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An Assessment Tool Helps Nursing Homes Meet Residents' Spiritual Needs

Sr. Kerrigan is a retired professor from Ursuline College, Pepper Pike, OH; and Ms. Harkulich is the director of research and professional services, Care Services, Beachwood, OH.

In caring for the whole person, nursing homes must look beyond their residents' physical needs to address their psychosocial and spiritual needs as well. But in 1991, the staff at Care Services, Beachwood, OH, realized that in the six homes it owns, the spiritual needs of many clients were not being met.

To remedy this problem, administrators set up a meeting with one of the authors, Sr. Ruth Kerrigan, CSA, a retired professor who has a master's degree in sociology and in nursing and has studied comparative religions. She became the volunteer coordinator of a project to assess the spiritual needs of long-term care clients and develop interventions to meet those needs.

Assessment Tool
The first step was to generate an assessment tool, adapted from the writings of Ruth I. Stoll ("Guidelines for Spiritual Assessment," American Journal of Nursing, September 1979, pp. 1,574-1,577). The tool was designed to be used with residents who belonged to organized religions, as well as those who lived according to certain principles but attended no specific church.

The tool used two formats: open-ended questions that clients could answer in a story-telling manner, and the same questions with a checklist of common answers for easy documentation (see "Spiritual Assessment Tool" at the end of this article). Either format maintained residents' privacy. The goal was to ascertain their spiritual interests, concerns, and needs that could be addressed by an individualized spiritual care program.

Once the tool was generated, the project team set up six different breakfasts with clergy who visited each nursing home. Sr. Kerrigan spoke at the breakfast about "spiritual distress" as a nursing diagnosis. She pointed out that the project was a way for clergy to make their visits more meaningful, to provide facility staff with input, and to help to meet the residents' needs. The clergy were given a list of publications and some copies of articles to read, as well as a copy of the spiritual assessment tool.

Initially, the project leaders had planned to launch the project in all six nursing homes. But because of other pressing issues at the facilities, they decided to pilot test the project in one facility—Pine Valley Care Center. Pine Valley, a 104-bed facility in Richfield, OH, had recently converted a room to a chapel for resident and family use. After completion of the pilot project, other homes would become involved in the project one by one.

Pilot Project
Initially, the project planners had expected nursing personnel to initiate this project. However, since they were too busy, Pine Valley's activity director—who has a good relationship with the clergy—was chosen to initiate the project. Under her direction, many other staff members, including nurses, helped carry it out.

Staff Cooperation This cooperative relationship between staff in different departments developed after a series of meetings with Sr. Kerrigan. She presented the tool to those in attendance and asked how they could become involved in an individualized spiritual care program for selected residents with whom they had good rapport.

The meetings were open to anyone interested in the project, including housekeeping staff, since many residents talk to them but not to other staff. The meetings were videotaped so staff not in attendance could also learn about the project.

First Meeting At the first meeting, the administrator stressed the importance of spiritual counselors focusing on clients' religious needs and concerns without trying to impose their own beliefs. Two volunteer clergy who had already used the tool advised the staff about approaching residents, asking questions, and remaining nonjudgmental. They suggested asking a few questions at a time, taking perhaps a month to complete the process. For example, a nurse's assistant on the night shift could inquire about the client's thoughts and fears about life and death and then fill out that portion of the tool. A few days later, the same resident might share some thoughts with the housekeeper, who would add them to the form.

Second Meeting At another general meeting, the project director encouraged staff to try to assess only one resident to test their own skills and the resident's receptivity to talking about spirituality. Five staff members brought their findings to the next meeting. They reported they were comfortable using the assessment tool and the residents were responsive in expressing their needs and desires regarding spiritual care and assistance.

