Spirituality within dementia care: perceptions of health professionals.
Abstract: There is an increasing awareness that people with dementia should have their spiritual needs addressed. The aim of this study was to investigate health professionals' understanding of spirituality within dementia care and their perceptions of how patients' spiritual needs are met and by whom. A phenomenological approach was used, with semi-structured interviews undertaken with four nurses, two occupational therapists, two physiotherapists, two doctors and one speech and language therapist (n = 11).

All the health professionals found defining 'spirituality' difficult, although common terminology was used. They agreed that spirituality was not solely related to religion. Chaplaincy staff were associated with the provision of spiritual care, but 10 of the health professionals identified themselves as staff who should address such spiritual needs. The majority (n = 10), however, reported a lack of confidence with spiritual care and agreed that training would be valuable.

The findings indicate that all health professionals should address the spiritual needs of patients with dementia. A working definition of 'spirituality' is needed and further research is also warranted into the type of training needed by health professionals with regard to the spiritual care of patients.

Key words:

Spirituality, dementia, health professionals.
Article Type: Report
Subject: Spirituality (Health aspects)
Dementia (Care and treatment)
Dementia (Religious aspects)
Medical personnel (Beliefs, opinions and attitudes)
Medical personnel (Practice)
Authors: Bursell, Jennifer
Mayers, Christine A.
Pub Date: 04/01/2010
Publication: Name: British Journal of Occupational Therapy Publisher: College of Occupational Therapists Ltd. Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2010 College of Occupational Therapists Ltd. ISSN: 0308-0226
Issue: Date: April, 2010 Source Volume: 73 Source Issue: 4
Topic: Event Code: 290 Public affairs; 200 Management dynamics
Product: Product Code: 8010000 Medical Personnel NAICS Code: 62 Health Care and Social Assistance
Geographic: Geographic Scope: United Kingdom Geographic Code: 4EUUK United Kingdom
Accession Number: 224520523
Full Text: Introduction

It is predicted that by 2051 the number of people with Alzheimer's disease and other dementias will be 1.8 million (Parliamentary Office of Science and Technology 2007). In acknowledging this, the National Institute for Health and Clinical Excellence and the Social Care Institute for Excellence (NICE and SCIE) (2006) published best practice guidelines for dementia care and the National Audit Office (2007) published a report on how dementia services could be improved. These documents highlight that a person's spiritual needs should be recognised, but they do not detail why this should be the case.

Research has, however, established that addressing a person's spiritual needs can have a positive impact on his or her mental health (Koenig 2001, Lawrence and Raji 2005, Mental Health Foundation 2007). Authors such as Goldsmith (2004), Higgins (2005) and Swinton (2008) specifically related this link to people with dementia and advocated for improved spiritual care. Bryden (who has dementia) clearly argued that dementia should not result in a person's spiritual needs being overlooked: 'We can find meaning in our spirituality, and you can connect with us, empower us' (Bryden and MacKinlay 2008, p138). The issue for health professionals is, therefore, how to integrate spiritual care into dementia services (Bell and Troxel 2001, Bephage 2008).

Defining spirituality

There has been much debate as to how the term spirituality is defined (for example, McSherry and Draper 1998, Swinton 2001, Greenstreet 2006). As there is no one definition used for spirituality within the current literature, Mowat (2004) suggested that when planning research in this area, a definition should be chosen that is relevant to the researcher. The present research was being conducted by an occupational therapist, so the definitions within occupational therapy literature were consulted. Johnston and Mayers (2005) completed a full literature review in this area and, following this, proposed a definition:

Spirituality can be defined as the search for meaning and purpose in life, which may or may not be related to a belief in God or some form of higher power. For those with no conception of supernatural belief, spirituality may relate to the notion of a motivating life force, which involves an integration of the dimensions of mind, body and spirit. This personal belief or faith also shapes an individual's perspective on the world and is expressed in the way that he or she lives life. Therefore, spirituality is experienced through connectedness to God/ a higher being; and/or by one's relationship with self, others or nature (Johnston and Mayers 2005, p386).

