Idea Transcript
Evidence-Based Guideline Promoting Spirituality in the Older Adult
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ealth promotion from a holistic perspective integrates physical, psychosocial, and spiritual dimensions of human life. Spirituality was central to Florence Nightingale’s philosophy of nursing (Macrae, 1995), and the history of nursing can be traced through associations with religious orders. With the emphasis on science and technology in the 20th century, the physical and psychosocial dimensions of health received greater attention in the development of nursing science. However, the emergence of faith community nursing as a specialty practice and greater acceptance of alternative medicine reclaims the importance of spirituality in health and healing. Thus, it is appropriate for nurses to include interventions to promote spirituality in their practice. Aging is typically characterized as a process of decline, but of all aspects of human development, the spiritual dimension is one that continues to grow (Heriot, 1992). A 2002 Gallup poll indicated religion was very important for 77% of adults living in America ages 75
the core of human being, and interventions directed at the spiritual dimension affect the physical, emotional, and social dimensions. The ultimate goal for promoting spirituality is to support and enhance quality of life.
years and older and 72% of those ages 65 to 74 (Gallup, 2002). Nursing studies of spirituality and aging indicate spirituality increases in importance (Lowry & Conco, 2002), is a source of hope (Touhy, 2001), aids in adaptation to illnesses such as arthritis (Potter & Zauszniewski, 2000), and has a positive influence on quality of life in chronically ill older adults (O’Brien, 2003). The purpose of this evidencebased guideline is to provide nursing care providers with guidelines for promoting spirituality in older adults. The authors believe the spiritual dimension of health is at
Definition of Spirituality Spirituality is defined as the experiences and expressions of one’s spirit in a unique and dynamic process reflecting faith in God or a supreme being; connectedness with oneself, others, nature, or God; and integration of the dimensions of mind, body, and spirit (Meraviglia, 1999). Spirituality is distinguished from religion, which is “an organized system of beliefs and practices. It is the spiritual application of the relationship between people and their God” (Schnorr, 1999, p. 44). Spiritual well-being and spiritual distress are also relevant concepts for this guideline. Spiritual well-being is the affirmation of life in a relationship with God, self, community, and environment that nurtures and celebrates wholeness (Ellison, 1983) and the ability to
Written by Carol Gaskamp, Phd, RN, Rebecca Sutter, RN, MN, CS, dd(h), and Marty Meraviglia, phd, RN, CNS Edited by Susan adams, msn, RN, and marita G. titler, phd, RN, FAAN
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experience and integrate meaning and purpose in life through connectedness with self, others, art, music, literature, nature, or a power greater than oneself (NANDA International, 2003). Spiritual distress, also known as spiritual pain, is an individual’s perception of hurt or suffering associated with that part of his or her person that seeks to transcend the realm of the material. Spiritual distress is manifested by a deep sense of hurt stemming from feelings of loss or separation from one’s God or deity, a sense of personal inadequacy or sinfulness before God and man, or a pervasive condition of loneliness of spirit (O’Brien, 1999). Individuals at Risk for Alterations in Spirituality Clinical and research findings have identified the following as risk factors for the development of alterations in spirituality in the older adult (Schnorr, 1999; SolariTwadell & McDermott, 1999; Taylor, 2002): l Events or conditions that interfere with a person’s ability to practice spiritual rituals (e.g., hospitalization, depression, immobility). l Diagnosis and treatment of a life-threatening, chronic, or terminal illness. l Circumstances that lead to the questioning or loss of faith. l Unspecified interpersonal or emotional suffering. l Cognitive impairment such as dementia or brain injury. Assessment Assessment Criteria
The following assessment criteria indicate at-risk older adults who are likely to benefit the most from use of this evidence-based guideline (O’Brien, 2003; Taylor, 2002): l Self-reported inability to practice spiritual rituals.
l Verbalized longing for spiritual rituals and spiritual support. l Verbalized questioning or loss of faith. l Expression of interpersonal or emotional suffering, loss of hope, lack of meaning, or the need to find meaning in suffering. l Presence of life-threatening, chronic, or terminal illness. l Development of cognitive impairment. l Evidence of depression.
