1. Ferrell, Betty PhD, FAAN, FPCN

Article Content


Palliative care nurses are centrally involved in continuous quality improvement (QI) efforts to improve the care provided to patients and families. Nurses are often leaders in their teams' QI activities because nurses are the professionals who spend the most time at the bedside delivering care and having intimate conversations with patients and families about all aspects of quality of life. Hospice and palliative care settings have used QI approaches to address common concerns such as how to eliminate medication errors, improve pain and symptom management, improve bereavement services, foster transitions across settings, implement bowel protocols, use comfort kits to treat urgent symptoms, and test interventions to address the complex needs of patients experiencing serious illness or facing the end of life.


The National Consensus Project for Quality Palliative Care has named spiritual care as 1 of the 8 essential domains in our national guidelines for quality palliative care that are used across all settings of palliative care.1 Yet, how often do we apply the same principles of QI to improve the quality of spiritual care provided in our settings? Has your organization carried out a QI project related to spiritual care? I rest my case.


Yet, every nurse who is committed to quality patient care-to the things that matter most to patients experiencing serious illness and their families-should be a strong advocate for improving spiritual care. How can we say we are providing "patient-centered care" or "whole-person care," the hallmarks of our field, if we are not providing truly excellent spiritual care? A definition we use is:


"Spirituality is recognized as a fundamental aspect of compassionate, patient- and family-centered palliative care. It is a dynamic and intrinsic aspect of humanity, through which individuals seek meaning, purpose, and transcendence and experience relationship to self, family, others, community, society, and the significant or sacred. Spirituality is expressed through beliefs, values, traditions, and practices."2


This definition of spirituality reminds us of the broad domain of spiritual care and the need to address religious as well as nonreligious aspects of spirituality. William Rosa,3 in the fifth edition of the Oxford Textbook of Palliative Nursing, in a chapter entitled "Spiritual Care Intervention," explains spirituality as "[horizontal ellipsis]one of the primary unifying forces of the human experience. It inextricably links us as human beings of the global village across cultures, continents, faith traditions, genders, socioeconomic differences, and the continuum of wellness-illness."3 And yet, how skilled are all palliative care team members in assessing spiritual needs, identifying spiritual distress, having conversations with patients about their spiritual longing, or need for forgiveness? How often is our response to spiritual distress an urgent "let us call the chaplain" instead of a commitment by the entire team to address the spiritual needs of patients and families? Chaplains are the spiritual care specialists, but we are all needed as spiritual care generalists.


This past year has brought significant and long overdue attention to racial disparities in health care, including end-of-life care. These disparities are also reflected in spiritual care. Are we as comfortable in caring for the patient whose religious and spiritual beliefs are different from our own, as we are for those who look like us and worship in the familiar ways that we understand or practice ourselves? As nurses who care for patients from diverse spiritual and religious backgrounds, we must be flexible and open to a variation of religious experiences and expressions to properly assess our patients' spiritual needs, which will then guide appropriate spiritual care.4 How often are ethical dilemmas really a reflection of our own failure to understand the deeply held cultural and religious beliefs that influence patients' and families' decisions about life and death?


We have published several articles on the topic of spirituality in the Journal of Hospice & Palliative Nursing in recent years.5-7 Virtually every article has reported a serious lack of knowledge, skill, and perceived confidence by nurses-yes, even palliative care nurses-in providing spiritual care. In my own research conducted over several years, we have asked nurses attending our End-of-Life Nursing Education Consortium Palliative Care training courses to rate which topics they find most difficult to discuss with patients. In every survey, which included topics such as advance directives, life support, and even sexuality (!), nurses consistently rated spirituality as the topic they were least comfortable discussing with patients. Consider this: If our knowledge and confidence in managing pain were found to be deficient, would not we respond with some sense of urgency that we need to do better?


