Palliative care nurses' spiritual caring interventions: a ...

Research

Palliative care nurses’ spiritual caring interventions: a conceptual understanding Susan Ronaldson, Lillian Hayes, Christina Aggar, Jennifer Green and Michele Carey

Abstract

Aims: To investigate spiritual caring by palliative care nurses and to describe their interventions. Background: Spirituality and spiritual caring are recognised as integral components of holistic nursing. Design: Qualitative data captured on a questionnaire were analysed thematically (Braun and Clarke, 2006). Methods: The study involved forty-two palliative care registered nurses working across seven palliative care services in Sydney, Australia. The research question was: ‘What spiritual caring interventions do palliative care nurses use in their practice?’ Nurses completed an open-ended questionnaire to identify and interpret their spiritual caring. Findings: Three sub-theme categories and four major concepts of spiritual caring. Categories identified are: humanistic, pragmatic and religious interventions; while concepts of spiritual caring are: ‘being with’, ‘listening to’, ‘facilitation of’ and ‘engaging in’. Conclusion: A conceptual understanding of spiritual caring was identified. Key words: l Spirituality l Humanistic l Presence This article has been subject to double-blind peer review

Susan Ronaldson, Honorary Senior Lecturer, Sydney Nursing School, The University of Sydney, Sydney, Australia; Lillian Hayes, Honorary Senior Lecturer, Sydney Nursing School, The University of Sydney, Sydney, Australia; Christina Aggar, Senior Lecturer, School of Health & Human Sciences, Southern Cross University, Gold Coast Campus, Australia; Jennifer Green, Senior Lecturer, Sydney Nursing School, The University of Sydney, Sydney, Australia; Michele Carey, Affiliate, Sydney Nursing School, The University of Sydney, Sydney, Australia Corresponding author: sue.ronaldson@sydney. edu.au

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is important to discover what interventions they are using in their individual spiritual care from which other nurses and health professionals may learn. In Australia, palliative care services are delivered as inpatient hospice care or provided in the community by a community palliative care nurse often with a clinical nurse consultant visiting the person’s home. The community service may be attached to a hospice or to an area health service’s community health program. Some patients may receive community palliative care only and die at home which is often their preferred choice (Hudson, 2003). Palliative care is also given in acute care units when appropriate. The nurses in this study were representative of the breadth of palliative care services offered in Australia i.e. inpatient hospice and community palliative care as well as those from palliative care services in acute care. Research needs to clearly identify the location and type of palliative care given its diversity (Taylor et al, 1999).

Aims This research aimed to investigate and describe, conceptually, palliative care nurses’ spiritual caring interventions. Being conceptual, this understanding of spiritual caring interventions may be beneficial to clinical nurses working in other clinical environments and also for nurses’ education.

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piritual caring has been identified as an integrated dimension of holistic nursing care. Interventions for spiritual care have been recognised in research (Rogers and Wattis, 2015). While a wide range of interventions have been identified, it is proposed that there remains some difficulty in their classification. This situation has arisen for many reasons, including the influence of the interpretations of spirituality and spiritual caring. Past research has investigated how nurses provide their spiritual care in different clinical environments for example, critical care, oncology, hospice, mental health and rehabilitation (Taylor et al, 1999; Sellers and Haag, 1998; Tuck et al, 2001; Brenner et al, 2003; Gebhardt, 2008). Spiritual caring in the hospice environment has been a research focus because of end-of-life care, where nurses share with people their last days and support them to reconcile, find hope and have peace with themselves and toward others. Palliative care nurses are well prepared to provide expert spiritual care at this time for the dying person, their family and friends. Palliative care nurses with extensive experience bring such experience to their clinical practice which also informs their spiritual care. It is valuable to capture their insights and experiences of spiritual caring so that this specialist area can be more fully understood. These palliative care nurses are well placed to provide such care and it