Spiritual Concerns and Resources
The nurse may use a semistructured interview guide, the Brief Assessment of Spiritual Resources and Concerns (Sidebar), to ascertain the older adult’s spiritual concerns and resources (Koenig, 2002; Meyer, 2003). The brief assessment opens the conversation between the nurse and older adult about spirituality. If the older adult is cognitively impaired, information may be obtained from a family member or significant other regarding the importance of spirituality and rituals, membership in a faith community, and beliefs that might affect health care decisions. Depression
Depression is related to spirituality and life satisfaction, and studies indicate spirituality mitigates the effects of depression (Larson & Larson, 2003; McClain, Rosenfeld, & Breitbart, 2003). Depression may be assessed using the Center for Epidemiologic Studies Short Depression Scale (CES-D10), a brief tool to identify depression in the general population (Stanford Education Research Center, n.d.). This tool is used with those who can report their feelings. The nurse will need to rely on observation of behaviors that indicate depression to determine depression in the cognitively impaired old adult. Depression in Medicare and Medicaid residents of long-term
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care institutions may be assessed and monitored with the appropriate Minimum Data Set (MDS) indicators for depression, sad mood, and mood persistence. Life Satisfaction
Life satisfaction is also positively associated with spirituality, as demonstrated in studies with a variety of populations (Acton, 1994; Brady, Peterman, Fitchett, Mo, & Cella, 1999; Cotton, Levine, Fitzpatrick, Dold, & Targ, 1999; Diener, 1984; Ellison, 1991; Ellison, Gay, & Glass, 1989; Hunsberger, 1985; Kennedy, Abbott, & Rosenberg, 2002; Martin & Sachse, 2002; Meraviglia, 1999; Mueller, Plevak & Rummans, 2001; Myers, 2000; Okun & Stock, 1987; Pargament, Tarakeshwar, Ellison, & Wulff, 2001; Reed, 1986; Siegel & Schrimshaw, 2002). The Index of Well-Being (Braden, 1990; Campbell, Converse, & Rogers, 1976) may be used as a measure of life satisfaction. Description of Practices to Promote Spirituality Nursing interventions to promote spirituality are grouped under two broad categories, active listening and spiritual support. Several specific practices are provided for each category. Active Listening
Through active listening, the nurse is able to hear, understand, interpret and synthesize what is being said by the older adult. The nurse establishes a trusting relationship and provides sufficient time for clients to interpret their own feelings and experiences (Fredriksson, 1999). Active listening includes the nursing actions of being present for the client, using touch, assisting the client in finding meaning of life events, and encouraging reminiscence (Ackley & Ladwig, 2004). Presence. The practice of presence or “being there” or “being
Brief Assessment of Spiritual Resources and Concerns Instructions: Use the following questions as an interview guide with the older adult (or caregiver if the older adult is unable to communicate). l Does your religion/spirituality provide comfort or serve as a cause of stress? (Ask to explain in what ways spirituality is a comfort or stressor.) Do you have any religious or spiritual beliefs that might conflict with health care or affect health care decisions? (Ask to identify any conflicts.)
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Do you belong to a supportive church, congregation, or faith community? (Ask how the faith community is supportive.)
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Do you have any practices or rituals that help you express your spiritual or religious beliefs? (Ask to identify or describe practices.)
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Do you have any spiritual needs you would like someone to address? (Ask what those needs are and if referral to spiritual professional is desired.)
establish long-term relationships with older adults are in a unique position to facilitate reminiscence and assist the older adult in making spiritual links by identifying inner resources for living through difficult life events (Cavendish, 1994). Reminiscence, either alone or with a group, has demonstrated effectiveness in reducing depression, improving well-being and cognitive function, and providing a sense of validation for a life lived (Brooker & Duce, 2000; Jones & Beck-Little, 2002; Reddin, 1996; Watters, 1995; Wilhoite, 1994).
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How can we (health care providers) help you with your spiritual needs or concerns?