This definition is very comprehensive and, since its publication, has been used not only in occupational therapy research but also in research regarding spirituality and health professionals in general (Collins 2006). The definition was therefore felt to be the most appropriate for use within this research.

Literature review

Spirituality and mental health

Much literature has been published about spirituality and health care (Cressey and Winbolt-Lewis 2000, Speck et al 2004, Mental Health Foundation 2007). Through the use of various mental and physical health standardised outcome measures, Koenig et al (2004) established that religion and spirituality have a positive effect on the psychological health, and to some extent the physical health, of older people. A previous systematic review had also concluded that despite religion frequently being perceived as having a negative impact on patients with mental health difficulties, it often actually enables patients to have positive experiences in life (Koenig 2001).

Spirituality within dementia care

In considering the specific needs of patients with dementia, Coleman and Mills (2001) argued that people are spiritual beings throughout their lives and that dementia should not hinder 'spiritual expression' (p76). Indeed, Bell and Troxel (2001) suggested that spiritual care is essential to quality of life and that dementia can actually make spiritual needs more apparent. They argued that because dementia affects cognitive skills, a patient with dementia may have an enhanced appreciation for the simple aspects of his or her daily life, such as watching wildlife in the garden or listening to a piece of music.

Whilst acknowledging the importance of spirituality within dementia care, Bruce (1998) highlighted the difficulty in measuring spiritual wellbeing with patients who have dementia. One of the main challenges of assessing spiritual needs in people with dementia is that dementia can affect the ability to communicate (Dunn 2004, Bephage 2008). The spiritual needs of patients with dementia should, however, be identified throughout all stages of dementia to ensure person-centred care (Goldsmith 2004, Wallace 2004, Lawrence 2007). Research therefore recommends that health professionals obtain as much information as possible, including speaking to a patient's carer, to identify what the patient had previously found meaningful (Bell and Troxel 2001, Dunn 2004).

The use of a formal spiritual needs assessment could identify the activities that a patient finds meaningful, although Draper and McSherry (2002) suggested that such assessments are not person centred. They argued that spirituality has individual meaning and should not be treated as a 'homogenous' term within assessments (Draper and McSherry 2002, p1). The important element of any spiritual needs assessment that is undertaken with a patient who has dementia, however, is that the information gained is then used to provide appropriate spiritual care to meet that individual's needs (Coleman and Mills 2001, Lawrence 2007).

Although guidance is available in terms of providing religious services for people with dementia (Christian Council on Ageing 2002), the definition being used within this research highlights that spirituality does not have to have a purely religious framework (Johnston and Mayers 2005).

The role of health professionals in addressing spiritual needs

There is an increasing amount of research that seeks to address whether health professionals should meet spiritual care needs, but these studies have tended to concentrate on the understandings of a particular professional group. For example, the role of occupational therapists in assessing and then addressing the spiritual needs of their patients has been investigated (Egan and Delaat 1994, Udell and

Chandler 2000, Hoyland and Mayers 2005).

Lawrence et al (2007) highlighted that psychiatrists have an awareness of the spiritual needs of patients and, when asked specifically about those patients with dementia, 54% of the psychiatrists identified that religion and spiritual advice were 'important'. Further qualitative analysis was undertaken, the results of which identified that the psychiatrists involved in the research felt that spiritual care provided emotional support, human dignity, comfort and hope, and value and meaning to patients accessing old age psychiatry. Research undertaken into the perceptions of nursing staff regarding the spiritual needs of patients (Draper and McSherry 2002, McSherry and Ross 2002) concluded that nurses do not feel confident when addressing spiritual needs. This was also recognised by the patients, who identified that they would initially approach nurses with their spiritual needs but felt that nurses lacked confidence when discussing issues around spirituality (Koslander and Arvidsson 2007).

Historically, spiritual care has been identified as a role for those within the chaplaincy team, although Sheikh et al (2004) concluded that while there is an important role in hospitals for chaplains, all health care professionals must be involved in spiritual care. Indeed, while research studies concentrate on spiritual care in single health professions, the Department of Health (2004) highlighted that the spiritual needs of patients should be addressed by all health professionals.

