Spirituality and spiritual care – missing concepts from core undergraduate children’s
nursing text-books
INTRODUCTION
Today’s nursing world with fast paced medically driven care, shorter hospital stays, staff
shortages and poor privacy means that acute care is a priority in children’s hospital care
(Tanyi 2002; Cavendish, Luise, Russo, Mitzeliotis, Bauer, McPartlan Bajo, Calvino, Horne and
MeDefindt, 2004; Smith and McSherry 2004; Mueller 2010). Children’s nurses are skilled in
acute care and proficient at meeting the physical, psychological, emotional and social needs
of the families they care for. However where acute care is the priority it is difficult to
address issues relating to holistic care, in particular spirituality (Smith and McSherry 2004).
A holistic approach to care represents an approach different to a biomedical approach. A
holistic approach recognises the complexity of the individual and acknowledges that many
people draw on a range of beliefs including ethnic, cultural, religious and spiritual (McSherry
and Smith 2007). Meeting a child’s and parents spiritual needs should be an integral part of
a child’s and family care (Cavendish et al. 2004; Feudtner, Haney and Dimmers, 2007).
Adopting a nursing model that recognises the importance of meeting the spiritual needs of
the child is the beginning of developing a holistic approach to care (McSherry and Smith
2007) and key to this is to assess the child’s and family’s spirituality, beliefs and faith
(Neuman 2011). However, the literature would suggest that there are some gaps in practice
in meeting the spiritual needs of children and their families.
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BACKGROUND AND LITERATURE REVIEW
The spiritual needs of children and their families.
When a child is sick or hospitalised their family often find themselves in very emotional and
challenging situations. Parents are often left feeling insecure and vulnerable in these
situations (Espezel and Canam 2003). Involvement in their child’s care can be very stressful
for parents particularly when their children are required to undergo unpleasant procedures
(Ygge, Lindholm and Arnetz 2006). Family centered care is the gold-standard in children’s
health care settings where the wide range and variation in child and family needs are
acknowledged. Meeting the spiritual needs of children and their families is an important
element of family-centered care.
Children, spirituality and faith development
Despite the perceived complexity in addressing the spiritual needs of children McSherry and
Smith (2007) highlight the importance of addressing this truly holistic part of their care.
Children and their families draw on previous experiences of life including religious and
spiritual beliefs to guide children in developing spirituality and in order to make sense of life
events and to cope with crises (Elkins and Cavendish 2004; McSherry and Smith 2004).
Depending on their stage of development and previous experiences children will also have a
range of preconceived ideas, fears and concerns. Therefore, the spiritual needs of children
should be incorporated into all family centred nursing care, beginning with assessment, so
that normal home routines are maintained and the family’s beliefs respected (McSherry and
Smith 2004). It is therefore necessary for the children’s nurse to understand the stage of
children’s development and how this will affect their awareness and spiritual needs.
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Nurses' attention to spiritual needs may help both the child and parents cope during times
of strain and/or crisis (O’Shea, Wallace, Quinn Griffin and Fitzpatrick, 2011).
Table one gives examples of how McSherry & Smith (2004) illustrate examples of children’s
expressions of inner thoughts and how this might affect their spiritual needs. In the
literature on children’s spirituality; spirituality, morality, religion and faith are linked. There
has been important research into child development including faith development in children
by Erik Eriksonn (1950), Laurence Kohlberg, and Jean Piaget (1959). Neuman (2011) outlines
that Fowler’s (1981) stages of faith development (See Table Two ) combined with children’s
nurses knowledge of child development is one way in which children’s nurses can effectively
address child and adolescent's spiritual needs. Understanding how children express their
inner thoughts and their stages of faith development are necessary to meet the spiritual
needs of children. Listening and communicating with children at different stages of
development is also necessary if spiritual distress is to be identified (McSherry and Smith,
2004).
Table One Examples of children’s expressions of inner thoughts (McSherry & Smith,2004 )
Age
First year of
life
Late infancy
Examples of children’s expressions of inner
thoughts that may have a spiritual dimension
It is difficult to identify the infant’s spiritual
needs because of their limited ability to
communicate on a linguistic level. However,
positive experiences of love and affection, and
a stimulating environment may foster aspects
of spirituality such as hope and security in an
infant (Bradford 1995).