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Adapted from: Meyer (2003) and Koenig (2002).
with” requires the nurse to be in relationship with and totally focused on the client (Fredriksson, 1999; Melnechenko, 2003). Through this focus, the nurse is able to connect with the other person through affirmation, valuing, vulnerability, empathy, serenity and silence (Stanley, 2002). The nurse is then fully available to hear and understand the client’s difficulty and suffering (Pettigrew, 1990). Touch. Caring touch, such as hand holding or touching an arm or shoulder, is a foundational aspect of nursing practice that facilitates communication with the client. As a nursing action for older adults, caring touch conveys acceptance, concern, comfort and reassurance, especially during stressful periods (Bush, 2001; Fredriksson, 1999). Several studies demonstrated positive benefits of caring touch, such as improved perception of wellbeing, life satisfaction, faith, and comfort (Butts, 2001; Routasalo & Isola, 1998). Meaning. Meaning entails understanding the significance of
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life events such as illness or loss, or having a sense of worthiness in one’s life (Frankl, 1988; Golsworthy & Coyle, 1999; Johnson, 2003; Meraviglia, 1999; Siegel & Schrimshaw, 2002). Older adults experiencing difficulty in finding meaning when faced with critical life events have a higher incidence of depression and suicidal thinking (Buchanan, 1993; Moore, 1994; Reker, 1997; Thompson & Pitts, 1993). The nurse then can have significant influence in the process of making meaning out of experiences. As a result of finding meaning, the older adult may experience spiritual growth and improved well-being and life satisfaction (Fry, 2000; Fryback & Reinert, 1999; Rizzo, 1990; Schnorr, 1999; Siegel & Schrimshaw, 2002). Reminiscence. Reminiscence, or the recalling and sharing of past life events, facilitates the aging process and improves meaning making by rethinking and clarifying prior experiences (Jonsdottir, Jonsdottir, Steingrimsdottir, & Tryggvadottir, 2001). Nurses who
Spiritual Support
Spiritual support is defined as “assisting the patient to feel balance and connection with a greater power” (McCloskey & Bulechek, 2000). Three NANDA nursing diagnoses present specific nursing interventions for providing spiritual support: risk for spiritual distress, spiritual distress, and readiness for enhanced spiritual well-being (Ackley & Ladwig, 2004). Interventions relevant to the care of the older adult are facilitating forgiveness, instilling hope, and praying. These interventions are supported in the psychology, theology, and nursing literature (Blazer, 1991; Boettcher, 1985; Kumar, 2004; Pargament, 1997; Sodestrom & Martinson, 1987; Taylor, 2002; Thompson & Pitts, 1993). Forgiveness. Giving or receiving pardon for an offense, debt, or obligation entails making a decision to no longer feel resentment toward another person for the offense. Nursing actions that facilitate forgiveness in the older adult include being available, listening especially when the person expresses self-doubt or guilt, providing guidance in the forgiveness of others and self, and offering to contact another person if intensive spiritual support is indicated (Ackley & Ladwig, 2004). For example, the nurse may offer to pray
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with the older adult to ask for forgiveness or ask the older adult if he or she is ready to forgive someone else. Hope. Spirituality is often identified by older adults as a bridge between their feelings of hopelessness and a renewed sense of hope and meaning (Frankl, 1988; Heriot, 1995; Hicks 1999; Keeley, 2004; Koenig 2002). The older adult’s positive experiences and personal strengths as well as the relationship with the nurse facilitate the development of hopefulness. When care, hope, and love are given and received by others, the older adult is influenced and strengthened (Cutcliffe & Grant, 2001; Duggleby, 2001; Keeley, 2004; Lueckenotte, 1997; Oakes 2000; Rizzo, 1990). Encouraging spiritual growth facilitates the level of hope (Duggleby, 2001; Golsworthy & Coyle, 1999; Johnson, 2003; Keeley, 2004; Northouse et al., 2002). Assisting the older adult to cope with grief from personal losses decreases feelings of hopelessness (Golsworthy & Coyle, 1999; Keeley, 2004; Koenig, 2002; O’Bryant, 1991). Support groups through religious, cultural or community affiliations are effective in reducing stress and facilitating coping and hope (Keeley, 2004; Lueckenotte, 1997). Prayer. Prayer is a spiritual communication with God or an object of worship. Nursing actions include offering to pray or meditate with the older adult or read from spiritual texts, and respecting a person’s time for quietness (Solari-Twadell & McDermott, 1999). Prayer offers relief from feelings of loneliness or isolation and improves a sense of general well-being (Meraviglia, 2001; Payne, 1990; Poloma & Pendleton, 1991). Outcome Evaluation Major outcomes to be monitored by the use of the guideline to promote spirituality include