Rationale for the study

Despite an increasing awareness of the need to address spirituality within health care settings, there was limited research that concentrated specifically on how staff address spirituality within dementia care. Much of the research into spirituality and mental health has also concentrated on the perspective of separate health professions. Research into the perceptions of spirituality of different health professionals within dementia care was therefore warranted.

Aims and objectives

This research aimed to establish what different health professionals working within dementia care understood by the term 'spirituality', how they felt such needs should be addressed and by whom. The objectives were therefore:

1. To analyse the common themes of health professionals regarding their understanding of spirituality

2. To determine health professionals' perceptions of how patients' spiritual needs should be met within dementia care

3. To evaluate who should provide the spiritual care to patients with dementia.

Method

A qualitative methodology was selected because such an approach is based on the exploration of thoughts and feelings (Polgar and Thomas 2000). A phenomenological approach was specifically chosen because this aims to describe a particular phenomenon and is concerned with the participant's perceptions, beliefs and attitudes (Denscombe 2007). It was felt that this basis would allow the health professionals' perceptions of spirituality to be explored and understood.

With a phenomenological approach, the method of data collection is often through different types of interview (Luborsky and Lysack 2006). Focus groups are an alternative method of gathering information from health professionals (Holloway and Wheeler 2002). However, attendance can be an issue; indeed, Green and Thorogood (2004) recommended recruiting by up to 25% more participants than are actually required. Researchers can experience difficulties in organising all participants together at a certain time and location (Holloway and Wheeler 2002), as would have been the case with the health professionals for this research who worked within an acute psychiatric ward and two community mental health teams.

Semi-structured interviews were therefore selected for this research. Such interviews have both open and closed questions and are more flexible in their format than a structured interview, giving the participants opportunity to explain their thoughts and experiences (Carter and Henderson 2005).

Ethical issues and consent

Ethical approval was granted by the Local Research Ethics Committee and research governance approval was granted by the primary care trust (PCT) in which the interviews were to take place. Each health professional volunteered to participate and gave informed consent in writing. This included consent to use digital recording of interviews and anonymised verbatim quotations in possible publications.

Sampling

Convenience sampling was used because this type of sampling allows the researcher to choose participants whose experiences assist in addressing the aim of the research from those who are easily accessible (Holloway and Wheeler 2002). Convenience sampling within this research enabled different health professionals to be selected who had worked in dementia care services for over a year. The exclusion of health professionals who had not worked in dementia services for a year or more ensured that those selected had enough experience to answer the interview questions.

Eleven health professionals volunteered to be interviewed: two occupational therapists, two physiotherapists, two doctors, one speech and language therapist and four nurses. The fact that four nurses were recruited reflected nurses making up the largest group of health professionals within dementia care in the PCT. Only one speech and language therapist could have been recruited because the PCT has only one employed in the local dementia care services.

Interview questions and research process

The interview questions addressed the three key themes of the research:

* The health professionals' understanding of spirituality

* The health professionals' perceptions of how patients' spiritual needs should be met

* Who the health professionals felt should provide spiritual care.

As part of these themes, the health professionals were also asked how confident they felt about addressing spiritual care and whether they felt they would benefit from training. Specific questions therefore sought to initiate conversation with each health professional, but the semi-structured nature of each interview enabled the issues that arose to be explored and clarified.

The interviews were completed by one of the researchers, who worked within the local dementia care services. Each interview was undertaken at a location and time convenient for each health professional and was between 20 and 35 minutes in length. The specific issue of the health professionals knowing the interviewer was a limitation. Such knowledge could have affected the health professionals' responses, that is, desirability/prestige bias (Drummond 1996). A different interviewer would have reduced this bias, but resources were not available. Such an interviewer would also have needed some knowledge of dementia care, and of spirituality, in order to conduct the interviews.

Each interview was recorded onto a digital recorder and, to ensure confidentiality, each health professional was given a unique code. The recordings of these interviews were sent to a transcriber (with only the unique code attached). The financial cost of this was supported by the granting of a Research Capacity Award by the College of Occupational Therapists.

