Commentary on Lundmark M (2006) Attitudes to spiritual care among nursing staff in a Swedish oncology clinic, Journal of Clinical Nursing (15, 863–874)


Linda Ross, School of Care Sciences, University of Glamorgan, Pontypridd, UK. E-mail:

The spiritual dimension of nursing care is a fairly new area of research, so it is always encouraging to hear of new studies in the field, like this most recent one conducted by Mikael Lundmark in Sweden.

A literature review I conducted in the late 1980s identified only six studies (dating from 1957) looking at the nurse's perspective on spiritual care (Ross 1997). These were all small North American studies mainly conducted within religious schools of nursing and only one was published (Highfield & Cason 1983). Since then, at least 18 studies have been conducted on nurses, mainly in the UK (nine) and USA (six) but also single studies have taken place in Australia, Finland and Sweden.

I was somewhat surprised, therefore, that many of these studies which make a significant contribution to our understanding of nurses’ perceptions and practise of spiritual care, are not referred to in Lundmark's paper. This is all the more surprising given that his first aim was to conduct a ‘review of international research reports’ to identify factors influencing attitudes to spiritual care for testing in the second part of his study. Either these factors were identified from an incomplete literature review, or certain criteria were applied to the search strategy and selection of the papers, which we are not privy to.

Lundmark's study also seeks partly to replicate the work of Strang et al. (2002) to ascertain nurses’ attitudes to spiritual care using a purpose designed questionnaire. However, rather than replicating Strang et al.’s study exactly, Lundmark develops a new questionnaire, which includes only some of Strang's questions and uses different response options (Lundmark includes a ‘don't know’ category and a five item scale instead of a seven item one) thus exact comparisons with Strang's work cannot be made.

Lundmark also cites as a weakness the fact that Strang et al. (2002) did not separate registered nurses from auxiliaries in their analysis. He cites my finding that ‘position of the nursing staff is important when it comes to attitudes towards spiritual care’ as a reason for separating registered nurses from auxiliaries in his analysis. There are two points to make in relation to this analytical decision.

First, whilst my initial finding was that ‘grade’ was associated with identification of spiritual needs by nurses, the distinction was between charge nurse and staff nurse grades, i.e. both were registered nurses. I did not include auxiliary nurses (incidentally age was not a factor associated with the identification of spiritual needs, as stated by Lundmark).

Secondly, one would expect to find differences in practice and attitudes to spiritual care between registered and auxiliary nurses as indeed in any other domain of care whether physical, psychological or social. Each has undergone different training/education, have different remits and roles and work in different ways. These fundamental differences could well explain the finding that more registered nurses than auxiliaries said they gave spiritual care (a finding that was not accounted for by organized or non-organized religiousness). As registered nurses are responsible for planning care and auxiliaries are not, it may have been more useful to have further explored factors contributing to differences in practice and perception between registered nurses. In fact Lundmark identifies this as an important area for further research in the conclusion of his paper and other studies already shed some light on this issue specifically. For example, the second part of my study showed that a complex range and interplay of factors appeared to influence whether or not and how spiritual care was given in the sample. These factors were probably more important than the ‘grade’ of the nurse and are discussed in detail elsewhere (Ross 1994, 1997). My sample included both nurses who had and had not identified spiritual needs/given spiritual care, as Lundmark recommends in his conclusion. Other studies have reported similar findings.

However, Lundmark's study does contribute to our understanding of factors influencing attitudes to and practice of spiritual care by nurses. Whilst the majority of his sample considered spiritual care important, only about one-third considered it was given in practice. This discrepancy between opinion and practice is illustrated in many other studies (e.g. Narayanasamy 1993, Ross 1994, McSherry 1998, Kuuppelomaki 2001) where the crucial factor relating to the practice of spiritual care seems to be the personal belief system of the nurse. Lundmark distinguishes between ‘organized’ (e.g. church attendance) and ‘non-organized’ (e.g. praying, private devotion) religiousness, with non-organized religiousness being more important in influencing attitude to and degree of ease in giving spiritual care in this Swedish sample. This raises the question of whether it is possible and/or ethical to attempt to alter the personal belief system of the nurse to equip them to deliver spiritual care and whether education can achieve this outcome. Lundmark touches on this important issue of education. He found that nurses who had received education in spiritual care felt more equipped to give spiritual care than those with little or no education. Most of the research and debate in the nursing literature stresses the importance of educating nurses in this regard, yet no studies have looked at how nurses can best be prepared to fulfil this part of their role. This is clearly an area requiring further attention.

Lundmark's study builds on previous research and further explores further the complexity and interaction of factors appearing to influence nurses’ attitudes to and practices of spiritual care. It may be useful if all the work to date could be developed into a model that could be further tested and refined through future research. I would agree that further research is certainly needed to provide us with a greater understanding of the factors facilitating and hindering the giving of spiritual care so that client need in this realm can be more adequately addressed.

Lundmark concludes that ‘Holistic care…is not yet realised in Swedish health care’ and that ‘Factors influencing attitudes to spiritual care are relevant in a Swedish nursing context’. I am not sure that such a sweeping generalization to the whole of Sweden can be applied. This can certainly be said of the oncology clinic in the Swedish hospital surveyed and the fact that Strang et al. (2002) concur with the findings suggests that it is possibly a trend in the particular area of Sweden studied, but only a wider study could enable such conclusions to be reached.