International Journal of Palliative Nursing 2017, Vol 23, No 3

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Research


Background Palliative care is a specialty in which spiritual caring and spirituality are most relevant. The focus of such care surrounds the context and issues of the end-of-life of patients (Carroll, 2001; Vassalo, 2001). It is well recognised that impending death is often accompanied by a state of life review as people face limited time to live due to a terminal illness (Keall et al, 2014). Such life review may bring about spiritual distress and nurses’ spiritual caring is most important at these times. In a review of published international research on spiritual caring in nursing, Cockell and McSherry (2012) identified that one third of the published studies included palliative care or oncology. It was acknowledged that while spiritual caring is discussed by health practitioners in palliative care and oncology it may also be useful in other clinical contexts. Nurses’ understanding of spirituality and spiritual care has an influence on their practice of such care. Spirituality may be considered simply as a dimension of the human experience with ‘some basic pursuit of understanding one’s place and purpose in the universe’ (Breitbart, 2009:139). An understanding of spirituality and spiritual caring by nurses is most important. Table 1 presents some understandings that are relevant to nursing and this research. Of note, education in spiritual caring has not been readily available to many nurses (Cetinkaya et al, 2013). They may be confused with the nature of such caring (Naravanasamy and Owens, 2001). It is sometimes difficult for nurses to articulate spiritual caring in their practice (Clarke, 2009). Nurses have a need for and would welcome such education (Ross, 2006). Acts of spiritual caring arise from a broad base and range from religious practices to esoteric alternative approaches. Sawatzky and Pesut (2005:19) propose spiritual care in nursing to be ‘an intuitive, interpersonal, altruistic and integrative expression that is contingent on the nurse’s awareness of the transcendent dimension of life but that reflects the patient’s reality’. It has also been noted that during end-of-life care hospice nurses’ personal spirituality most influenced their spiritual caring (Taylor et al, 1999). The religious background of the nursing profession has had a significant influence on the origins of spiritual caring (O’Brien, 2014). Alongside the historical developments of nursing in the late 20th century, interest, research and conceptualisation of spirituality and spiritual caring also developed (Sawatzky and Pesut, 2005). In the subsequent scientific era assessment tools


Table 1. Relevant understandings of spiritualty and spiritual caring Spirituality

Spiritual caring

A dimension of the human experience with ‘some basic pursuit of understanding one’s place and purpose in the universe’ (Breitbart, 2009:139)

‘…. spiritual nursing care is an intuitive, interpersonal, altruistic and integrative expression that is contingent on the nurse’s awareness of the transcendent dimension of life but that reflects the patient’s reality’ (Sawatzky and Pesut, 2005:19)

Meaning and purpose, forgiveness, belief and faith in oneself, others and for some a higher power/deity, personal values, love, creativity and self-expression (Royal College of Nursing, 2011)

Sensitivity to spiritual belief systems, establishing relationships, integration of spirituality into care plans, nurses’ sense of presence (Callister et al, 2004)

were developed in order to accurately measure this difficult to grasp concept. With quantitative research there was a risk that the spiritual domain would exclude the person and their holistic care. However, it kept alive the developing awareness of spiritual caring and the dimensions of spirituality in health care. Moreover, interaction between patient and carer incorporates the humanness of spiritual caring (Naravanasamy and Owens, 2001; Sawatzky and Pesut, 2005). Specific spiritual caring interventions, for example, prayers and referral to spiritual services and support persons, have generally not been related back to nurses’ backgrounds and the experience they bring to such care. Patients’ understanding of spiritual caring is different to that of nurses and other health carers. However, they have been found to expect nurses and other health professionals to provide spiritual care especially in end-of-life situations (Baldacchino, 2011). It is recognised spiritual caring requires engagement and presence (Chiu et al, 2004). Being open and non-judgemental is also important when interacting with a patient at a deep spiritual level (Sawatzky and Pesut, 2005). With spiritual caring there is also a need to be aware of ethical considerations and that permission be sought first before any specific action is taken e.g. praying with a patient (Winslow and Winslow, 2007). That is, professional boundaries must be respected and interventions that are receptive to the patient be considered in union between the patient and nurse. Spiritual presence establishes connectedness with a patient (Snyder et al, 2000). Spiritual caring can facilitate a transcendence to discover a higher meaning and purpose with an outcome of connectedness in their life and to hope within a patient’s personal context (Conco, 1995). Taylor’s review (2005) of research on spiritual caring in nursing highlights the incorporation of being present, active listening and referral.

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Design

Methods

Qualitative data captured on a questionnaire were analysed thematically (Braun and Clarke 2006).