The audio recording of an interview does, however, mean that an interviewee's behaviour and body language are not recorded (Holloway and Wheeler 2002). After the recording of each interview, a research diary entry was therefore written; such entries can provide extra detail, but they need to be written as soon as possible after the interview (Denscombe 2007). It is particularly important that the presence of the researcher is recognised within phenomenological research (Holloway and Wheeler 2002). These reflections are referred to as 'reflexivity' and should be continued throughout the research, as was the case with this study through the completion of a research diary.

Reliability and validity

In addressing the issue of reliability with the interview transcripts, each of the health professionals was asked to check his or her transcription for accuracy. Trustworthiness in qualitative research is important because the approach seeks to convey experiences and meanings within a particular area (Luborsky and Lysack 2006). If the researcher has been in a setting for a period of time, participants may already trust the researcher and therefore provide truthful answers (Holloway and Wheeler 2002). The researcher who completed the interviews had indeed worked within dementia care services for several years.

Data analysis

Content analysis was used with the interview transcripts, which is a form of analysis appropriate for use with phenomenological research (Donovan and Sanders 2005). Such analysis involves the coding and categorising of the text to determine common themes within it (Grbich 2007). The initial analysis of the interview transcripts was carried out using the research objectives. Each transcript was read many times and the lines of the transcripts were coded into each of the research objectives. Additional analysis of the coded transcripts then identified further categories, with several subthemes emerging within each of the three research objectives.

Findings and discussion

The findings and discussion of the research are presented together, a suggested approach when writing up qualitative research (Denscombe 2007, Grbich 2007). Selected quotations from the interviews are used to demonstrate key points, because the use of such quotes can assist in establishing credibility for the emerging themes (Holloway and Wheeler 2002). In order to maintain the anonymity of the health professionals, the following codes are used:

* Therapist (numbered i-v)

* Nurse (numbered i-iv)

* Doctor (numbered i and ii)

Objective 1: To analyse the common themes of health professionals regarding their understanding of spirituality

No distinct differences were noted in the responses between the different types of health professional interviewed: they all found defining spirituality difficult. Indeed, three of the health professionals commented that they had looked up the word 'spirituality' in the dictionary prior to the interview. A further six of the health professionals commented explicitly on difficulty in defining the term:

... I think it is very hard to put into words ... (Nurse iii). You've stumped me now (Therapist iii).

When there is so much debate within the literature on the definition of spirituality (for example, Swinton 2001, Bephage 2008), it is not surprising that the health professionals also found this difficult. Udell and Chandler (2000), in analysing their interviews with occupational therapists, concluded that the concept is 'difficult to articulate' (p492). The health professionals, however, did use similar terminology, but despite this they had difficulty in trying to define the words they used associated with 'spirituality'. For example, six health professionals used the word 'belief' during the discussion about defining spirituality, but a 'belief' can have a religious or non-religious basis. The majority of the health professionals (n = 7) did associate religion with spirituality and all of them (n = 11) agreed that spirituality involved the interpretation of experiences with or without a religious framework. The health professionals therefore recognised similar ideas to those within the definition suggested by Johnston and Mayers (2005), which states that spirituality 'may or may not be related to a belief in God or some form of higher power' (p386).

As the health professionals found defining spirituality difficult, three actually suggested that each individual patient should be allowed to define spirituality himself or herself:

... what I would call spirituality perhaps somebody else wouldn't or they wouldn't put it into that same little box ... (Nurse iv).

... it is what makes a person tick and what is important to them in their ethos and their values ... (Doctor ii).

If patients define spirituality in different ways, this may add to the confusion and resulting lack of confidence among health professionals in providing spiritual care. Coyle (2002) suggested that the most important aspect of spiritual care is that health professionals understand how the meeting of such needs has benefits for patients. This is unlikely to happen if health professionals continue to be unclear as to their understanding of spirituality. The use of a comprehensive definition of spirituality, such as the one used within this research (that is, Johnston and Mayers 2005), may however address this, particularly because all the aspects of spirituality identified by the health professionals are included within this definition.

