A critical view of spirituality and spiritual assessment
The concept of spirituality is emerging from the shadows to occupy a prominent position in the vocabulary of contemporary healthcare. Research theses are being written on the topic (we have written, supervised and assessed some of them ourselves), and it is quite common for journals to publish papers on the methodology of spiritual assessment, the philosophical meaning of the concept, and to a lesser degree practical aspects of its implications for care (McSherry & Ross 2002, JAN38, 479–488. Like mother love and apple pie, the word spirituality carries with it a feeling of wholesomeness; who could doubt that the nursing profession's recent interest in this concept is a positive move, signalling a rejection of the mechanistic materialism that seems to characterize contemporary, technology-driven health care, and replacing it with a more inclusive and holistic emphasis?
We argue however, that the concept of spirituality is a problematic one. The first problem is that we are a long way from having universal agreement about what it means. One aspect of the meaning of spirituality is inextricably bound up in religion (Bradshaw 1994, Pattison 2001) where it may refer to the patterns of worship and prayer that are constitutive of religious observance. A different stream of meaning can also be traced, which relates the concept to people with a secular outlook on the world (Cawley 1997). It is also important to remember that the suggestion that life has a spiritual dimension of any kind rests on an assumption; research currently being undertaken by WM is disclosing a significant proportion of people who either do not know what is meant by the word spirituality, or positively disagree with the suggestion that their lives have a spiritual dimension (McSherry & Ross 2002, JAN38, 479–488).
Some authors have sought to combine the religious and secular strands, suggesting or implying that each is a specific and particular example of an overarching spiritual dimension with a universal scope. We argue that a second problem arises at this point. It is easy to lose sight of the fact that there are fundamental differences in the ways in which people experience the world, and find meaning in that experience (Martsolf & Mickley 1998). There is a danger that the blanket application of an undifferentiated, ‘one-size-fits-all’ concept of spirituality will be equally disrespectful to the views of those who subscribe to a broadly religious world-view, as to those who adopt a secular orientation. Equally, of course, it is easy to make the false assumption that the people in either of these camps necessarily have much in common, as considerable diversity of belief can be found in both the religious and secular spheres.
The view that nurses should be competent to assess the spiritual needs of patients, clients and even whole communities is so widely accepted in the profession that it is expressed as a requirement for registration (UKCC 2000). It is only possible to assess spiritual needs in this way if we are prepared to accept that the experience and expression of human spirituality is relatively homogenous. An illustration from physical assessment clarifies this point. We assume (with good reason) that everyone has a blood pressure that can be measured if the correct approach is used, and the practice of taking and interpreting X-rays rests on assumptions about the density of human tissues. The view that we can develop instruments for the assessment of patients' spiritual needs rests on an extension of this view from the physical sphere into the metaphysical sphere of concepts and meanings. In our view there are no grounds for making this move, for as we have argued there is no evidence that people share a common understanding of the existence of a spiritual realm, or of its meaning.
Of course, it could be argued that it is legitimate for health professionals to classify people's needs as spiritual if they find it useful to do so, even if the person to whom the term is applied does not recognize the validity of the term. After all, we do not seek permission before suggesting that a person belongs to a particular social class. But spirituality is different from other concepts because if it refers to anything, it refers to cherished systems of belief. We argue that universalizing the concept of spirituality may have the paradoxical effect of ascribing to people values they may not share. We do not feel that this is justified, as to do so would be profoundly paternalistic.
It should not be concluded from what we have said that we advocate or subscribe to a materialistic or mechanistic view of health and illness. We recognize the importance of many of the issues that are often subsumed under the eclectic view of spirituality (Cobb 2001) and suggest that the search for and expression of meaning is particularly important. Nursing has always been a profession with an acute sense of this ‘existential’ dimension of human life; we frequently encounter people whose sense of meaning is challenged and shaken by the circumstances of their health and illness, and as a profession we recognize that our work entails supporting people as they work through the implications of loss, or body image change, or the onset of chronic illness, or challenges to psychological integrity. We suggest that an adequate conceptual vocabulary already exists to enable us to understand and support them (or at least to try) – this is the vocabulary of loss, grief, fear, anxiety, hope, despair, joy and realization. We can see no advantage in superimposing a further vocabulary of spirituality.
In summary, we endorse the view that from time to time nurses and other health professionals will support patients and clients who are attempting to find meaning in the changing circumstances of their health and illness. This clearly entails effective communication skills and personal qualities such as an empathetic and caring nature. Inevitably, this kind of work will usually be hidden from view, because it generally consists of quiet conversations, effective listening, communication through touch and the use of presence. These are all aspects of care that are integrated and not separated within the provision of holistic care. However, we argue that it is unnecessary and potentially harmful to place this activity under the umbrella of spirituality and spiritual care.