Sample Palliative care registered nurses (RN) working in one of seven major health facilities that provide palliative care in metropolitan Sydney, Australia, were asked to describe the interventions they incorporated as part of their spiritual caring. These facilities included hospices (n=3), acute care hospitals (n=3) and a community palliative care service (n=1). Nurses working in the palliative care in these facilities were invited to participate in the study. The invitation had been displayed on notice boards and pamphlets for nurses to self-select their participation in the study. The self-selected nurses represented approximately 18% of the total palliative care nurses in the facilities.

acute care nurses’ spiritual caring (Ronaldson et al, 2012). In the comparative study the same group of palliative care nurses were considered experienced in their specialty based on averages of 9.5 years palliative care experience, 5.3 years in their current position, 6.9 years in the palliative care facility and 18.3 years of nursing experience (Ronaldson et al, 2012). Many held senior positions in their palliative care service. Nearly half were clinical nurse specialists (CNS), clinical nurse consultants (CNC), nurse unit managers (NUM) or clinical nurse educators (CNE). Half held a graduate qualification in palliative care and therefore had academically progressed their career specialty.

Thematic analysis method Palliative care nurses’ responses to an openended request on their spiritual caring interventions were analysed thematically as identified by Braun and Clarke (2006). The data were analysed in 6 phases.

Data collection

Phase 1

Forty-two (n=42) palliative care registered nurses responded to open-ended statements on their spiritual caring interventions which generated qualitative data for thematic analysis. These statements invited the nurses to provide examples of spiritual caring from their clinical palliative care practice. For example: ‘describe some of your spiritual caring interventions, giving examples’; and, ‘list any other interventions you provide for the spiritual care of your patients’. Each nurse’s response was transcribed verbatim and attached to a record of the specific characteristics of each palliative care nurse. Demographic data collected profiled the characteristics of this group of palliative care nurses. As a group, these nurses had practiced for many years in their clinical specialty and also in their overall nursing career. Many held advanced clinical specialty palliative care positions. Demographic data included age and gender, years in palliative care, years in nursing, and basic qualifications including specialist graduate qualifications in palliative care. Also obtained were nurses’ current position and the number of years held. Data were identified for analysis of their spiritual caring interventions. Ethics approval was obtained from institutional ethics committees prior to commencement of the study.

Once transcription of all nurses’ responses was completed the qualitative data were read as a whole. Each nurse’s response was then read a number of times to gain an appreciation of its content and meaning in regard to the study’s research question: ‘what spiritual caring interventions do palliative care nurses use in their practice?’ Having become familiar with the data in the initial read, groups of data began to emerge and those with common meaning were designated as ‘statement markers’.

Experienced palliative care nurses

Phase 5

The qualitative data collection was an addendum to a comparative study of palliative care and

Previous phase analysis resulted in descriptive major themes of spiritual caring interventions.

Phase 2 In a second reading of each ‘statement marker’, free code(s) was/were derived from its wording.

Phase 3 These free codes were linked to the raw data through their ‘statements markers’. The free codes were then read a number of times and sorted into groups according to common wording and/or meaning within and across codes. This induction resulted in analytic subthemes.

Phase 4 Each of the analytic sub-themes was then considered to identify descriptive major themes that would be inclusive of data’s free codes.


❛Some nurses do not participate in spiritual caring for a range of reasons including lack of education and of opportunity.❜



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Phase 6

Table 2. Summative Statements and Free Codes (Phase 2)

Each descriptive major theme was aligned with (at least) one of the analytic sub-themes. In the final stage of analysis, nurses’ specific responses were identified that illustrated each major theme and the research question.

Summative Statements (n=18)

Free Codes (n=13)

Facilitate involvements spiritual/religious practices

Facilitate practices

Engage with in spiritual/religious practices or rituals

Engage in practices and rituals

Results

Contact preferred pastoral carers or religious person

Contact spiritual support

Address spiritual needs in preparation for end of life

Attend spiritual needs

Consider / Awareness of spiritual needs

Identify spiritual needs

Encourage communication

Communication

Listen to them

Listen

Create/Allow opportunity to express spiritual needs

Spiritual needs expression

Human contact

Presence

Talk with and reflect

Presence & Communication

Show empathy and compassion

Presence

Refer to other health disciplines for spiritual care

Referral to health team

Offer them support to a cleric

Referral to cleric

Access to spiritual care

Referral to spiritual care

Discuss spiritual needs as desired

Explore & Communicate


Assessment of spiritual needs

Referral to services

Referral

Reassurance and peace

Presence & Spiritual comfort

The majority (79%) of palliative care registered nurses responded to the request for descriptive statements on their spiritual caring interventions. A number of nurses responded with more than one example of their interventions. Some responses were in considerable detail and others brief statements. Through inductive reasoning the raw data—that is the qualitative responses—were analysed initially into a ‘summative statements’ (n=18) and then into ‘free codes’ (n=13) without a hierarchical structure (table 2). Some free codes incorporated a number of summative statements hence their lower number. Two responses did not identify any spiritual caring interventions and made a definite statement of non-involvement in spiritual care. Seven responses did not identify any interventions. Both of these non-involvement responses were classified as ‘disengagement’ in the thematic analysis.