Objective 2: To determine health professionals' perceptions of how patients' spiritual needs should be met within dementia care

All the health professionals (n = 11) agreed that spiritual care should be provided, with recognition that although dementia may mean that a patient's needs change, spiritual care should be provided throughout the patient's illness:

If we are providing patients holistic care, we should be looking at that aspect [spirituality] and trying to meet their needs wherever possible... (Therapist iii).

Previous research has demonstrated that the addressing of patients' spiritual needs can have a positive impact on their mental and physical health (Koenig et al 2004). Patients themselves would also like their spiritual needs to be acknowledged (Koslander and Arvidsson 2007). When the health professionals were asked what their perceptions were of the spiritual care provided, they all said that the service was limited:

I think it is quite ad hoc ... (Therapist i).

Six felt that there were many ways in which a patient's spiritual needs might be met; for example:

* Attending chapel /church services

* Going outside for walks, including seeing the sunshine

* End of life care

* Providing quiet time /space

* Listening to, and facilitating, the patient's wishes

* Providing multisensory activities, including listening to music.

These activities are all identified in other research that has sought to identify how a patient's spiritual needs can be addressed within dementia services (Bell and Troxel 2001, Higgins 2005). Activities can range in complexity; for example, from smelling flowers to attending a church service (Shamy 2003, Wallace 2004). A difficulty with these activities, however, is that they could be seen as part of general patient care. It is not surprising that four of the health professionals felt that through their individual work with a patient, they might be meeting that patient's spiritual needs unintentionally:

[Within your role, do you feel you currently address the spiritual needs of patients with dementia?]

Not explicitly probably within my role, but I would like to think that I probably meet them without really realising (Therapist iii).

Yes, I do in some ways actually, but usually inadvertently (Therapist v).

This uncertainty about how spiritual needs are addressed is not surprising given that the health professionals found defining spirituality difficult. In order for health professionals to feel confident in meeting the challenge of integrating spiritual care into dementia services, they must first understand the terminology and then understand how spiritual needs can be addressed (Johnston and Mayers 2005).

Three of the health professionals felt that patients had at times verbalised their own spiritual needs, but six stated that it was only a patient's religion that was recorded at assessment, with no other questions being asked. However, as the discussions with the health professionals have already established, spiritual care is not just about a person's religious beliefs. When asked whether they were aware of any spiritual needs assessment tools, all the health professionals (n = 11) stated that they were not. Eight said that they felt a 'prompt' question within the initial assessment would remind them to ask about a patient's spiritual needs.

Research, although not providing examples of assessments that could be used, does advocate for a formal framework or assessment to be identified to ensure that a patient's spiritual needs are recognised, both when he or she accesses dementia care services and also throughout the different stages of dementia (Bruce 1998, Bell and Troxel 2001, Bephage 2008). If such a prompt is added to the initial documentation, it needs to result in action. Previous literature has identified that it is often the case that a patient's religion is noted but there is no follow-up (Cressey and Winbolt-Lewis 2000, Wallace 2004). As well as a clear definition of spirituality, an assessment could help health professionals to feel more confident about spirituality. Belcham (2004) concluded that occupational therapists felt more confident when spirituality was addressed within an assessment or model of practice.

The confidence of the health professionals in addressing the spiritual needs of patients was raised during the interview. All the health professionals stated that they did not or would not feel confident in addressing spiritual needs:

No I wouldn't say I was confident because it is difficult area of the job, it is the area that takes you outside your traditional training ... (Therapist ii).

A lack of clarity regarding the definition of spirituality must have an impact on how confident health professionals feel. Other research has also identified a lack of confidence in addressing patients' spiritual needs (Belcham 2004, Beagan and Kumas-Tan 2005). Patients themselves feel that nursing staff lack confidence and this affects whether they would approach them with any spiritual matters (Koslander and Arvidsson 2007). When questioned about their lack of confidence about spiritual care, 10 of the health professionals indicated that they would benefit from training:

I think it would probably be beneficial for all staff to have some training ... (Therapist iii).

Yes, probably because I am quite, in some ways, I am quite ignorant to things like that (Nurse iv).