A three-year-old was describing what happens
3
Key developmental stage
(Erickson 1963, Piaget
1959)
A sense of trust can develop
during infancy in response
to feeling comfort and
having basic needs met. A
tentative link has been
made between the support
parents provide
an infant and an ability to
foster spiritual wellbeing
This is a time when young
and
when a person dies: ‘People who die go to
toddlerhood prison’. This little boy was an avid watcher of
the A-team, where lots of ‘bad guys’ were
blown up as a matter of routine, and
somehow end up in prison’ (Pfund 2000).
The little boy’s brother was terminally ill.
Pre-school
years
Jason, a four-year-old was in hospital:
‘Jason slept very little the night of his hospital
admission. The nurse brought in his breakfast
tray and set it on the bed-side table in front of
him. Before anyone realised what was
happening Jason pushed the tray of food
off his table and onto the floor’ (Steen and
Anderson 1995).
Junior
Jessica, a seven-year-old, told her nurse that:
school years ‘She got cancer because she hit her brother.
When the nurse explored this with her, Jessica
stated that God was mad at her for being
mean to her brother’ (Anderson and Steen
1995).
Middle
Mary, a nine-year-old demonstrated mastery
school years of knowledge: ‘I saw a neighbour, and he’d
been in an accident, and he told my dad that
he’d just as soon die later because of all the
pain he has … the funny thing – our neighbour,
he smiles, despite his troubles. He’s glad he
can see the sun come up in the morning, my
mom says. Today I saw the sun coming up, and
I was glad, and I thought, I should be double
glad, because I can see it, and I love the way
the whole sky becomes lit up, presto, and I
don’t have any pain’ (Coles 1990).
Adolescence John, a hospitalised 18-year-old, was dying of
leukemia: ‘The first day that John’s nurse
cared for him, she noticed how depressed and
hopeless he seemed. During a quiet moment
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children are fascinated with
magic and mystery and
may express themselves in
elaborate thoughts.
Children at this age may
take meanings very literally.
In this three year- old’s
example there appears to
be a link between illness
and death, with punishment
and wrongdoing.
At this age the child
experiences a challenging,
widening social world
where active, purposeful
behaviour is needed to
cope with these challenges.
There may be link between
Jason’s spiritual distress,
fears and anxiety, which are
being exhibited through
disruptive behaviour.
At this age the child
develops a sense of
responsibility. Jessica may
be associating her illness
with being irresponsible and
the consequence is illness.
At this age the child
develops initiative, bringing
them into contact with a
wealth of new experiences.
This natural need for
knowledge can be fostered
and developed. Mary
appears
to be able to reflect on this
knowledge and applies it to
herself when considering
her neighbour. In many
ways this is powerful
representation of selfawareness.
Adolescents are faced with
many new roles – romantic,
vocational – which they
need to explore in a healthy
one afternoon, she asked John if he would like
her to rub his back. John readily accepted and
stated that she was the first person who had
touched him since he had been in the hospital.
John had been on the unit for one month and
felt totally isolated from people. Through
touch, the nurse reached out and comforted
John’ (Anderson and Steen 1995).
manner and should be
neither pushed nor
restricted. John appeared to
have a need for contact
with people.
However this had nor been
recognised by the nursing
staff.
Table Two Fowlers stages of Faith Development (Fowler 1981).

Stage 0 – "Primal or Undifferentiated" faith (birth to 2 years), is characterised by an
early learning of the safety of their environment (i.e. warm, safe and secure vs. hurt,
neglect and abuse). If consistent nurture is experienced, one will develop a sense of
trust and safety about the universe and the divine. Conversely, negative experiences
will cause one to develop distrust with the universe and the divine. Transition to the
next stage begins with integration of thought and languages which facilitates the use
of symbols in speech and play.

Stage 1 – "Intuitive-Projective" faith (ages of three to seven), is characterised by the
psyche's unprotected exposure to the unconscious

Stage 2 – "Mythic-Literal" faith (mostly in school children), stage two persons have a
strong belief in the justice and reciprocity of the universe, and their deities are
almost always anthropomorphic.