Final Meeting At the final meeting, the group developed interventions based on some of the residents' expressed needs. For example, staff decided to secure videotapes of the services of particular churches so residents could "attend" their own church on the Sabbath. Staff has also asked churches to mail bulletins to certain residents, and staff will be encouraged to read them to the residents. Although the project started with only a few residents as part of the pilot program, it now is offered to all residents who are interested and able to respond to an individualized program.

New Forms Based on the findings from the use of the initial assessment tool, the project leaders developed another form for easy documentation of interventions to use with residents (see "Religious-Spiritual Interventions" below). Both the assessment and the intervention forms are included in the residents' chart, and a sticker on the outside of the chart alerts staff that the tools are inside.

Documentation
The project at the pilot facility is now working smoothly. Two additions to the process are to document clergy visits and obtain their input in the plan of care. Families and residents can refer to the chart to keep up-to-date on clergy visits, spiritual interventions, expressed needs, and tools used. At a quarterly care plan meeting, the care team and family (if present) refer to the information about the client's spiritual needs and adjust the interventions as appropriate.

Replication The next step is to replicate this project in another facility and eventually in all six facilities. As the tools are used in more facilities, they may be revised again. For example, the pilot project took place in a rural facility, and inner-city facilities may find they have different assessment needs.

Initial results show, however, that the spiritual assessment tool can be used successfully with diverse individuals. Members of the same religion have differing needs: Not all Catholics are interested in the rosary, not all Christians want a cross in their rooms, and not all Jews are concerned about their diets. The spiritual assessment tool helps staff members discover what works for each individual, regardless of the religion. Residents who have expressed no religious beliefs are comfortable with staff validating their lives, accomplishments, and goodness.

At present, the program is effective in satisfying the needs of residents who have a relatively healthy spiritual life. But a program needs to be developed to meet the needs of residents who evidence spiritual distress and more complex psychospiritual problems. A further enhancement would be to solicit a qualified pastoral care team to work with those in other disciplines to foster the health and adjustment of residents who manifest spiritual distress as one aspect of their overall health problems.

The project has increased staff's comfort in addressing spiritual topics. For example, they seem more comfortable praying with dying patients. As the activity director stated, "I thought I was meeting the religious needs of all my residents, but now I realize I have much more to do. The difference is, I now know how to go about doing it."

Additional Readings

V. Brooke, "The Spiritual Well-Being of the Elderly," Geriatric Nursing, July-August 1987, pp. 194-195

S. Burns, "The Spirituality of Dying," Health Progress, September 1991, pp. 48-52

J. T. Culliton, "Commitment through the Personalization of Time," Spirituality Today, Winter 1982, pp. 335-349

R. Delbene, Into the Light—A Simple Way to Pray with the Sick and Dying, Upper Room, Nashville, 1988

C. W. Ellison, "Spiritual Well-Being: Conceptualization and Measurement," Journal of Psychology and Theology, vol. 11, no. 4, 1983, pp. 330-340

S. Kratzke and J. Moffett, "A Survey of Spiritual Needs," Visions, October 1987, pp. 1-2

D. S. Martin and W. G. Fuller, "Spirituality and Aging: Activity Key to 'Holiest' Health Care," in P. M. Foster, ed., Activities in Action: Proceedings of the National Association of Activity Professionals 1990 Conference, Haworth Press, New York City, 1991

Spiritual Assessment Tool

This is a form to be used to quickly record what was identified in an interview or discussion with the resident. This is part of the permanent record which reflects a collection of data gathered by any staff member or volunteer. Place your initials beside the selected information you have obtained.

