Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary. The recommendations that follow are based on the previous version of the guideline.
The grades of evidence (A-D) are defined at the end of the "Major Recommendations".
Individuals at Risk
Clinical and research findings have identified the following as risk factors for the development of alterations in spirituality in the older adult (Schnorr, 1999; Solari-Twadell & McDermott, 1999; Taylor, 2002. Evidence Grade = D):
- Events or conditions that interfere with a person's ability to practice spiritual rituals (e.g., hospitalization, depression, immobility)
- Diagnosis and treatment of a life-threatening, chronic, or terminal illness
- Circumstances that lead to the questioning or loss of faith
- Unspecified interpersonal or emotional suffering
- Cognitive impairment (e.g., dementia, brain injury)
Assessment Criteria
The following assessment criteria indicate at-risk older adults who are likely to benefit the most from use of this evidence-based protocol (O'Brien, 2003; Taylor, 2002. Evidence Grade = D):
- Self-reported inability to practice spiritual rituals
- Verbalizes longing for spiritual rituals and spiritual support
- Verbalized questioning or loss of faith
- Expression of interpersonal or emotional suffering, loss of hope, lack of meaning, or the need to find meaning in suffering
- Presence of life threatening, chronic, or terminal illness
- Development of cognitive impairment
- Evidence of depression
Assessment Tools, Instruments, and Forms
Assessment tools for the protocol promoting spirituality in the older adult are selected for their usefulness in clinical practice and availability to the public without cost. The tools, located in appendix A of the original guideline document, include:
- Brief Assessment of Spiritual Resources and Concerns (Koenig, 2002; Meyer, 2003. Evidence Grade = D)
- Center for Epidemiologic Studies Short Depression Scale (CES-D 10) (Stanford Patient Education Research Center, n.d. Evidence Grade = C)
- Depression in Medicare and Medicaid residents of long-term care institutions may be assessed and monitored with the MDS indicators E1 and E2 of the MDS Medicare PPS Assessment Form, Version July 2002 for depression, anxiety, sad mood, and mood persistence (Centers for Medicare and Medicaid Services, 2002. Evidence grade = D)
- Index of Well-being (IWB) (Braden, 1990; Campbell, Converse, & Rodgers, 1976; Dirksen, 1995; Reed, 1986. Evidence Grade = C)
No assessment form is provided for documenting older adult's medical diagnosis or health condition that indicates the presence of life threatening, chronic or terminal illness, or the development of a cognitive impairment. Depression may also be included in a medical diagnosis, or identified through behavioral observation. The CES-D 10 or other tool can be used to identify depression.
Refer to the original guideline document for detailed description of the tools mentioned above.
Forms to assist in documentation of patient care related to promoting spirituality are also available. An example of a process evaluation monitor may be found in Appendix C of the original guideline document, and of an outcomes monitor in Appendix D of the original guideline. Use of these or similar tools and forms are recommended to document the use of the protocol with each patient.
Description of the Practice
Two broad categories of interventions are included in this protocol, active listening and spiritual support. Several specific nursing practices are provided for each category in the original guideline document.
Active Listening
The process of promoting spirituality in older adults includes the nursing intervention of active listening. By actively listening to the client the nurse is able to hear, understand, interpret, and synthesize what is being said. In addition, the nurse establishes a trusting relationship and provides sufficient time for the clients to interpret their own feelings and experiences (Fredriksson, 1999. Evidence Grade = C). Listening actively includes the nursing actions of: being present for the client, use of touch, assisting the clients in finding the meaning of life events, and encouraging reminiscence about their life (Ackley & Ladwig, 2004. Evidence Grade = D).
Presence
Presence is described as "being there" and "being with" the client in meaningful ways. "Being there" encompasses much more than physical presence; it includes a relationship with sincere communication (Fredriksson, 1999. Evidence Grade = C). In "being with" the client the nurse is fully available to hear and understand the client's difficulty and suffering (Pettigrew, 1990. Evidence Grade = D).
As a nursing action for older adults, being present requires knowing and being comfortable with oneself and connecting with the person through affirmation, valuing, vulnerability, empathy, serenity, and silence (Stanley, 2002. Evidence Grade = D). This type of presence doesn't take more time but necessitates the nurse being completely focused on the client (Melnechenko, 2003. Evidence Grade = D).
Touch
Caring touch is an important nursing action for promoting spirituality in older adults. As a foundational aspect of nursing practice, caring touch, such as hand holding or touching an arm or shoulder, facilitates communication between the nurse and client. As a nursing action for older adults, caring touch conveys acceptance, concern, comfort, and reassurance especially during stressful periods (Bush, 2001; Fredriksson, 1999. Evidence Grade = C). Several studies have demonstrated positive benefits of caring touch. Butts examined the influence of touch in elderly institutionalized women. Using an experimental design she found caring touch significantly improved the women's perception of their self-esteem, well-being, health status, life satisfaction, and faith (Butts, 2001. Evidence Grade =B). Routasalo and Isola (1998) described variations in frequency and types of touch in a study of the use of touch with nursing home residents who had poor health and difficulty communicating. Touch was used to provide comfort and show caring, and was individualized to both the nurse and the resident (Routasalo & Isola, 1998. Evidence Grade = C).