Stage 3 – "Synthetic-Conventional" faith (arising in adolescence; aged 12 to
adulthood) characterised by conformity to religious authority and the development
of a personal identity. Any conflicts with one's beliefs are ignored at this stage due to
the fear of threat from inconsistencies.

Stage 4 – "Individuative-Reflective" faith (usually mid-twenties to late thirties) a
stage of angst and struggle. The individual takes personal responsibility for his or her
beliefs and feelings. As one is able to reflect on one's own beliefs, there is an
openness to a new complexity of faith, but this also increases the awareness of
conflicts in one's belief.

Stage 5 – "Conjunctive" faith (mid-life crisis) acknowledges paradox and
transcendence relating reality behind the symbols of inherited systems. The
individual resolves conflicts from previous stages by a complex understanding of a
multidimensional, interdependent "truth" that cannot be explained by any particular
statement.
5

Stage 6 – "Universalising" faith, or what some might call "enlightment". The
individual would treat any person with compassion as he or she views people as
from a universal community, and should be treated with universal principles of love
and justice.
Children’s nurses’ spirituality knowledge and education
Children have spiritual needs in illness just as they have biological, psychological and social
needs (Pendelton et al. 2002). Children’s nurses need to know how a child’s spirituality may
affect their overall health state and well-being, and what its impact may have on healing
and coping (Pendelton et al. 2002). It is incumbent on children’s nurses to asses a child's or
an adolescent's religious and spiritual beliefs and to know how to intervene if necessary
(Neuman, 2011). Yet, it has been established that nurses are not comfortable discussing
spirituality with children and their families (Elkins and Cavendish 2004; McEwen 2004;
Kenny and Ashley 2005; Hufton 2006). This may stem from inadequate education on the
subject and a lack of time discussing spirituality in an environment away from the acute
clinical area in order to become more comfortable with the area.
Most nurses believe spiritual care is an integral component of quality, holistic nursing care.
Yet it has been reported in the literature nurses feel unprepared to meet their patients
spiritual needs. This is somewhat contradictory as there is a universal acceptance in the
literature of the need to prepare nurses to provide spiritual care (McSherry 2000a;
Narayanasamy 1999; McEwen 2004). Adequate spiritual education can remove barriers so
that spiritual needs of children and families can be better addressed (O’Shea et al. 2011).
However there has been some criticism of the preparation student nurses receive in order
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to provide spiritual care and it has been suggested that nursing education does not provide
adequate preparation for performing spiritual care interventions (Smith and McSherry 2004;
Feudtner et al. 2003).
Nursing education should prepare students to recognise and act on spiritual cues (Cone and
Giske, 2013) and assess the child and family from a spiritual perspective. A child’s family
provides the child’s earliest culture and religious practices. These traditions and beliefs can
positively or negatively shape the way a child understands health, illness and death
(Neuman 2011). A starting point for addressing the spiritual needs of hospitalised children
would be to understand the child’s home environment and family profile and try to
compensate for the change in environment on an individual basis where possible (Bull and
Gillies 2007). Nurses’ attention to spiritual needs may help both the child and parents cope
during times of strain and/ or crisis (O’Shea, Wallace ,Quinn, Griffin and Fitzpatrick, 2011)
and not addressing these may deprive the child and family of a source of comfort.
Education can also assist nurses in deciding what children and family need through
assessment because as indicated by Neuman (2011) not every patient will need or should
have a detailed spiritual history done. However, understanding the way the child may
express spiritual awareness and the importance the child and family places on this may give
the nurse the ability to recognise and therefore react to a child in distress (McSherry and
Smith 2007) and provide assistance. This can only be achieved through education. It is
unclear however just how well the concepts of spiritual development, care, and assessment
are addressed in the core children’s nursing textbooks.
