard 1993,

Narayanasamy 1993, Ross 1996, McSherry 1998). Yet it is

by no means clear what form this education and training

should take in order to be effective.

A third ethical dilemma concerns the confidentiality and

documentation of information. If patients have divulged

information about their spiritual life, the nurse must decide

if any of this information should be shared with other

professionals, and if so, under what circumstances. The

nurse must also decide if, how much, and in what form

this information should be documented. Some level of

documentation may be required in order to ensure conti-

nuity of care during hospitalization and discharge. Ideally

discharge should be a seamless process; however, what

happens when a patient is discharged and spiritual issues

remain unresolved or are at a crucial stage in being

resolved?

These are some of the dilemmas inherent in assessment of

the patient’s spiritual needs. In the next section some of the

available tools for spiritual assessment are reviewed.

Review of available assessment tools and ideas forassessment

The literature review undertaken suggests that there are

distinct levels of spiritual enquiry – ranging from the

descriptive to an in-depth personal history. In this critique

the following will be discussed, Direct Questioning, Indi-

cator Based Tools, Audit, and Value Clarification Tools.

Finally the features required of spiritual assessment tools are

considered.

Table 1 Stoll’s guidelines for spiritual assessment (Stoll 1979, with

permission)

1. ‘Concept of God or Deity’

Examines theistic and to some degree religious elements

Examples of questions

‘Is religion or God significant to you?’

‘Is prayer helpful to you?’

‘What happens when you pray?’

2. ‘Sources of Hope and Strength’

Investigates sources of support, particularly surrounding people

and relationships


‘Who is the most important person to you?’

‘To whom do you turn when you need help?’

3. ‘Religious Practices’

Reviews the impact that an illness might have on the patient’s

ability to maintain religious practices


‘Do you feel that your faith (religion) is helpful to you?

‘Are there any religious practices that are important to you?’

4. ‘Relationship Between Spiritual Beliefs and Health’

Explores existential issues such as the patient’s concerns or

visions for the future


‘What has bothered you most about being sick (or in what is

happening to you)?’

‘What do you think is going to happen to you?’



Direct questioning

Stoll’s model

One form of spiritual assessment is direct questioning. A

pioneer of this approach is Ruth Stoll (1979) who published

Guidelines for Spiritual Assessment. Stoll advocates that four

broad areas should be explored and suggests questions that

could be used by nurses to obtain the required information

relevant to each area (Table 1).

One criticism of Stoll’s guidelines is that the areas for

assessment are religiously focused, and therefore, are only

appropriate for people with a religious faith. For example, it

would be inappropriate for assessing the spiritual needs of

atheists, agnostics and humanists (Burnard 1988). In this way

the tool is limited. More specifically Stoll’s work reflects a

Judeo-Christian approach to the area of spiritual assessment

and may therefore have limited use even with patients

professing different faiths.

Use of direct in-depth questions might be considered

offensive and intrusive by some patients, especially if they

are approached on admission. Such questioning may also be

inappropriate in certain health care contexts, for example

acute and critical care where the priority is on stabilization

and preservation of life. However, caution needs to be

exercised because in such areas this important dimension can

be missed and left unaddressed.

It is further assumed that the assessing person will feel

comfortable and will have the skills and time to undertake

such an in-depth assessment. Stoll herself acknowledged that

an assessment, like the one she proposes, may arouse

discomfort and apprehension for the assessor and the

assessed.

Despite these criticisms, Stoll’s work has provided a

template for the construction of subsequent spiritual assess-

ment tools. For example, Muncy (1996) and Govier (2000)

use a similar framework.

Indicator based tools

The indicator based model of spiritual assessment reflects the

Spiritual Diagnosis – Spiritual Distress approach to spiritual-

ity presented in the work of Carpenito (1983, p. 451) who

identifies defining characteristics that may indicate underlying

spiritual distress, for example,

Expresses concern-anger, resentment, and fear over meaning of life,

suffering, and death.

Indicator based assessment tools entail the user identifying

specific verbal or non verbal cues that may be indicative of

underlying spiritual need. For example patients display some

clinical feature such as crying, anger, or they may verbalize

some inner conflict suggesting they are seeking explanation to

an event, such as ‘why has this happened to me?’ or ‘what

have I done to deserve this?’ In essence the nurse uses

potential spiritual needs assessed by the presenting indicator

to establish a possible cause for the underlying spiritual

distress. We have encountered several unpublished variations

of these indicator-based tools. Some contain visual analogue

scales where the patients place a cross on a line indicating the

degree of inner conflict they are experiencing, while others

may ask the patient to score or prioritize certain emotions

such as anger, fear, feelings of value and worth. Irrespective

of whether a visual analogue scale or scoring system is used,

the intended outcome is the same – to determine the degree of

spiritual need a patient may be experiencing by quantifying it.

