Linda Ross and Wilfred McSherry: spiritual care should be part of the Code

New NICE guidance highlights the need to address dying patients' spiritual needs. The case for including this important area of care in the Code is now overwhelming.

New NICE guidance highlights the need to address dying patients' spiritual needs. The case for including this important area of care in the Code is now overwhelming

 Spiritual needs are often overlooked in the last days of life. Picture: iStock 

We welcome the new National Institute for Health and Care Excellence (NICE) quality standard, which calls for individualised care plans that address the 'cultural, religious or social preferences' of people in the last two to three days of life and those important to them.

The standard does not include the word 'spiritual', yet it appeared in Nursing Standard's recent news coverage of the guidance ('Nurses urged to address dying patients' spiritual needs' and 'Nurses respond to guidance on addressing patients' spiritual needs') in preference to the words 'cultural, religious or social'. 'Spiritual' was also the word used by a NICE quality standard committee member and by eminent nurses who were interviewed after the new standard was released.

Does this mean that 'spiritual' is a more acceptable term for people to use than 'religious'? And if so, why wasn't it included in the quality standard?

That aside, the standard should help to ensure that spiritual needs are given the same priority as physical needs in the last days of life, something that often does not happen. A 2016 report by the Royal College of Physicians (RCP) found that only 15% of people dying in acute hospitals in England had discussions about their spiritual wishes documented. Discussions with less than a third (27%) of people important to those who were dying were documented.

Spiritual care 

The RCP has called for improvement in these figures. Encouragingly, 89% of people whose discussions were documented had their spiritual needs met, suggesting that there is huge potential for spiritual care to make a difference to people and their loved ones in the last days of life.

The quality standard applies only to the last two to three days of life. This is leaving it late to start discussing and documenting deep-seated wishes that may have been important to the person for an entire lifetime. The process should start a lot sooner, when the person has been diagnosed with a life-limiting illness.

However, we also support the quality standard because it reinforces our appeal for the NMC to provide a much stronger lead for nurses on spiritual care as an aspect of holistic care. We would like to see Standard 3 of the NMC code – 'make sure that people's physical, social and psychosocial needs are assessed and responded to' – expanded to include spiritual needs.

International healthcare policy, including the World Health Organization definition of palliative care, acknowledges the importance of spiritual care, and there is widespread evidence of its benefits. Patients tell us that the spiritual part of their life is important to them, especially at the end of life.

Further education 

The Code is supposed to reflect what is important to patients and the public, and nurses are supposed to 'practise in line with the best available evidence'. So why is there such reluctance to include spiritual needs in the Code?

Nurses have been saying for a long time that they see spiritual care as an important and everyday part of their role, but an RCN survey published in 2011 showed that they also felt unprepared and in need of further guidance and education.

Training of nursing and medical staff in spiritual care is a key recommendation in a number of end of life care reports, including the RCP report and One Chance to Get It Right, by the Leadership Alliance for the Care of Dying People.

We are responding to this call through a three-year European-funded project called EPICC (Erasmus+ K2 Enhancing Nurses Competence in Providing Spiritual Care through Innovative Education and Compassionate Care). It is aimed at developing best practice in spiritual care education for nurses, based on evidence.

Please contact or if you would like to be involved.

About the authors





Wilfred McSherry is professor in nursing at the School of Health and Social Care, Staffordshire University and University Hospitals of North Midlands NHS Trust. He is also a part-time professor at VID University College, Bergen, Norway




Linda Ross is a reader in innovation and engagement, University of South Wales, and secretary of the British Association for the Study of Spirituality



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