1. What gives your life meaning?
   ____ God ____ My spouse/family ____ I'm still alive
   ____ God is still in charge ____ Chance to get better
   Chance to set myself right with:
   ____ God ____ Family ____ World
   ____ We have good insurance
   ____ Care is good here
   ____ I find no meaning
   ____ Can't answer that
   ____ Other/Explain
2. To whom do you turn when you are most in need or most afraid?
   ____ God/Jesus/Allah
   ____ My spouse/family
   ____ My doctor
   ____ My clergy person
   ____ My church/parish/synagogue
   ____ My prayer group/bible study group
   ____ I pray
   ____ I meditate
   ____ I work harder
   ____ I get hold of myself
   ____ I lead a better life
   ____ I practice stress management
   ____ Other/Explain
3. What bothers you most about your inability to take care of yourself?
   ____ Why me, I've lived a good decent life
   ____ I'll probably die here
   ____ Who will take care of me? I can't help myself.
   ____ Why is God punishing me?
   ____ I should have lived a better life
   ____ I'm no good anymore to anyone
   ____ Other/Explain
4. What bothers you most about living here?
   ____ I'll probably die here
   ____ Life is over for me
   ____ Who will pay the bills?
   ____ I could still manage but they put me here
   ____ Who will take care of me?
   ____ I'm not ready to die yet
   ____ I'm a burden to everyone
   ____ Other/Explain
5. Is God important to you?
   If answer is No/Ask if God was ever important in life and when God was important.
   If answer is Yes/Ask the following:
6. How would you describe God? Or tell me about your moral/ethical life principle.
   ____ Good
   ____ Loving
   ____ Just
   ____ A judge
   ____ Remote and uninvolved
   ____ Other/Explain
7. What does God do for you?
   ____ He loves me
   ____ He cares for me
   ____ Helps me keep on living
   ____ Judges me for my sins
   ____ Impersonal and distant
   ____ Not much help
   ____ Nothing
   ____ Other/Explain
8. Have your understandings or feelings about God changed as a result of your present limitations?
   ____ Begin to question my faith
   ____ God can't be loving and permit all this suffering
   ____ Not sure there is a God
   ____ Can't concentrate on prayers
   ____ Too tired/weak to pray
   ____ Clergy person didn't come when I called
   ____ No value in praying
   ____ Why am I being punished?

   ____ Made me closer to God
   ____ More time to think about God
   ____ Gives me more time to get straight with God

   ____ Other/Explain

9. Do these questions frighten you or make you nervous?
   ____ YES
   ____ Don't understand why you want to know these things
   ____ Makes me think I'm going to die
   ____ I don't like to think about these things
   ____ It's none of your business
   ____ Other/Explain

   ____ NO
   ____ It's a good idea
   ____ Makes me realize I've had a good life
   ____ Helps me remember about God
   ____ I'm glad you're interested in these things about me

10. What church/synagogue/place of worship would you call "home"?
    ____ Other/Explain
11. What can we do here to make you feel "at home" spiritually?
12. What spiritual practices or rites are important to you?
    ____ Others to pray with me:
    
    ____ Once in a while
    ____ Every day
    ____ Every morning
    ____ Every night
    
    ____ Read the Bible:
    ____ Daily
    ____ Once in a while
    ____ On Sunday/Saturday
    
    ____ Go to church/Mass
    ____ Have a prayer group
    ____ Say the rosary
    ____ Receive Communion
    ____ Say my special prayers
    ____ Read one of my books to me like I used to at home
    ____ Hear a good talk once in a while
    ____ Opportunity to give alms
    ____ Meditate
    ____ Environmental cues in room (holy pictures/symbols)
    ____ Nothing
    ____ Other/Explain

    How can we help you with these special practices?

13. What religious symbols are significant to you?
14. What books provide you with spiritual or moral strength?
15. Is religion helpful to you now? How is it not helpful now?
16. What do you think happens to us when we die?
    ____ It's the end
    ____ There is another kind of life
    ____ I don't know
    ____ Don't think about it
    ____ I'll be with my spouse/family/friends
    ____ I'll be with God
    ____ First there is a time for punishment for sins/then heaven
    ____ Heaven or hell
    ____ I will come back to earth in a different body
    ____ I will come back to earth in a different form
    ____ Nothing
    ____ Other/Explain

Religious-Spiritual Interventions