Meaning
Meaning for the older adult can refer to a clear understanding of the significance of an illness, the death of a loved one, or the loss of independence (Golsworthy & Coyle, 1999; Johnson, 2003; Siegel & Schrimshaw, 2002. Evidence Grade = C). Meaning can also refer to the spiritual concept of meaning and purpose in life, which is the capacity to find a sense of personal worthiness in one's life (Frankl, 1988; Meraviglia, 1999. Evidence Grade = D).
For the older adult, finding the meaning of critical life events or the meaning in life can be a challenging process wherein the nurse can have significant influence. This is especially important for older adults who experience difficulty finding meaning because research has shown they have a higher incidence of depression and suicidal thinking (Buchanan, 1993; Moore, 1994; Reker, 1997; Thompson & Pitts, 1993. Evidence Grade = C). The nurse can facilitate an older adult's search for meaning by asking probing questions, offering additional explanations, and reframing, when necessary, maladaptive interpretations of life events (Taylor, 2002. Evidence Grade = D).
Through the process of finding meaning, the older adult often grows spiritually (Fry, 2000; Schnorr, 1999; Siegel & Schrimshaw, 2002. Evidence Grade = C). In addition, several research studies have shown that a sense of meaning in life was associated with improved psychological well-being, satisfaction with life, and overall quality of life (Fry, 2000; Fryback & Reinert, 1999; Rizzo, 1990. Evidence Grade = C).
Reminiscence
Reminiscence is the recalling and sharing with another person past life events. The process of reminiscence can facilitate the aging process and improve meaning making by rethinking and clarifying previous experiences (Jonsdottir et al., 2001. Evidence Grade = B). Cavendish described reminiscence as making spiritual links by expressing personal beliefs that represented inner resources for living through difficult life events (Cavendish, 1994. Evidence Grade = C). Nurses are in a unique position to facilitate reminiscence by developing long term relationships with older adults.
Reminiscence, either alone or in a regular group, has positive benefits such as successful adaptation to growing old and decreasing depression (Jones & Beck-Little, 2002. Evidence Grade = D). Numerous research studies have found reminiscence was positively related to increased psychological well-being, self-esteem, and ego integrity (Brooker & Duce, 2000; Reddin, 1996; Wilhoite, 1994. Evidence Grade = C). In addition, stimulation of cognitive function and a sense of validation for the life lived were reported by several researchers (Watters, 1995; Wilhoite, 1994. Evidence Grade = C).
Spiritual Support
Spiritual support is defined as "assisting the patient to feel balance and connection with a greater power" (Dochterman & Bulechek, 2004). Three North American Nursing Diagnosis Association (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. Evidence Grade = D).
A person's world-view provides the foundation for their belief system about the nature of God, people, and reality, thus determining their understanding of the interplay between the physical, emotional, social, and spiritual dimensions. It is essential for nurses and spiritual support persons working with the older adult to assess each person's belief system to effectively care for their spiritual needs. Spiritual assessment tools, such as the Brief Assessment of Spiritual Resources and Concerns in Appendix A1 of the original guideline document may be used to assess spiritual needs. Additional spiritual assessment tools are described in Appendix E1 of the original guideline document. Whether the nursing intervention is assisting with forgiveness, encouraging hope, reading scripture or other texts requested by the older adult, each action taken must be carefully planned and evaluated. Please see Appendix E3 of the original guideline document for a compilation of scriptures related to coping and hoping that may be used when an older adult requests scripture reading. Additional nursing interventions for the older adult include referrals to pastoral care, hospital chaplains, or their own spiritual support person for more intensive assistance.
Forgiveness
Forgiveness is the act of giving or receiving pardon for an offense, debt, or obligation. It entails making a decision to no longer feel resentment towards another person for their offense. Oakes encourages the use of forgiveness to promote constructive change in a person's life, and stresses the therapeutic value of a person's spiritual and religious orientation, faith development, and transcendence in facilitating forgiveness (Oakes, 2000. Evidence Grade=D).
Forgiving behaviors have been shown to give a person a sense of renewal, reaffirmation, and reconciliation with God, church, and one's inner being (Solari-Twadell & McDermott, 1999. Evidence Grade = C). This area is known as pursuing spiritual integrity and allows a person to maintain or regain meaning from their spiritual and religious beliefs. Additionally, research has shown that groups emphasizing learning about forgiveness, sharing experiences of forgiveness, and prayer smooth the progress toward forgiving others (Wuthnow, 2000. Evidence Grade = C).
Older adults frequently need to experience healing of relationships. Improving a broken relationship through forgiveness is especially relevant for a victim of rape or incest or someone who experienced domestic violence (Ackley & Ladwig, 2004; Carson, 1989. Evidence Grade = D). In addition, older adults experience traumatic events such as widowhood, retirement, and loss of home or pet, which cause them great distress. Nurses can enhance older adults' lives by encouraging forgiveness of others and themselves. Through forgiveness older adults can discover new meaning and continue the development of the spiritual self (Carson, 1989; Ebersole & Hess 2001; Siegel, 1986, 1989. Evidence Grade=D).