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There has been some previous research on the content related to spirituality in nursing
texts. McEwen (2004) examined 50 books from the Brandon Hill List (The Brandon–Hill list is
a list of journals and books recommended for a small hospital library). McEwen (2004) found
that chapters tended to contain reference to religions and cultures, health assessment and
health promotion, palliative care, and managing patients’ psychosocial needs and only
tended to contain references to spirituality. However rarely, some texts did devote an entire
chapter to spirituality. Cusveller (1998) looked at spiritual content in Dutch introductory
nursing textbooks. Cusveller (1998) reported that most Dutch introductory nursing
textbooks presented only vague, general references to spirituality and that the information
was confusing due to many different concepts and a lack of precise meanings in the
textbooks. Pesut (2008) also investigated the presence of spirituality and spiritual care
content in nursing fundamentals textbooks. The findings from that study suggested that
although the body of literature provided comprehensive content about spirituality and
spiritual care, there were some underlying conceptual problems in the textbooks. However
none differentiated between adult and children’s nursing textbooks. Therefore, specifically
looking at children’s nursing textbooks can add to an already of existing body of knowledge.
This paper is part of a large study that did an exploration of the extent of inclusion of
spirituality and spiritual care concepts in core nursing textbooks (Timmins et al. 2014). This
paper relates to the extent of inclusion of spirituality and spiritual care concepts in core
children’s nursing textbooks
STUDY
This study was conducted to examine the content related to spirituality in children’s nursing
textbooks in order to determine where spiritual care is addressed and evaluate how well it
8
is addressed in children’s nursing textbooks. Textbooks were identified using The Core
Collection Titles (Tomlinsons 2010) which acts as a reliable acquisitions guide for health
libraries in the UK and Ireland. The most recent edition of the Core Collection for Nursing
was published in July 2010 and contained reference to 580 nursing books.
METHODS
The aim of the study was:

To explore whether spirituality, spiritual care or core elements of spirituality are or
are not defined in core nursing textbooks in children’s nursing.
The objectives of the study were as follows:
•
To statistically examine and present whether or not core undergraduate nursing
textbooks include spirituality or spiritual care content using a specifically designed
tool.
•
To examine whether or not core nursing textbooks define spirituality or spiritual care
or the core elements of spirituality.
•
To examine the extent to which core nursing textbooks advocate spiritual
assessment by nurses.
Research Instrument
A 23 item survey was devised by the research team that comprised five University Staff
including one nursing subject librarian during a series of team meetings. The Spirituality
9
Textbook Analysis Tool (STAT) was specifically designed as the data collection tool for this
study. It aimed to capture information about the inclusion of spirituality, definitions, use of
assessment and overall approach to spirituality in nursing texts (See Table Three for
example of part of the STAT with the specific search terms that were included in the study).
Content validity was assessed using criteria recommended by Polit and Tatano Beck (2012).
Content validity of the STAT was established by presenting the tool to a panel of eight
experts internationally in the field, who were asked to rate the relevance of each question
and sub question (n=58). Responses were collected using surveymonkey©. Calculations of
mean scores revealed an overall content validity average index (S-CVI /Ave) of 0.90. A score
of 0.90 or above is required for the tool to be at an acceptable validity level (Polit and
Tatano Beck 2012).
The initial S-CVI (Scale Content Validity Index) score S-CVI was 0.63.
This reflects universal agreement; and needs to be above .80 (Polit and Tatano Beck 2012).
Test retest was performed using Spearman and there are no significant differences between
the test and retest.
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Table Three Search Terms in the STAT
Indicate the frequency with which the following related search terms are included in the index: (circle relevant
answers):
1.
Spirituality
1.
Once
2.
Spirit
1.
3.
Religion
4.
2.
2-4 occasions
3.
Once
2.
3.
1.
Once
2.
Transcendence
1.
Once
2.
5.
God
1.
Once
2.
6.
Sacred
1.
Once
2.
7.
Meaning
1.
Once
2.
8.
Religious belief/s
1.
Once
2.
2-4
occasions
2-4
occasions
2-4
occasions
2-4
occasions
2-4
occasions
2-4
occasions
2-4
occasions
3.
3.
3.
3.
3.
3.
5-10
occasions
5-10
occasions
5-10
occasions
5-10
occasions
5-10
occasions
5-10
occasions
5-10
occasions
5-10
occasions
4.
4.
4.
4.
