370 Geriatric Nursing Volume 24 Number 6

Initially, the practice of combining spirituality and healthcare was difficult for me when the topic was presented ingraduate school. I felt resistant and somewhat defensive

toward my instructor, a primary care physician, as he de-scribed how he incorporated a spiritual assessment into hisinitial consultation with patients. My arguments againstthis practice were the added time needed to complete theassessment, and, more important, my anxiety in discussingsuch a personal subject during a first patient-clinicianvisit. To add to my debate, I was unsure how I felt aboutmy own beliefs; how could I, therefore, assess and care forthese needs in another if I felt shaky with my own spiritu-ality? You are not alone if you feel uncomfortable assess-ing spirituality.

Since taking this class more than 2 years ago, I havefound that the amount of time required to conduct a spiri-tual survey is minimal and can be combined with otherparts of a psychosocial assessment. More important, Ihave found a comfort level in discussing topics that, up tothis time, were considered taboo. I have learned to initiatea discussion regarding spirituality without offending pa-tient, family, or myself. In this article, I will explore someof the methods I have used, and the theory base for spiri-tuality in health care. I have come to believe that spiritual-ity must be a key component of any comprehensiveassessment, particularly in the elderly.

Spirituality and religiosity are not the same word orconcept, although the terms are sometimes used inter-changeably. Religion refers to a belief system to which anindividual adheres, whereas spirituality denotes a person’sactual experience with others, nature, or God.1 Others de-fine spirituality as subjective, individualistic, personal,and dynamic. It relates to the inner dimension of beinghuman and guides significant choices in life.2 For manypeople, spirituality is found through religion or a personalrelationship with God. However, a belief in God or reli-gious dogma is not a requirement for spirituality.3

THE ELDERLY AND SPIRITUALITY

The literature suggests that the elderly are a uniquegroup of spiritual individuals.4,5 As aging processes de-

crease physical productivity, the spirit may enable thebody to adapt and cope. Key themes expressed by thespiritual elderly include enhanced life satisfaction, in-creased coping skills, and validity of intrinsic religiousbehavior. Spirituality crosses all socioeconomic groupsand has proven beneficial in the lives of those who prac-tice their faith or beliefs.

SPIRITUAL ASSESSMENT

Initiation of a spiritual assessment can be a challengingbut insightful part of the holistic nursing assessment.Several mnemonic algorithms in the literature are useful inassessment and can be modified as needed. Maugans6useda 7-step method with the mnemonic SPIRIT as a guide forthe assessment. It contains the components of one’s beliefsystem, his or her practice with a public or private reli-gious community, implications for medical care, and end-of-life care. A breakdown of the components is as follows:

S Spiritual belief system (religious affiliation)P Personal spirituality (personal belief practices)I Integration into a spiritual community (sources of

support)R Ritualized practice (daily practices, restrictions,

and their significance)I Implications for medical care (spiritual aspects in-

corporated into care)T Terminal event (end of life)

Another tool for spiritual assessment is the series of HOPEquestions, which cover basic areas of inquiry.3 They include

H Hope, strength, comfort, love, and connectionsources

O Organized religionP Personal spirituality and practicesE Effects on medical care and end-of-life issuesThis mnemonic is simple, though less in-depth than the

SPIRIT assessment. The use of either tool should be de-termined by the nurse caring for the elder, or no formal-ized guideline can be used.

A less formal assessment can be done through casualconversation with the elder and family. Listening for the“God talk” can provide a nonthreatening opportunity for

The Importance of Spiritual Assessment:One Clinician’s Journey

Kristin Larson, RN, ANP, GNP

Home Health Care

further exploration.7 This invitation is the mechanism I usemost often in my practice. Statements such as “I praynothing goes wrong” or “It’s in God’s hands” provide anideal opportunity for me to further investigate spirituality.I echo back what has been said and ask why faith or spir-ituality is important to the elder’s health or illness. I’vebeen surprised how open many older patients are when wehave had an in-depth assessment. I initially feared I wouldoffend or hinder the patient-nurse relationship, but I havefound this not to be the case. In fact, such open communi-cation tends to increase the bond and the understandingbetween patient and nurse.

