Soul survivors

The importance of caring for older people's spiritual needs while in care is attracting increased attention. Professor Ian Philp, national director for older people's services, has said: 'The spiritual and social needs of our patients are as important as the physical ones and we must, as professionals, support them in those ways.'

1The national service framework for older people specifies that spiritual needs must be met as part of end-of-life care, and the minimum standards for care homes for older people also make reference to this dimension.

But what does spiritual care comprise: and how do staff and managers understand the term? Most of the research has been focused on acute hospitals and hospices. Little is known about whether awareness of the importance of meeting spiritual needs has permeated other settings; particularly nursing and residential homes, where increasing numbers of older people are now living and dying.

Last autumn, we undertook a study to address this issue. All homes in the Trent region were surveyed with a postal questionnaire. Following a pilot run of 50 homes, over 1,500 questionnaires were sent out and a response rate of 42 per cent was achieved, encompassing 644 homes. The responses spanned all types, sizes and locations of homes found within this sector: 56 per cent were residential, 29 per cent were dual registered and 15 per cent were nursing homes.Most (79 per cent) were in private ownership, but 14 per cent were local authority and 7 per cent were voluntary sector homes. Small homes with 4-20 places were well-represented (25 per cent), but there were also responses from homes with as many as 95 beds.

The health sector is awash with definitions of spiritual care.Most make a distinction between religion on the one hand and a diffuse, generic spirituality on the other. This spirituality is commonly associated more with 'existential concerns' (like the search for meaning and purpose in life), than notions of God and transcendence.

Such broad understandings, which mirror the current spiritual zeitgeist, are often favoured within the NHS and are particularly popular with nursing staff. They provide a mechanism for minimising underlying nervousness about the place of religion in a public sector environment and enable spiritual care to be incorporated into the role of healthcare professionals without any religious affiliation. But how do those working in nursing and residential homes understand the spiritual dimension? Is it still closely associated with religious observance, or have broader definitions begun to influence the care home environment?

The survey took a practical approach, asking respondents to indicate which of eight different activities they considered to be spiritual care (see box). These were selected to include tasks that were obviously religious in nature, as well as others where the focus was social or emotional support.

The results point towards a broad, allencompassing perception of spirituality on the part of home managers. All activities - be they religious, emotional, physical or social in orientation - were considered spiritual care by most respondents.

While it is hardly surprising that items with religious connotations ranked highly, tasks connected with relationships and remembrance also featured strongly. In addition, comforting a resident worried about continence - an emotional issue of an intimate personal nature, but without any overt connection with spirituality - was also considered to have a spiritual dimension by 60 per cent of managers.

The two activities least frequently felt to be associated with spiritual care were making sure residents saw their favourite television programme and taking them on trips to the country.

Nevertheless, significant numbers of home managers (over 300 in each case) still accorded them a connection with spirituality. One home manager said: 'When one of my staff asked why I considered a resident watching a favourite TV programme spiritual, I was rather surprised.Most of our residents like to watch Songs of Praise and Coronation Street and others. Surely this is life; life is spiritual.'

Such views of spirituality are now mainstream and reflect the collapse of boundaries between spiritual care and more specific components of holistic care.

Spiritual care becomes any task which produces a 'feel-better' outcome.

The view of home managers was sought on where the main responsibility for providing spiritual care lay from a choice of four categories: external religious leaders, friends and family, all home staff or some home staff.

More than 60 per cent of homes thought the responsibility lay with all home staff and about half thought external religious leaders should also be involved. Family and friends were also seen as important by more than 40 per cent of homes.

Spiritual care is clearly understood to be part of the basic remit of care homes.

But 99 homes (15 per cent) felt that providing such care was not their responsibility at all, and again, there was little difference here between nursing, dual and residential categories.

Some homes made very clear statements of what was expected of staff. The policy of one residential home was: 'Every resident has a right to have their spiritual needs fulfilled. It is the care assistant's responsibility to ensure that these needs are met, either by herself or by informing the care manager.'

Whether the care assistants were trained or equipped in any way to identify and 'fulfil' spiritual needs is less clear: definitions and examples of what this meant in practice were thin on the ground.

Around 16 per cent of homes felt responsibility for this area of care, rather than being a corporate task, lay with specific groups of home staff. These were commonly identified as managers, senior staff, or 'staff with a religious faith themselves'. Indeed, a number of home managers indicated that they saw a definite link between the beliefs of individual staff and the ability to provide spiritual care. One manager commented: 'Most staff have no religious beliefs, so it is normally impossible for them to come alongside someone needing spiritual care.'

Another said: 'I believe that some staff find it difficult because of their own beliefs. They may not agree with the resident's wishes.'

But this suggests a misunderstanding in what is involved in providing spiritual care, with a reversion to a traditional understanding that links it closely with religion. The comments imply an inability on the part of 'non-religious' staff to empathise with the needs of residents.

Younger staff seemed to find this area particularly difficult. Intergenerational (and indeed intercultural) care has many benefits, but spirituality may be one area where the gap is difficult to cross.Young staff have rarely had much exposure to structured religious belief systems in the way that would have been common just 50 years ago. They may have a schoolbook knowledge of the major religions, but little familiarity with the basic currency of religious expression - rites, rituals and terminology.

One manager commented that non-Christian staff, though willing to read passages from the Bible to residents if they requested it, did not know how to approach the task. They had to be shown where to find 'comforting words' rather than having some idea that, say, the Psalms might be helpful. In addition, younger staff may simply be insufficiently mature to cope with matters of spirituality and mortality. One manager said: 'Our staff are getting younger and haven't had enough experience of life to understand these deep and complicated issues.'

But reference to responsibility for spiritual care provision being allocated to staff who had particular training in this area was minimal.

Most homes (85 per cent) held services organised by local churches or religious groups.Many simply had one service per month, but others had fortnightly or even weekly input.Of the 97 homes where no services were held, a slightly higher proportion were private sector homes and one-third of them were small homes with under 20 beds.

While some home managers commented that there was a reluctance on the part of churches to visit and that occasionally it was even difficult to get clergy to come out for a dying resident, most appeared content with the level of support provided. Over 70 per cent of homes agreed with the statement 'our home is adequately supported by local religious and church groups'.

While the survey results showed awareness in the care home sector of the broader discourse of spirituality currently in play in the NHS, there were also a number of clues that practices on the ground are variable.

The comments of many managers indicated that, despite the increased profile of spiritual care, it is still something of a taboo area and one which staff often find embarrassing.

Access to appropriate training and education was a common concern for home managers. It is clear that training which provides basic facts, dispels myths and helps staff to explore boundaries is a key component in enabling those who work in this environment to meet better the needs of the significant numbers of older people living in the residential sector.

Key points

The importance of meeting spiritual needs when caring for older people is increasingly acknowledged.

A survey of nursing and residential homes in the Trent region showed managers interpreted spiritual care very broadly, according favourite television programmes and countryside visits some spiritual significance.

Most thought all home staff had a responsibility for residents'spiritual care.

Which of the following activities would you consider to be spiritual care?

Saying a prayer with a resident when asked to do so.

Taking the residents on a trip out to the countryside.

Arranging for the local school to come and sing Christmas carols.

Comforting a resident who is worried about continence issues.

Ensuring a resident sees their favourite TV programme.

Reading a resident an old letter they particularly treasure.

Discussing with a resident their funeral wishes.

Listening while a resident reminisces about their spouse.

The responses to this survey showed that more than half the managers considered all these activities to be spiritual care.Results were particularly high for saying a prayer with a resident, discussing funeral arrangements (both 90 per cent), reading letters and listening to reminiscences.