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. Evidence Grade = D). For example, the nurse may offer to pray with the older adult to ask for forgiveness, or ask the older adult if he or she is ready to forgive someone else.
Instilling Hope
Hope is an "expression of a positive orientation, faith, and will to live" (Keeley, 2004). It is defined "to wait or to look forward with eager expectation" (Theological Wordbook of the Old Testament, 1994 as cited in Strong, 1996). Also hope is "a confidence in regard to a good and beneficial future" (Swanson, 1997). In order to understand hope as a nursing intervention, it must be differentiated from feelings of hopelessness. "Hopelessness is a subjective state in which the individual sees limited or unavailable alternatives or personal choices and is unable to mobilize energy for problem solving on his or her own behalf" (Keeley, 2004).
The following considerations are recommended when using nursing actions to instill hope:
- The older adult's definition of hope may change as the effects of a life event or illness is experienced (Fryback & Reinert, 1999; Keeley, 2004; Kylma, Vehvilainen-Julkunen, & Lahdevirta. Evidence Grade = C).
- The source of hope is very important to assess as a variable (Beckerman & Northrop, 1996; Cutcliffe & Grant, 2001; Gaskins & Forte, 1995; Keeley, 2004. Evidence Grade = D).
- Information about the older adult's current situation allows the nurse-older adult relationship to redefine hope in the present (Fowler, 1981; Frankl, 1988; Keeley, 2004; Oakes, 2000. Evidence Grade = C).
- Understanding the underlying factors that contribute to feelings of hopelessness in order to focus interventions more appropriately (Keeley, 2004; Kumar, 2004; Melnechenko, 2003; Pargament, 1997. Evidence Grade = C).
- The older adults' 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. Evidence Grade = D).
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. Evidence Grade = D). Research demonstrates that encouraging a person to grow spiritually facilitates their level of hope (Duggleby, 2001; Golsworthy & Coyle, 1999; Johnson, 2003; Keeley, 2004; Northouse et al., 2002. Evidence Grade = D). Also, assisting an older adult to cope with their grief from personal losses decreases their feelings of hopelessness (Golsworthy & Coyle, 1999; Keeley, 2004; Koenig, 2002; O'Bryant, 1991. Evidence Grade = D). In addition, support groups are effective in reducing stress and facilitating coping and hope (Keeley, 2004; Lueckenotte 1997. Evidence Grade = D). Nurses are essential in identifying and referring older adults who need the spiritual support of instilling hope provided through these support groups, whether religious, cultural, or community affiliated.
Prayer
Prayer is a devout petition to, or any form of spiritual communion with God or an object of worship. Prayers may include adoration and expressions of love, confession, thanksgiving, or supplication and asking for help (Foster, 1992).
There are numerous benefits for the older adult to including prayer in nursing care. Older adults are vulnerable to feelings of isolation and loneliness, which can be relieved through supporting their prayer beliefs and practices. Nurses can participate in prayer with older adults to enhance their trust, self-worth, and hope. Additionally, research has demonstrated a positive relationship between the use of prayer and feelings of general well-being (Meraviglia, 2001; Payne, 1990; Poloma & Pendleton, 1991. Evidence Grade = D). Overcoming barriers to the use of prayer in nursing practice has been the focus of much discussion in the nursing literature (Harris, et al., 1999; Meisenhelder & Chandler, 2000; Meraviglia, 1999; Mull, Cox, & Sullivan 1987; Schnorr 1999; Sodestrom & Martinson, 1987; Taylor 2003. Evidence Grade = D).
Nursing actions for the spiritual support intervention of prayer include offering to pray, meditate, or read spiritual text with the older adult, arranging for another member of the health care team to do so, and respecting a person's time for quietness and prayer (Solari-Twadell & McDermott, 1999).
Nursing Interventions
The Nursing Interventions Classification (NIC) is a comprehensive, standardized classification of interventions that nurses perform. The Classification includes the interventions that nurses do on behalf of patients, both independent and collaborative interventions, both direct and indirect care. An intervention is any treatment, based upon clinical judgment and knowledge that a nurse performs to enhance patient/client outcomes. NIC can be used in all settings (from acute care intensive care units, to home care, to hospice, to primary care) and all specialties (from critical care to ambulatory care and long term care) (Dochterman & Bulecheck, 2004).
Refer to the original guideline document for the Nursing Interventions Classification.
Definitions:
Evidence Grading
- Evidence from well-designed meta-analysis
- Evidence from well-designed controlled trials, both randomized and nonrandomized, with results that consistently support a specific action (e.g., assessment, intervention, or treatment)
- Evidence from observational studies (e.g., correlational descriptive studies) or controlled trials with inconsistent results
- Evidence from expert opinion or multiple case reports