The type of training required was not explored with the health professionals, but the need for training is also acknowledged within the literature (Kirsh et al 2001, Lawrence 2007). Swinton (2001) argued that training should begin during the education of health professionals in the universities to ensure that staff feel confident in addressing spiritual issues once qualified.

Objective 3: To evaluate who should provide the spiritual care to patients with dementia

Chaplaincy staff

When asked who they associated with the addressing of a patient's spiritual needs, eight of the health professionals identified chaplains or pastoral care staff connected with a particular faith group:

I guess any sort of religious leader whether it be clergy or whoever (Nurse ii).

... somebody that has a similar religious background or is maybe a pastor... (Doctor i).

The health professionals, when trying to define spirituality, felt that it was about more than just religion and religious practices. However, six health professionals identified chaplaincy staff as people whom they could approach for advice and support about a patient's spiritual needs:

I think they [the clergy] are the ones that need to give us guidance as to how to meet needs if the person isn't able to articulate it themselves... (Nurse ii).

... I would probably need to approach either a member of the chaplaincy staff or somebody from that religion that I could talk to (Nurse i).

By emphasising chaplaincy staff as providers of spiritual care, the broader nature of spirituality, as identified by the definition by Johnston and Mayers (2005), is forgotten. Although chaplains have reported that their role is more than religious care (Wright 2001), previous research has concluded that chaplains do not always feel part of the multidisciplinary team (McSherry and Ross 2002). Of the questionnaires sent to old age psychiatrists, 96% (n = 302/316) indicated that no religious or spiritual adviser ever attended their ward rounds (Lawrence et al 2007).

Other health professionals

When asked at the beginning of each interview whether they currently addressed the spiritual needs of patients with dementia, only five of the health professionals stated that they did. Ten of the health professionals stated that they felt that they should address such spiritual needs:

... it could be anybody and should be everybody and anybody (Therapist iv).

I think it should probably be part of everybody's role ... (Therapist iii).

The fact that the activities identified by the health professionals included non-religious activities indicates that all health professionals could address a patient's spiritual needs. The Department of Health (2004) stated that all health professionals should address spiritual needs; indeed, the document Standards for Better Health noted that the spiritual care of patients is a developmental need for services to address. The majority of the participants (n = 8) identified chaplaincy staff as the main providers of spiritual care. However, chaplains feel that such care should be provided by other health professionals as well as themselves (Sheikh et al 2004).

Both occupational therapists interviewed thought that they should become involved with a patient's spiritual needs and one of them felt that she did not currently address spiritual needs enough. Three of the other health professionals recognised occupational therapists as being able to address spiritual needs because they engaged patients in meaningful occupation and six participants felt that spiritual needs could be addressed through different activities. Research that sought to investigate occupational therapists and spirituality has concluded that occupational therapists recognise this as part of their role, but that they lack confidence in this aspect of patient care (Belcham 2004, Beagan and Kumas-Tan 2005).

Three nurses stated that they thought spiritual care should be part of their role. The other nurse stated that she did not feel it was an explicit part of her role, but that she would facilitate activities in order to meet a patient's spiritual needs. In comparing this with other research, there are many studies that advocate occupational therapists and nurses providing spiritual care (for example, Coyle 2002, McSherry and Ross 2002, Belcham 2004). Patients have said that they would initially speak to nurses about spiritual matters, although they perceive a lack of confidence among them (Koslander and Arvidsson 2007).

Both of the doctors commented on the importance of spiritual care and agreed that they should consider patients' spiritual needs, but had limited time in which to discuss spirituality. Lawrence et al (2007) similarly concluded that old age psychiatrists, while recognising spiritual needs as important, lacked the time, and also the formal training in terms of spiritual care, to address such issues.

Three of the health professionals suggested that psychology staff and counsellors could assist with the spiritual care of patients with dementia and one of them observed that voluntary services should become more involved with the spiritual care of patients. A wide variety of people can therefore assist in meeting the spiritual needs, which can be very varied, of patients with dementia (Goldsmith 2004, Wallace 2004, Higgins 2005). The initial challenge for all health professionals is how they identify the spiritual needs of patients who have dementia in order that they may then work towards meeting those needs.