Clark (1997) offers case examples of how different defining

characteristics may distinguish or determine the type of

spiritual distress a patient is experiencing. Nevertheless, all

the case examples offered are derived from Judeo-Christian

scenarios. The work is a detailed attempt to analyse the

usefulness of indicators based assessment tools.

Analysis of these tools reveals that there is interplay

between the spiritual and psychosocial domains. Dudley

et al. (1995) carried out a review of 53 assessment forms used

by hospice workers in three states in the USA. They found

that only four of the forms had spiritual assessment questions

integrated with the psychosocial domain. Their findings

suggest that there is still some uncertainty about the

relationship between the spiritual and the psychological

dimensions and highlight a further potential area of difficulty

in constructing spiritual assessment tools.

The indicators or characteristics offered in some unpub-

lished UK tools could equally be interpreted as indicators of

psychological or spiritual distress, for example areas address-

ing, guilt, hopelessness, withdrawal, fear. Some tools also ask

the carer and health care professional to undertake the

assessment or reassessment, bringing into question issues of

reliability and validity of the assessment process.

It is important to distinguish between the assessment of the

spiritual and psychosocial dimensions so that needs relating

to each dimension are dealt with appropriately. As Dudley

et al. (1995) state:

It is important to note that some of the questions that were asked in

the spiritual assessment could be interpreted as either spiritual or

psychosocial in nature (p. 34)…However the intent of the question

and the nature of the exploration could be very different depending

upon which type of assessment is being conducted. (p. 35)

Further debate is needed to distinguish between the spiritual

and psychosocial dimensions, not only to ensure appropriate



intervention, but to protect patients from unnecessary assess-

ment.

The benefits of indicator based tools are that they are

quick, simple to use and provide a quantifiable measure

against which to base subsequent evaluation. Yet there are

still concerns with these tools, for example subjectivity in

conducting the assessment, possible differences in perceptions

between carers and patients, the type of pain being referred to

(spiritual, physical, or psychosocial). Whilst these tools may

provide some quantifiable measure for analysis they may also

lead to loss of individuality and the emergence of a mechan-

istic approach to assessment.

Audit tools

Increasing numbers of institutions are attempting to assess

the effectiveness of practitioners in providing spiritual care.

Many health care institutions are setting their own standards

and actively monitoring and auditing areas of religious and

spiritual needs to establish if they have been addressed. The

drivers for this, as indicated earlier, may originate from The

Patient’s Charter (DOH 2001). Orchard (2000, p. 22) states

The Patient’s Charter…encouraged the local NHS to produce its own

standards to ensure these were met.

The Government’s introduction of the (nine) standards may

also have raised public expectation of available services.

Despite some confusion between right and expectation

(Orchard 2000), the ‘Charter’ provides the public with a

vehicle whereby it can raise concern or express satisfaction in

relation to issues pertaining to respect for privacy, dignity,

and religious and cultural beliefs. The net result is that there

is even greater pressure placed on practitioners to address this

dimension of care.

Audit is being used as a means of monitoring wards’ and

institutions’ performance in implementing and meeting the

Charter’s standards. However, there is a need to exercise

caution when evaluating the quality of data derived through

the audit cycle. For instance what happens if an area scores

badly with regard to documenting, implementing and achiev-

ing this standard? This does not necessarily mean that the

issues have not been raised or addressed. There may be

numerous reasons why information has not been identified,

for example fear of mismanagement, different sets of beliefs

and values, language barriers, or inability to understand the

jargon surrounding spirituality.

Ongoing research by one of the authors (WM) exploring

nurses’ and patients’ understanding of the terms ‘spirituality’

and ‘spiritual care’ indicates that a large proportion of

nurses view spirituality as a universal concept, based on an

existential philosophy. Patients are revealing that they do not

understand the term. This has serious implications for the

manner in which nurses, and indeed all-health care profes-

sionals, address this area within the confines of practice. This

also suggests potential reasons why this area might be poorly

addressed within practice. However, the development of such

standards implies spiritual care is firmly on the health care

agenda.

