Abstract

Spirituality is an integral component of holistic care; the initial assessment of a patient’s’ spiritual needs often poses a challenge. I recognised that nursing staff frequently expressed feelings of inadequacy when exploring this area.

It was expected that chaplains would record such assessments; yet it became clear to me that in engaging with patients both in the initial admission process and ongoing conversations this area of a patient’s care was in fact being addressed. What was lacking was their recording of this information.

After reviewing literature, exploring the experience of other hospices, and reflecting on our experience, we have developed a holistic assessment recorded as narrative on SystmOne.

The initial recording of the assessment is completed by the admitting nurse as he/she reflects upon their conversation with the patient and/or their carers.

Literature and experience indicate that ‘‘relationships’’ are at the heart of a person’s spirituality which therefore forms an integral part of the assessment. On the SystmOne template are found text boxes in which information relating to a patient’s relationships with ‘‘self’’, ‘‘others’’, ‘‘the world’’ and ‘‘belief system’’ can be recorded. Guidance on its completion can be found on the template.

Initially there was some resistance to the concept, nurses citing lack of expertise and time constraints as contributing to their unease. To a large degree this has been overcome by provision of internal training and one- to-one support as necessary. Compliance of completion will be checked as part of a records keeping audit this year.

I found that nursing staff are becoming more confident in the completion of the assessment which informs the wider multidisciplinary team and enhances the holistic care offered to patients and their carer’s.

Take home message; “Spiritual Assessment is not about ticking boxes but rather about listening, reflecting and recording!”