The HealthCare Chaplaincy Network has created a document entitled "What is Quality Spiritual Care in Health Care and How Do You Measure It?" ( This document, developed by an interdisciplinary panel, provides guidance on quality indicators for improved spiritual care and includes metrics and measurement tools, so that organizations can truly measure the quality of care they provide. Think of it as a tool kit to do the work of improving spiritual care.


Thus, here is my challenge to you, my colleagues in palliative nursing: I challenge you to commit to improve the quality of spiritual care in your organization. Look at the spiritual care domain in the National Consensus Project guidelines for our field ( and hold it up as a mirror for your clinical setting. How does your care compare? Access the HealthCare Chaplaincy Network document cited above and use it as a roadmap to launch a spiritual care QI project in your agency. And perhaps we should begin with getting our own house in order by training our nursing staff in spiritual care. Ask yourself and your colleagues:


Do your staff receive initial and ongoing training in spiritual care encompassing diverse faith traditions?


Has your organization carried out a QI activity related to spiritual care?


Is spirituality regularly measured and reported in your organization's overall QI program?


Are procedures in place to access spiritual care for patients and families from diverse cultures and traditions?


How are spiritual needs assessed for those who are nonreligious, do not belong to a faith tradition, or are agnostic or atheist? Does a response of "no religion" to the usual admission assessment end conversations about spirituality? Such responses are invitations for us to explore further with patients what gives their life joy, meaning, and purpose.


How is spirituality addressed for the staff? How do we provide spiritual care for our colleagues?


Palliative care nurses have been outspoken advocates and leaders in improving critical aspects of care. What could palliative care nurses do to spark a true national effort to improve spiritual care? What if hospices and palliative care settings nationwide launched serious efforts that would help us practice the original vision of whole-person care envisioned by the founders of our palliative care field?


I am eager to hear from you. Please share with me (mailto:[email protected]) your own stories of what you have done or are doing to improve spiritual care? What models exist that could be shared with others? I am confident that we can raise the bar if nurses nationwide work collaboratively with chaplains and all members of the palliative care team to launch QI efforts in spiritual care.


What is quality care? I have always said that it is the kind of care that we would want if we or those we love were facing serious illness or death. That is the highest bar we can set. I would want excellent spiritual care.


Betty Ferrell, PhD, FAAN, FPCN


JHPN Editor-in-Chief




1. National Consensus Project for Quality Palliative Care. Clinical Practice Guidelines for Quality Palliative Care. 4th ed. 2018. [Context Link]


2. Ferrell BR, Twaddle ML, Melnick A, Meier DE. National Consensus Project clinical practice guidelines for quality palliative care guidelines, 4th edition. J Palliat Med. 2018;21(12):1684-1689. Special report. [Context Link]


3. Rosa W. Spiritual care intervention. In: Ferrell BR, Paice JA, eds. Oxford Textbook of Palliative Nursing. 5th ed. New York, NY: Oxford University Press; 2019:447-455. [Context Link]


4. Taylor EJ. Spiritual screening, history and assessment. In: Ferrell BR, Paice JA, eds. Oxford Textbook of Palliative Nursing. 5th ed. New York, NY: Oxford University Press; 2019:432-446. [Context Link]


5. Ricci-Allegra P. Spiritual perspective, mindfulness, and spiritual care practice of hospice and palliative nurses. J Hosp Palliat Nurs. 2018;20(2):172-179. doi:. [Context Link]


6. Lukovsky J, McGrath E, Sun C, Frankl D, Beauchesne M. A survey of hospice and palliative care nurses' and holistic nurses' perceptions of spirituality and spiritual care. J Hosp Palliat Nurs. 2021;23(1):28-37. doi:. [Context Link]


7. Petersen C, Schiltz S. Care of the spirit. J Hosp Palliat Nurs. 2020;22(4):298-304. doi:. [Context Link]


8. HealthCare Chaplaincy Network. What is quality spiritual care in health care and how do you measure it? 2021. [Context Link]