the use of spiritual resources, decreased depression, and increased life satisfaction. Use of spiritual resources may be revealed through the client discussing spirituality and spiritual needs, and observation that the client participates in religious or spiritual practices. The CES-D10 and Index of Well-Being may be used to monitor changes in depression and life satisfaction. Nurses caring for older adults have an opportunity to promote the health of the whole person– body, mind, and spirit. The evidence-based guideline for promoting spirituality in the older adult provides specific nursing actions to take to care for the spiritual dimension of the human being and expected outcomes of providing such interventions. Spiritual care inherently involves an interpersonal dimension (Greasley, Chiu, & Gartland, 2001) and requires strong communication skills. Nurses providing spiritual care also must be mindful of how their own spiritual histories affect care given to clients (Sulmasy, 2002). Expertise in spiritual care comes about through self-awareness, education, practice, and sensitivity to the older adult’s spiritual needs. REFERENCES
Ackley, B., & Ladwig, G. (2004). Nursing diagnosis handbook: A guide to planning care (6th ed.). St. Louis, MO: Mosby. Acton, G.J. (1994). Well-being as a concept for theory, practice, and research. The Online Journal of Knowledge Synthesis for Nursing, 11(1). Retrieved February 1, 2004. Blazer, D. (1991). Spirituality and aging well. Generations, 15(1), 61-65. Boettcher, E.G. (1985). Linking the aged to support systems. Journal of Gerontological Nursing, 11(3), 27-33. Braden, C.J. (1990). Learned self-help response to chronic illness experience: A test of three alternative learning theories. Scholarly Inquiry for Nursing Practice, 4, 23-41. Brady, M.J., Peterman, A.H., Fitchett, G., Mo, M., & Cella, D. (1999). A case for including spirituality in quality of life measurement in oncology. Psycho-Oncology, 8, 417-428.
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(n.d.). Center for Epidemiologic Studies Short Depression Scale (CES-D 10). Retrieved August 4, 2006, from http:// patienteducation.stanford.edu/research/cesd10.pdf Stanley, K.J. (2002). The healing power of presence: Respite from the fear of abandonment. Oncology Nursing Forum, 29, 935-940. Sulmasy, D.P. (2002). A biopsychosocialspiritual model for the care of patients at the end of life [Special issue]. The Gerontologist, 42, 24-33. Taylor, E.J. (2002). Spiritual care: Nursing theory, research, and practice. Upper Saddle River, NJ: Prentice-Hall. Thompson S.C., & Pitts J. (1993). Factors relating to a person’s ability to find meaning after a diagnosis of cancer. Journal of Psychosocial Oncology, 11(3), 1-21. Touhy, T.A. (2001). Nurturing hope and spirituality in the nursing home. Holistic Nursing Practice, 15(4), 45-56. Watters, C.L. (1995). An ethnographic study of reminiscence patterns in older adult females (Doctoral dissertation, North Carolina State University, 1995). Dissertation Abstracts International, 56(4), 1216A. (UMI No. 9526953) Wilhoite, C.A. (1994). Depression and fac-
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tors of psychological well-being in the elderly. Dissertation Abstracts International, 56(1), 177. (UMI No. 9516728) About the Authors
Dr. Gaskamp and Dr. Meraviglia are Assistant Professors of Clinical Nursing, and Ms. Sutter is retired Assistant Professor of Clinical Nursing, University of Texas at Austin, School of Nursing, Austin, Texas. Ms. Adams is Project Director, Research Translation and Dissemination Core, Gerontological Nursing Interventions Research Center, and doctoral student, University of Iowa College of Nursing, Iowa City, Iowa, and Dr. Titler is Director, Research, Quality and Outcomes Management, Department of Nursing and Patient Care, University of Iowa Hospitals and Clinics, and Director, Research Translation and Dissemination Core, Gerontological Nursing Interventions Research Center, University of Iowa College of Nursing, Iowa City, Iowa. Address correspondence to Carol Gaskamp, PhD, RN, University of Texas at Austin, School of Nursing, 1700 Red River, Austin TX 78701.
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