4.
4.
4.
4.
More than
occasions
More than
occasions
More than
occasions
More than
occasions
More than
occasions
More than
occasions
More than
occasions
More than
occasions
10
5.
None
10
5.
None
10
5.
None
10
5.
None
10
5.
None
10
5.
None
10
5.
None
10
5.
None
Data Collection and sample
The research team collected the data at one University Library site, which is a copyright
library for Ireland and the UK. Using the STAT tool, the index of each book was checked for
keywords - spirituality; spirit; religion; transcendence; god; sacred; meaning and religious
belief/s. Those that made no mention of any of these terms were not included in the final
analysis. Five books were excluded as the team were unable to collect data (as they had no
index) and the remainder of the books were duplicated in the core collection or unavailable.
Data analysis methods
The Spirituality Textbook Analysis Tool (STAT) was specifically designed as the data
collection tool for this study. The Quantitative data from the STAT were analysed using the
Statistical Package for Social Scientists (SPSS). SPSS was employed to do simple descriptive
statistics and frequency counts.
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Ethical Issues
Ethical approval was not sought for this project as the information is in the public domain.
Therefore consent and confidentiality are also not applicable.
FINDINGS
The study aimed to explore whether spirituality, spiritual care or core elements of
spirituality are or are not defined in core nursing textbooks in children’s nursing. A sample
of five hundred and forty three books (543) was accessed from the Nursing and Midwifery
Core Collection list (Tomlinsons 2010) representing 94% of the total collection (n=580). 130
books had 1 or more of the terms present with 413 (76%) books making no reference to
spirituality or related terms. 14 of the books were in the category ‘Child Care’ in the
collection. Of the 14 books in this category 6 contained none of the inclusion terms in the
STAT. Eight of the books had one or more of the related terms. Five other books outside of
the children’s category were deemed as relevant to children’s nursing which brings the total
number of books to 13 books included. Of the 5 that were in other categories, 3 related to
death and bereavement and palliative care, 1 was on community nursing and 1 on
complimentary therapies. Table Four outlines the books included from Children’s category
that contained reference to one or more search terms in the index. Table five includes the
books include in the STAT that were from outside the children’s category but were deemed
to be relevant to children’s nursing practice. Of the 13 books that contained reference to
one or more search terms in the index when the content was examined 7 books had less
than 1 page devoted to spirituality. One book had a full chapter dedicated to spirituality, a
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complimentary therapy book called “Developing Holistic Care for Long Term Conditions”
Wong's Clinical Manual of Pediatric Nursing 7th Edition contained some information on
spiritual development and a brief explanation on the BELIEF Model. In addition, a textbook
on ‘Practices on Children’s Nursing’ related to clinical practice contained a significant
amount of information on religion in a chapter in the book ‘Bereavement Care’.
A further aim of this study was to examine whether or not core nursing textbooks define
spirituality or spiritual care or the core elements of spirituality. There were a variety of
textbooks in the audit such as books on practices in children’s nursing, professional issues,
medical-surgical nursing, maternal-child health nursing, critical care nursing, palliative care
nursing and community health nursing. Of those that made reference to the search terms in
the STAT such as spirituality, religion, transcendence, god, sacred, meaning and religious
beliefs, it was found that content mainly addressed two areas. The first was an introduction
to religions and the different practices from religious faiths that would impact on nursing
care. The second area addressed was in the spiritual care of the child that was dying. Within
that, areas mentioned included; care of the child, parents and siblings and also the religious
practices around death for different religious faiths. Religion and religious beliefs are
included to an extent in 12 books with the majority of books presenting information related
to Christianity. Six of the 13 books provided a definition of spirituality. Of those that
provided a definition of spirituality, 5 indicated that it is a system of religious and nonreligious beliefs.
While none of the books made any reference to meaning in the index,
those that provided a definition of spirituality included reference to ‘that which gives life
meaning in their definition of spirituality’.
