I would like to thank Ross for her response to my paper and would like to respond to some of her criticisms and make some clarifications. One part of my study was to identify factors in relevant research reports that might influence attitudes to spiritual care among nurses. The aim was to test these factors in a Swedish nursing context. Ross suggests that either my literature review is incomplete or that certain criteria were applied that the reader is not privy to. The latter is not the fact. I would, however, agree that my study could benefit from Kuuppelomäki's study (2001) whose results would have been important and interesting to compare with mine. I do not see how any of the early studies, mentioned by Ross, could have contributed to the identification of possible factors influencing attitudes to spiritual care in a way that is better and clearer than the somewhat later studies I have chosen to refer to. The studies referred to by Ross are in some cases sparse when it comes to details on the sampling method or biased in different ways, which Ross herself points out (Ross 1997, p. 40–42). As I see it, the only significant study for my purpose of the ones Ross is referring to in the first part of her commentary is Piles (1990) study, to which I actually do refer. An unfortunate mistake in my paper is my referring to Ross’ life experience/maturity factor (Ross 1994) as an age factor. I can nothing but apologize for this.
Ross addresses the question of replication. I clearly state in my paper that the part of my study that is a replication of Strang et al. (2002) is only a replication of parts of their study. Moreover, I have not stated that it is an exact replication. I did not classify the type of replication I was doing, assuming that it is obvious to the reader that it is an approximate replication (for discussions of different kinds of replications, see for example Kazdin 2003, pp. 489–491).
Ross fails to see the importance of my finding that there is sizeable difference between registered nurses and nursing auxiliaries when it comes to their considerations of how often they give spiritual care. It is true that they have different remits and roles and work in partly different ways but it is an open question what it is in these different roles that makes the difference. Why is it that the registered nurses seem to give more spiritual care than the nursing auxiliaries instead of the other way around? At least in a Swedish context there are areas of work that overlap, for example, many of the basic nursing interventions which could be conducted by either category. Also, in a Swedish context, the nursing auxiliaries are often working as close to the patients as the registered nurses (in matter of for example daily hygiene and nutrition), in my opinion, often even closer than the nurses (depending of what kind of ward we are talking about). One reason which surprised and intrigued me is that, as I see it, the closeness to the patients would suggest an increased ability for the patients to ventilate spiritual or existential concerns with the nursing auxiliaries, as the closeness could generate a sense of familiarity and trust. That would speak in favour of nursing auxiliaries giving spiritual care maybe even more often than registered nurses. However, according to my results, this is not the case. Unfortunately, from the data we have now, it is only possible to speculate in this issue. More research would be necessary to shed some light here.
Ross suggests that it is time to try to develop a model from all the work done in this field up to date, which could be further tested and refined through future research. Such a model would, indeed, be useful but I am not optimistic about the possibility of developing such a model. The spiritual ‘climates’ in different parts of the world is enormously different (Halman 1994). Even in the same country, the spiritual climates can vary significantly, differing from areas with rather high percentage of actively religious people to areas with high secularity, areas with concentrations of conservative denominations and areas with liberal denominations (Carlsson 1990). This would certainly affect the spiritual climate also at the local hospitals, giving different connotations to words like ‘spirituality’ and ‘spiritual care’ and maybe significantly different attitudes between countries and even between different areas of one country. This is why I suggest that it is possible that other factors, not identified in international studies but specific for Swedish conditions, may influence attitudes to spiritual care in a Swedish context. Probably, Ross has misunderstood this part of my conclusion as she insinuates that I am asking for research that is already performed by her and others. I clearly state that it is to identify such factors – specific to a Swedish context – that I recommend more research of the kind I have suggested. I find that neither Ross, nor any one else has done this. Two studies have identified obstacles to existential support (Strang et al. 2001) or spiritual care (Lundmark 2005) reported by nursing staff in a Swedish context, which might be useful tools in further studies identifying factors specific for a Swedish context. Be it as it will with this, I find here an interesting question for further research: do attitudes to spiritual care vary between different geographical areas with different spiritual climates, as I'm assuming here? If this is not the case, then it might be meaningful to try to develop a grand model.
Finally, Ross is addressing the question of generalization. She thinks it is a too sweeping generalization to say that my results, together with Strang et al., are relevant for the whole of Sweden. This might be true, but I want to point out that the two studies are conducted in three different geographical areas, together covering a considerable part of the country: The areas of Gothenburg, Uppsala and Umeå. Whether this is a too sweeping or a reasonable generalization, I leave for the reader to judge.