INTERVENTIONS

The delivery of spiritual care should see each elder asbeing on a unique journey and should place the nurse as theindividual who enhances the journey without influence,bias, or arrogance.1 Hicks8 describes 3 types of nursing in-terventions for spiritual care. They include silent witness-ing, liaison, and active listening. Silent witnessing allowsthe elder to express his or her feelings with the nurse as asilent member of the dialogue. Liaison activities allow thecoordination of resources for the patient, such as spiritualmaterials or providing silent time for prayer or meditation.Coordination of a home care visit by a religious leaderwould also be an example of liaison activities. Active lis-tening involves dialogue with the elder, although the nurse’sbeliefs should not overshadow or impose on commentaryby the elder. I have used active listening, especially withcognitively impaired elders. Sometimes my common linkwith them is to offer a common remembered prayer. I havefound it lessened the patient’s anxiety and allowed me toconduct a physical assessment that otherwise would havebeen impossible because of fear or combativeness.

EXAMPLE OF SPIRITUAL CARE IN ACTION

As a home care or community nurse, you are visitingMr Smith, an elderly, black man, after right-below-the-knee amputation for a nonhealing diabetic ulcer. Duringyour weekly assessment of his wound, you notice a bookof inspirational readings placed by his wheelchair. Youknow that surgery can cause grieving related to bodyimage and self-esteem. You follow the HOPE assessmenttool and ask Mr Smith about sources of comfort andstrength after his operation. You discover he is a memberof a local church and that reading the Bible and listeningto music are part of his daily religious practice. He be-lieves prayer will help him physically and emotionally re-cover and continue with the rest of his life.

Using spiritual interventions, you empathetically listen toMr Smith’s concerns about the loss of his leg. A liaison ac-tivity could be to call his church and ask if there is a visitingministry that could come to Mr Smith’s home for support.Active interventions would be to offer prayer with Mr Smithor to read aloud from his Bible or other spiritual book.

November—December 2003 371

SUMMARY

Assessing spiritual values of a patient causes the nurseto assess and or re-examine his or her own beliefs. Self-reflection makes one aware of how spirituality affects theindividual’s life and nursing practice. Those who findthemselves uncomfortable with spiritual issues may havedifficulty in delivering spiritual care to others.Nonetheless, the ability to seek appropriate assistanceshould be possible, but in-depth conversation regardingspirituality may need delivery by another caregiver.8

Before assessing spirituality, examine your own beliefsto provide compassionate care related to meeting the pa-tient’s spiritual needs. Today, I regularly ask if the elderhas a religious or faith-based belief he or she follows. Ifso, I probe further to determine how this belief systemhelps them with their health care concerns. I watch forsymbols such as a Bible, inspirational readings, or reli-gious items in the home or health care setting. A practicechoice I have made is to offer prayers together with my pa-tients and families. This is an individualized involvementthat some believe crosses the boundaries of professional-ism and political correctness. However, this level of in-volvement provides a positive opportunity to providefulfillment in my nursing practice for my patient and my-self. I will continue this added dimension of care.

Spiritual assessment involves the evaluation of spiritualneeds and the relationship to health care issues, whereasspiritual care involves compassion, presence, listening, andthe encouragement of hope. It may or may not involve Godor religion. To best serve the elderly patient, nurses shouldexamine their own spirituality and how this may affect theirown unique ability to assess or deliver spiritual care.

REFERENCES1. Berggen-Thomas P, Griggs MJ. Spirituality in aging: spiritual need or spiritual

journey? J Gerontol Nurs 1995; 21:5-10. 2. Meyerhoff H, Van Hofwegen L, Harwood CH, Drury M, Emblen J. Spiritual

nursing interventions. Can Nurse 2002;98:21-4.3. Anandarajah G, Hight E. Spirituality and medical practice: using the HOPE

questions as a practical tool for spiritual assessment. Am Fam Physician2001;63:81-9.

4. Isaia D, Parker V, Murrow E. Spiritual well-being among older adults. JGerontol Nurs 1999;25:15-21.

5. Foley L, Wagner J, Waskel SA. Spirituality in the lives of older women. JWomen Aging 1998;10:85-91.

6. Maugans TA. The SPIRITual history. Arch Family Med 1996;5:11-6.7. McBride JL. The new focus on spirituality in medicine. J Med Assoc Ga

1998;87:281-4.8. Hicks TJ. Spirituality and the elderly: nursing implications with nursing home

residents. Geriatr Nurs 1999;20:144-6.

KRISTIN LARSON, RN, ANP, GNP, works in the division of nephrology atthe Medical University of South Carolina in Charleston.

© 2003 Mosby, Inc. All rights reserved.0197-4572/2003 $30.00 + 0doi:10.1016/j.gerinurse.2003.10.020