Sub-themes: humanistic, pragmatic and religious interventions When the free codes were reviewed once again the ideas that appeared to be shared by the participants generated three sub-themes. These sub-themes were: humanistic interventions, pragmatic interventions and religious interventions (figure 1). Humanistic interventions were those where the nurse was actively involved in the spiritual caring and which showed that they were able to exhibit their professional presence to the dying person. They were also closely involved in communication and listening, and allowed the person to express their spiritual needs. They explored possibilities to resolve spiritual unrest and to find peace (figure 2). Pragmatic interventions involved referral to services and pastoral carers and other health practitioners with spiritual caring experience. They were active in assessment of the person’s spiritual needs and attended to them when possible. That is, their interventions were mainly related to referral and facilitation (figure 3). Religious interventions were those directly related to a practice or ritual of a specific belief system or to a pastoral service, or the engagement of a religious person e.g. a priest or cleric (figure 4).


Humanistic

Pragmatic

Religious

Spiritual caring interventions

Figure 1. Three sub-theme categories of spiritual caring interventions. Explore & communicate

Presence

Human contact

Spiritual needs expression

Humanistic Interventions

Listening

Empathy & compassion

Reflection

Spiritual comfort

Figure 2. Humanistic interventions sub-theme and free codes Disengagement sub-theme The disengagement sub-theme involved responses that possibly exhibited a reluctance to be involved


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Assessment of spiritual needs

Attend spirtual needs

Pragmatic Interventions

Referral to health team

Referral to cleric/pastor

Another RN with 30 years’ experience in palliative care said: Referral to spiritiaul advisor

Figure 3. Pragmatic interventions sub-theme and free codes

Facilitate practices / rituals

Referral to services

Religious Interventions

Engage in practice/ rituals

Figure 4. Religious interventions sub-theme and free codes

Non-involvement in spiritual care

‘Sitting and hearing what a patient/carer says and responding to their spiritual needs e.g. involving pastoral care teams if needed, parish priest, religious leaders if required; organising communion, attendance at church service; just listening! Being with the person’.

‘On admission, cultural, religious and spiritual priorities are identified, so that at the time of death these may be honoured’.

Some nurses demonstrated awareness about referring their patients to other spiritual carers when not in an optimal position. For example, a CNC spanning 20 years nursing experience, 16 years of which were in palliative care, also expressed an awareness of her spiritualty as well as her limitations:

Disengagement

No response

Figure 5. Disengagement sub-theme and free codes in spiritual caring or a lack of knowledge in this area (figure 5). Further investigation showed that those who did not respond to the research question were RNs who did not hold a senior clinical position and had less than 2 years’ experience in both current position and palliative care.

Descriptive Understandings In contrast, the more experienced palliative care nurses responded with some very deep understandings of their spiritual caring. For example, one CNS with 14 years palliative care experience and 37 years nursing in total said:

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A palliative care nurse with 25 years’ nursing experience said:

A NUM with extensive palliative care experience (40 years) highlighted the need to assess early in the trajectory of end-of-life care stated:

Contact pastoral / religious support

Broad overview of issues

‘Listening without intervening just ‘being;’ with the patient ... Just listening to them speak; being non-judgemental; considering special needs’.

‘A key element is knowing myself and my limitations in the therapeutic role of a nurse. I have no hesitation in referring patients and families on to others, chaplains, counsellors etc if I don’t have the skills or resources required’.

These experienced palliative care nurses were committed to spiritual care and had witnessed its benefits for their dying patients and their families.

Major themes: ‘being with’, ‘listening to’, ‘facilitation of’ and ‘engaging in’ These descriptive statements are some examples illustrating that in the humanistic interventions sub-theme there was a strong identification of the role of presence and listening which incorporated communication, exploration and expression. From this further analysis, ‘being with’ and



‘Discussing fears and hopes; encouraging talking about dreams; allowing time to express thoughts and remembrances from their life, and about their belief systems, trying to make meaning of this time [in their life].’