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The final aim of the study was to examine the extent to which core nursing textbooks
advocate spiritual assessment by nurses. Only five of the books recommended doing a
spiritual assessment. Of these 2 recommend the use of a spiritual assessment tool. Other
recommendations were asking open ended questions and referral to pastor/ chaplain. Two
books indicated that nurses have the overall responsibility for spiritual care with 3
recommending it is the role of the pastor/ chaplain with another stating it is the role of a
social worker. The final question of the questionnaire asks the question “In your view does
the book consider the provision of spiritual care as an adjunct of nursing care” of this the
researchers indicated yes (n=13) for all cases. While there was some evidence of the need
for the nurse to provide spiritual care this was not consistent across the core textbooks
in children’s nursing.
Overall the findings of this study indicated poor inclusion of
spirituality concepts within core undergraduate nursing textbooks relevant to children.
Table Four Books included in the STAT from the Children’s Category
Books included from Children’s category that contained reference to one or more search terms in the index
Wong's Clinical Manual of Pediatric Nursing 7th Edition
Oxford Handbook of Children's and Young Peoples Nursing
Practices in Children's Nursing
Good Practice in Childcare
Developing Person Through Childhood
Child Development
Wong's Nursing Care of Infants and Children
Maternal and Child Health Nursing, Care of the Childbearing and Childrearing Family
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Table Five Books that included information on Children’s Spirituality but were not in the
Children’s category in the core collection.
Books that included information on Children’s Spirituality but are not in the Children’s category in the core
collection.
Name of Book
On the Death of a Child
Palliative Care Nursing of Children and Young People
Helping the Patient with Advanced Disease, A Workbook
Foundations of Nursing in the Community
Developing Holistic Care for Long Term Conditions
Category in Core Collection
Death and Bereavement
Palliative Care
Palliative Care
Community Nursing
Complimentary Therapies
Table Six Books excluded from Children’s Category that contained no reference to search
terms in the index
Books excluded from Children’s Category that contained no reference to search terms in the index
Paediatric Advanced Life Support
Cancer in Children and Young People
Caring for Children with Complex Needs in the Community
Introduction to Child Development
Paediatrics, A Clinical Guide for Nurse Practitioners
Managing Pain in Children
Nursing the Highly Dependent Child or Infant
Perioperative Care of the Child
Surgical Nursing of Children
Counselling Children
Child and Family Centred Healthcare
DISCUSSION
Spirituality in children’s nursing has received growing attention (Kenny and Ashley 2005)
and does not have same quantity of literature published as adult nursing. O’Shea et al.
(2011) identified that information on children’s spirituality is scant in particular around
nursing education. Lack of preparation to provide spiritual care in nursing education may
15
not be helped by spiritual care, spirituality and related concepts not being adequately
addressed in core nursing text books. This study confirms there is a specific dearth of this
information in the core children’s nursing textbooks that were examined in this study.
Previous studies have not examined core children’s nursing textbooks in such depth. While
the sample of children’s nursing texts included in this study was small it is disappointing to
note the number and type of textbooks that had to be excluded from the audit as they
contained none of the search terms in the STAT. The lack of attention to spirituality in the
core undergraduate nursing books may be a factor in the difficulty with spirituality in
practice as noted in the literature.
The importance of addressing the spiritual needs of children and their families is well
addressed in the literature (McSherry and Smith 2007). It is therefore imperative that
children’s nurses are taught and have the appropriate knowledge to assess and care for
children’s spiritual needs. However, it may prove difficult for students to assimilate these
concepts into their learning if frequently used textbooks rarely refer to them.
It is disappointing to report that an entire textbooks (SEE TABLE SIX) on ‘Caring for Children
with Complex Needs in the Community’ and ‘Child and Family Centred Healthcare’ did not
address the spiritual needs of children and their families. Wong's Clinical Manual of
Pediatric Nursing 7th Edition, Nursing, Care of the Childbearing and Childrearing Family that
are published in the USA addressed both spiritual and religious needs of children and their
families well compared to texts from other countries in particular the UK. In fact, books
published in the USA made significantly more reference to religion and different practices
around religion and death related to religion.