Value clarification tools

Spiritual assessment tools have also been constructed for use

in the area of research and education. Harrison and Burnard

(1993) and McSherry (2000a) provide examples of value

clarification scales. These are usually Likert scales asking

respondents to state the extent to which they agree or

disagree with a particular statement. These tools are quick to

administer, providing the researcher with some quantifiable

measure or students with an insight into their own values and

perceptions of the concepts being investigated.

Some tools have been further refined and are used to

generate scores that may indicate the level of spiritual

wellbeing a person is experiencing, for example the Ellison

Spiritual Well-being Scale (ESWS) (Ellison 1983).

Perhaps a major reason for the use of clarification tools is

that they maintain anonymity, and a safe distance between

respondent and researcher. Whilst these tools have an

important role to play in research and education by gener-

ating insight and discussion into an often complex, subjective

and personal dimension, they also have certain drawbacks.

They can only provide superficial insight into a given topic

and whilst they might prove useful in eliciting numerical data

for statistical analysis, their application within practice is

limited. The danger with utilizing such tools is that spiritual

assessment is again reduced to a mechanical activity, which

depersonalizes the individual. Furthermore, it is not always

clear to what extent such scales have been tested for

reliability and validity.

Features of spiritual assessment tools

It seems that the development of any spiritual assessment tool

needs to incorporate certain features. For example Catterall

et al. (1998, p. 4) write:

Assessment tools should be easy to use, flexible and take little time to

assess the spiritual state of patients at different times and in different

situations.

This quotation implies that spiritual assessment tools must

be adaptable in order that they can be modified to suit

different care contexts, and client needs. There may be a



need, for instance, to separate the in-depth spiritual assess-

ment from the descriptive religious enquiry. For example in

some acute settings initial assessment focuses only upon

identifying the individual’s religious beliefs, affiliations and

practices. A second stage in-depth assessment may follow

for those patients/clients whom the health care professional

feels are displaying possible indicators of spiritual distress.

This in-depth assessment could form part of the routine

assessment process for patients admitted into longer stay

settings. Catterall et al. (1998) suggests such a two-stage

assessment.

The tools must also be nonintrusive, therefore the type and

order of questions, and the mode of delivery require careful

consideration – remembering it is an assessment not an

interrogation! It is paramount that the tool focuses upon the

need of the individual, rather than on routine, procedural or

corporate strategies/targets. Wording and language should be

in a style that encourages participation of the individual in

the assessment process. Language should not alienate or

discriminate between different religious groups. This would

go some way to resolving some of the concerns around

spirituality being Judeo-Christian focused within health care

contexts (Markham 1998). In addition, the assessor is

responsible for ensuring that the process is conducted in a

nonthreatening, nonjudgemental manner.

Catterall et al. (1998) suggest that we may have one health

care professional doing the assessing and a spiritual care

specialist (whom they suggest be the chaplain) readily

available to provide and facilitate spiritual care for patients

and carers. This approach may be possible within a hospice

but has much larger resource implications for use within large

NHS Trusts. There is also the danger that spiritual assess-

ment and spiritual care becomes fragmented, as discussed

previously. It is the authors’ experience that patients usually

identify their own sources of spiritual support.

This paper has focused upon assessment of patients’

spiritual needs. A large proportion of literature surrounding

spiritual assessment relates only to the initial assessment

stage. It is important that the information gleaned from the

assessment results in the planning, delivery and evaluation of

spiritual care to meet the spiritual needs, identified. As Govier

(2000, p. 34–35) states:

Otherwise the information is of little use, fulfils the purpose of ‘form

filling’ and contributes to an increasing volume of perfunctory

paperwork.

This systematic approach to the delivery of spiritual care is

discussed in detail elsewhere (Harrison 1993, Ross 1996,

Govier 2000, McSherry 2000a).

Conclusion

It is clear from the spiritual assessment tools reviewed, and

the discussion of the dilemmas inherent within spiritual

assessment in a health care context, that spiritual assessment

in all its forms has not been adequately worked through. It

seems there is a need for a systematic review of the available

evidence within the area of spiritual assessment. The authors

feel that this is necessary if the spiritual dimension is to be

adequately addressed and assessed in practice.

Acknowledgements

We would like to thank Dr P. Draper, Dr S. Kirkman, Prof. L.

Moseley and Prof. R. Watson for their helpful comments on

the manuscript.

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Dilemmas of spiritual assessment: considerations for nursing practice