Limitations of the research

Sampling: Convenience sampling was the strategy used within this research to ensure that the health professionals who were interviewed had experience within dementia care. Denscombe (2007) warned, however, that this type of sampling is not the most rigorous of techniques. The participants were aware that they would be asked about spirituality when they volunteered to take part. It is possible that those who did not volunteer felt that spirituality was not relevant to health professionals. There were also staff associated with dementia care services (for example, psychologists) who were not interviewed.

Interview format: The interview questions elicited information that enabled the objectives to be addressed. Further questions regarding the type of training that the health professionals would like would have assisted in clarifying the format of training required.

Content analysis: Although the use of content analysis has been recognised as appropriate within a phenomenological approach (Donovan and Sanders 2005), the process still raises issues. The analysis for this research was completed by only one person and, therefore, could be influenced by prior personal assumptions. The transcripts were checked by the participants, but a second person verifying the categories identified would have enhanced the reliability and validity of the research.

Conclusion

This research sought to begin to explore different health professionals' perceptions of spirituality within dementia care. All felt that spiritual care should be provided within dementia care, although only five said that they addressed patients' spiritual needs themselves. This disparity between acknowledging the importance of spirituality and the actual provision of such care may in part be due to the health professionals' difficulty in defining the term 'spirituality'. All of them (n = 11) struggled initially to provide a definition, yet used common terminology when they discussed the actual provision of spiritual care. As the health professionals reported that they lacked confidence in addressing spiritual needs, clarifying a working definition may improve their understanding and confidence. The definition used within this research (Johnston and Mayers 2005) contains all the elements suggested by the health professionals. Further exploration should therefore be undertaken as to how this definition could be used more widely within dementia care services.

The health professionals acknowledged that patients are not routinely asked about their spiritual needs, but that such a question within the initial assessment would prompt staff to think about spiritual care. No specific spiritual needs assessments were named by the health professionals as currently being used. An assessment that asks patients about spiritual beliefs and values would therefore be beneficial, although health professionals need to be able to identify spiritual needs even if the patient has difficulty in communicating.

Although the majority of the health professionals felt that spirituality did not relate only to religion, eight of them associated chaplaincy staff with the provision of spiritual care. Other responses from the participants illustrated their uncertainty around their role in this area. However, they stated clearly that spiritual care should be provided by health professionals and 10 of them felt that they themselves should address such spiritual needs. This is consistent with documents that highlight the need for spiritual care within dementia services, but do not single out particular health professionals for this role (NICE and SCIE 2006, National Audit Office 2007).

In acknowledging their lack of confidence about spirituality, 10 participants felt that training would be valuable and this need for training had also been identified by other studies (Kirsh et al 2001, Swinton 2001). Research is therefore needed into the type of training that is required. Such training in spirituality and spiritual care should, however, be multidisciplinary and should consider issues such as the nature of spiritual care and who should address spiritual needs. This should result in patients with dementia having their spiritual needs identified and met routinely.

Acknowledgements

The authors would like to thank all the health professionals who volunteered to be interviewed and Alona Duff who transcribed all the interviews.

The first author received a Research Capacity Award from the College of Occupational Therapists to assist in the cost of transcribing the interviews and completed this research as part of an MSc in Professional Health Studies.

Key findings

* The different health professionals identified themselves as staff who should address spiritual needs.

* The health professionals reported a lack of confidence with spiritual care and requested further training.

What the study has added

The study involved different health professionals and all found it difficult to define spirituality and their role in this area. There was agreement that all health professionals should be involved with spiritual care.

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Jennifer Bursell (1) Christine A Mayers (2)

(1) North Yorkshire and York PCT.

(2) York St John University, York.

Corresponding author:

Professor Christine A Mayers, Chair in Occupational Therapy, Faculty of Health and Life Sciences, York St John University, Lord Mayor's Walk, York YO31 7EX. Email: c.mayers1@yorksj.ac.uk

Reference: Bursell J, Mayers CA (2010) Spirituality within dementia care: perceptions of health professionals. British Journal of Occupational Therapy, 73(4), 144-151.

DOI: 10.4276/030802210X12706313443866
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