Research

‘listening to’ are the descriptive major themes connected to the sub-theme of humanistic interventions. In both the religious interventions and pragmatic interventions sub-themes, nurses have identified the many practices of referral to spiritual services in addition to their own assessment of and attention to spiritual needs, rituals, and other spiritual carers for their patients. ‘Facilitation of’ and ‘engaging in’ are the third and fourth descriptive major themes identified for these two sub-themes (figure 6).

Major concepts Being with

Humanistic Listening Religious Facilitation of

Categories and concepts The study’s sub-themes, humanistic, religious and pragmatic, are considered to be categories of intervention. The major themes, ‘being with’, ‘listening to’, ‘facilitation of’ and ‘engaging in’, being conceptual, have meaning to nurses in their spiritual caring practice. As such they are also applicable to nursing across clinical environments beyond palliative care. The interactive nature of the four major concepts with the three sub-theme categories of spiritual caring interventions are depicted in figure 6.


Discussion In this study, categories and concepts of spiritual caring interventions were identified. The three subtheme categories are: religious, humanistic and pragmatic interventions. A non-participant subtheme, disengagement, was also identified. Humanistic interventions were secular in intent and had a more existential basis. Interventions with a religious theme had a sole focus on aspects of religion or religious practices. Pragmatic interventions were neither solely religious nor humanistic. They were cognizant of personal experiences and focused on the delivery of spiritual services to the patient as requested or needed. The disengagement sub-theme included statements by some nurses that indicated they were not involved in spiritual caring. Non-participation in spiritual caring was either directly or indirectly expressed. Reasons for low level or non-involvement was not able to be determined in this study. It is recognised that the majority of palliative care nurses in this study were most experienced in nursing and also in their specialty. The other notable difference was they were much older than less experienced acute care nurses whose spiritual caring was previously studied (Ronaldson et al, 2012). These three differences are most relevant to the main findings, namely, the identification by experienced palliative care nurses of their spiritual caring interventions. The experience that nurses bring to their spiritual care has been noted to be a substantial influence


Sun-theme categories

Pragmatic Engaging in

Figure 6. Relationship of major concepts and sub-theme categories of spiritual caring interventions (Ronaldson et al, 2012). The degree of experiences and exposure to others who are experts in spiritual caring also enhances nurses’ spiritual caring practice (Giske and Cone 2012). Another consideration is that older, more experienced nurses are more likely to have a heightened sense of their own spirituality and this definitely enhances nurses’ spiritual caring (Belcher and Griffiths, 2005). Being older, they may be involved in their own life review which will impact on their spiritual care. In addition, being older, they also bring more life experience to their spiritual caring. Therefore, the older, more experienced palliative care nurses are an excellent example of spiritual carers. There was a difference in distribution of responses between less experienced RNs and those holding more senior positions in a clinical or management specialty (NUM, CNC, CNS and CNE). Equal numbers of less experienced RNs identified interventions belonging to each of the three sub-theme categories. While only two senior nurses (4.8%) identified interventions in the religious sub-theme, a greater number identified those that belonged to the humanistic and pragmatic sub-themes of spiritual caring interventions (19% and 31% respectively). Therefore, with more experience in palliative care the nurses in more senior roles have developed their practice of spiritual caring beyond the confines of a long held view of spirituality and spiritual caring as being closely aligned to religion. Approximately half (46%) of the nurses held a senior speciality position (CNS 14.3%; CNC 16.6%; NUM 9.5%; CNE 2.4%). Of these, the majority had greater than 15 years’ experience. Of note however, statements made by a small


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number of nurses that were allocated to the disengagement sub-theme may reflect their limited level of spiritual care knowledge and experience. All were RNs who did not hold a senior position. In addition, they had worked less than 2 years in both their current position and in palliative care. Therefore, their disengagement response was considered to reflect the limited experience for this relatively small group. Balboni et al (2014), found that some nurses do not participate in spiritual caring for a range of reasons including lack of education and of opportunity. This study found 17% of nurses did not identify any spiritual caring interventions in their practice while Sellers and Haag (1998) found 14% of nurses also did not. That is, in 20 years there has been no notable change. It was considered important to include these disengagement findings for comparison to the other sub-themes identified in this group of palliative care nurses. Research that described specific spiritual caring interventions e.g. presence, listening and referral, support this study’s findings of humanistic and religious intervention categories. The most common spiritual caring interventions of oncology, parish and hospice nurses were communication and religious supports including referral to clergy (Sellers and Haag, 1998). A range of interventions including active listening, prayers and presence were also identified. Other common spiritual caring interventions identified have included prayer, scripture, presence, listening and referral (Emblem and Halstead, 1993). Nurses validated their dying patients’ thoughts and feelings and instilled hope. While these were nurses from a mixed group of specialties, including hospice nurses, their age and nursing experience were similar to this study. Of note, approximately half (57%) of the group were parish nurses, presumably with a significant religious alignment and/or background, which may have impacted their research participation. Parish nursing is community focus inclusive of a faithbase and professional nursing practice (Solari-Twadell and Hackbarth, 2010). This current research is designed to be representative of the breadth of palliative care services. The health facilities in this study were inclusive of secular and religious palliative care services so that it was not likely to be influenced markedly by any one specific religious or other belief philosophy. Involvement of nurses from religious palliative care services in spiritual caring research is a significant consideration as many religious facilities have a well-founded philosophy of care based on the principles of their religious tradition. In turn, this religious foundation may