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It is not surprising as a number of authors have identified that religion is very important to
the American culture (King and Bushwick 1994; Bishop 1999; Pendelton, Cavalli and
Pargament, 2002). In fact Pargament (1997) reported that 75% of Americans state that faith
is the most important part of their lives. Spirituality is frequently linked with religion
(Cavendish et al. 2004; Elkins and Cavendish 2004) and although religious needs may
overlap with spirituality, addressing only religion may not encompass the child’s full spiritual
needs. Practitioners need to be cautious about only identifying religious practice as
completing a full spiritual assessment for the child (O’Shea et al. 2011) which may prove
inadequate. Reasons for inadequate spiritual care have been identified in the literature to
include lack of formal education related to spiritual care, discomfort in assessing spiritual
care, confusion between the terms religiosity and spirituality (O’Shea et al. 2011) and a lack
of information about a child’s spirituality.
Nursing care has always been considered spiritual and patients still continue to believe that
nurses are providers of spiritual care (Cavendish et al. 2004). However, the textbooks are
also inconclusive when documenting who has overall responsibility for spiritual care with
nurse, pastor/ chaplain or social worker mentioned. In a more secular society nurses may be
more comfortable to refer a family requiring religious needs to a chaplin or clergy (Mueller
2010) but it also may be a reflection that they are not comfortable to deal with spiritual or
religious needs or indeed a belief that spiritual care is not seen as a priority. Having poor
reference to spiritual care in the core nursing text books may substantiate this belief. The
fact that the book that includes the most reference to spirituality is not in the children’s
17
category also can mean that published information on children to include in reading lists
may be difficult to find.
The absence of specific reference to spiritual care in a number of important core children’s
nursing textbooks may inadvertently undervalue this important facet of nursing care to
nursing students and may even suggest that emphasis is not required in this area of nursing
practice. Holistic nursing care is advocated and is espoused as best practice in the
philosophy of family centered care in children’s nursing. The delivery of holistic nursing care
should encompass meeting the spiritual needs of children and their families and without
adequate education this dimension of care cannot be adequately met (O’Shea et al. 2011).
Children’s nurses require education about children’s spiritual developmental stage and age
appropriate spiritual assessment. In this study spiritual assessment is dealt with very poorly
with no reference to any assessment tools in the books.
Children’s nurses structure their practice daily practice around the core concepts of Family
Centered Care which is espoused as the gold standard in the care of children and their
families. The philosophy of the nursing programme and curriculum where the authors work
is guided by the importance of the learning and integration of theory for nursing practice.
The curriculum endeavours to facilitate the development of knowledge, skills, attitudes and
professional values necessary for safe, competent and caring professional nursing practice.
It would appear however; that a lack of content in core nursing textbooks may devalue this
as Kenny and Ashley (2005) indicate that in order to teach spirituality, children’s nurse
educators have to rely largely on adult based literature to guide their teaching and
curriculum.
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Conclusion
To improve spiritual care for children and families nurses must be comfortable and
knowledgeable about what it entails (O’Shea et al. 2011) and how to implement it. A lack of
information in core nursing textbooks means that this area of nursing practice may be
taught as an adjunct to care and not as an element of holistic care which is the gold
standard that children’s nurses should strive for. Children’s nurses need to know how a
child’s spirituality may affect their overall health state and well-being, and what its impact
may have on healing and coping (Pendelton et al 2002). As the healthcare system becomes
increasingly complex there is a professional requirement for nurses to increase their
competence and delivery of spiritual care. It is important that nurses develop a plan of care
that addresses a child’s spirituality, religion and culture taking into account the child’s stage
of development and the family’s needs as well as the physical care that is required by sick
children (Elkins and Cavendish 2004). Spiritual care in children’s nursing could potentially be
improved if core children’s nursing textbooks were more comprehensive in incorporating
this essential component of care.
Recommendations

Clear guidance is required from the children’s nursing profession and core
children’s textbooks to support and underpin effective and appropriate spiritual
care in children’s nursing practice.

To provide truly holistic nursing care to children and their families children’s nurses
must include the fundamentals of spiritual assessment and care and to meet their
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ethical responsibility of spiritual support to families. Authors of texts in children’s
nursing must include this type of information in their text books.

Textbooks in children’s nursing need to be more fully aligned with agreed
conceptualisations of spirituality and unified approaches to spiritual care.
20
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