have an effect, either direct or indirect, on the nurses’ care, in particular spiritual care. When involving such nurses in research studies in this area, it is proposed that they are more likely to include interventions that have a religious focus and are not in disharmony with their employing facility’s philosophy of care. These nurses may be attracted to work in such a facility because of their own religious beliefs or their attraction to working in such a facility is possibly from previous experiences. Either way, the environment of a religious health facility will have an influence to some degree on their clinical practice. These findings provide a conceptual framework for understanding palliative care registered nurses’ spiritual caring (figures 1–6). Palliative care nursing education programs at all levels would benefit from the inclusion of this conceptual framework. The three intervention categories, humanistic, pragmatic and religious, provide a construct for interpretation of specific actions of spiritual care. Being conceptual, the four major themes of ‘being with’, ‘listening to’, ‘facilitation of’ and ‘engaging in’, are applicable to a breadth of clinical nursing practices.

Limitations of the study While the recruitment of nurses was from seven health care facilities across a large health care region in a major city in Australia the total number of responses to the research question by the palliative care nurses was relatively limited. However, some of these responses were rich in depth and detail. This limitation would have been overcome by recruitment of a larger number of nurses into the study. The study involved nurses at the clinical level and so there was liaison with each NUM in an endeavour to recruit a maximum number of clinical palliative care nurses through that avenue. While this approach had a number of benefits to the study it also had its own limitations as it extended the period of participant recruitment. However, it was the researchers’ preferred method of recruitment to involve each health care service through a direct personal invitation as it was seen as the optimal avenue for this research topic and one which would involve more experienced palliative care nurses. It is acknowledged that self-selection may have a bias toward nurses more motivated and hence more aware of the topic under study. The main limitation of the study is that it was self-reporting with no method of validating responses. This could be overcome in future by dialogue between researcher and participants however that option was not available for data collection in this study.


❛A conceptual understanding of spiritual caring needs to be incorporated into nursing education programs addressing spiritual caring.❜



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Conclusion and Recommendations This study has identified categories and major concepts of palliative care nurses’ spiritual caring interventions. These concepts are: ‘being with’, ‘listening to’, ‘facilitation of’ and ‘engaging in’. ‘being with’ and ‘listening to’ belong to a humanistic category, ‘facilitation of’ belongs to both religious and pragmatic categories, while ‘engaging in’ is related to a pragmatic category. The importance of nurses’ ‘presence’ in palliative care nursing, that is, both their physical and deep caring self, has also been highlighted. It is recommended that the study’s findings be considered for incorporation into nursing education programs addressing spiritual caring. It is also recommended that a future study be designed to include the collection of both dialogue and self-report data to increase rigour and validate this study’s findings. Semi-structured interviews may help to explore these findings further.

Implications for Nursing Practice Spiritual caring has been recognised as an integral component of holistic nursing. The findings here may aid in the education of both student and graduate nurses in their development of spiritual caring knowledge and skills. The findings may be also be relevant and beneficial for nursing practice in a variety of clinical environments. This would represent an important transfer of knowledge given the need for inclusion of spiritual caring in JPN modern models and practices of health care.I● Declaration of interests: The authors have no conflict of interest to declare Acknowledgements: We thank the palliative care registered nurses who contributed to this research and the health care facilities for their support.


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Continuing professional development: reflective questions ●●Which spiritual caring categories do your interventions belong to? ●●What spiritual caring concepts do you most frequently use? ●●Consider observing experienced palliative care nurses’ spiritual caring if you need some guidance.

