34 paediatric nursing November vol 19 no 9

research

Spiritual needs of children

Rev. Alister Bull,
BD(Hons), MTh,
Dip Min is head of
chaplaincy services,
with complex healthcare
needs in hospital
Abstract
Aims: To explore the views of hospitalised school-aged children with complex healthcare needs related
to spiritual care. This could help inform national policies and raise awareness of the impact that a stay in
an acute paediatric hospital can have on the spiritual needs of some of the children who use the NHS.

Marjorie Gillies, MSc,
DipN, RGN, RSCN is
senior nurse (Patient
Services)
Yorkhill Division/
Women and Children’s
Directorate
Greater Glasgow Health
Board
Method: Pictures used in previous (US) studies were used to facilitate story telling, enabling children to
talk about concepts that may not have emerged through direct conversation. A convenience sample of
five hospitalised children were presented with the pictures one at a time and asked open-ended questions
about each picture. Data analysis involved identifying emerging themes from the transcriptions using a
grounded theory approach.
Findings: The main themes to emerge from the interview data were: the role of the child’s relationships
with family, friends and healthcare professionals; the impact of the hospital environment on the child;
coping with invasive procedures; belief – children’s views about their health and belief system.
Conclusion: There is a need for all healthcare professionals to recognise that children have spiritual
needs that can include religious beliefs, and that it is part of their duty of care to attempt to identify and
meet such needs.

Key words
● Children: hospitalised
● Culture and religion
● Spiritual care
This article has been
subject to peer review.
To find related articles go
to the archive section of
www.paediatricnursing.co.uk
S
piritual care is being reshaped and developed
in NHS Scotland, with the meaning of
spirituality used in the broad sense of personal
well-being, which can also include a religious
framework (Scottish Executive 2002). A letter issued
by the Scottish Executive distinguishes between
religious and spiritual care, stating that: ‘Religious
care is given in the context of the shared religious
beliefs, values, liturgies and lifestyle of a faith
community. Spiritual care is usually given in a one-
to-one relationship, is completely person centred and
makes no assumptions about personal conviction or
life orientation.’ (Scottish Executive 2002)
Implementation of this policy requires an
understanding of children’s spiritual care needs.
Research has suggested that the two main
components of children’s spirituality are their
relationships and their cognitive development (Hart
1997, Hay 1998). However, very little is known
about how a child’s stay in hospital can affect his or
her spirituality and not much is known about the
spiritual needs of children with complex healthcare
needs.
This article reports on a study that explored the
views of hospitalised school-aged children with
complex healthcare needs with regard to spiritual
care. The term ‘complex healthcare needs’ is used
here in an all-encompassing way and includes
treatments from several specialties considered to be
complex. The objectives of the study were to inform
NHS Scotland policies as well as raise awareness of
the impact that a stay in an acute paediatric hospital
can have on the spiritual needs of some of the
children who use the NHS.
Previous research
There were no UK studies on children’s spiritual
care identified in a literature search, but three US
studies were found (Ebmeier 1991, Wilson 1994,
Pendleton et al 2002). Ebmeier (1991) studied
28 children in a US hospital using pictures that
had been tested for specific age groups to address
specific questions on their ideas, feelings and
behaviour towards God. The findings suggested that
a child’s relationship with God could be helpful in
coping with the fears and anxieties normally present
during hospitalisation.
Wilson (1994) used the same pictorial tool in
the context of a paediatric intensive care unit. She
focused on the spiritual conceptualisations of
seven school-aged children in a southern American
culture. Categories that emerged from this grounded
theory study included the children’s feelings about
their illness, anticipating home and wellness,
paediatric nursing November vol 19 no 9
Fig. 1. The four
Pictures pictures
used used to story
to stimulate elicit telling
story telling by the with
Ebmeir et al (1991))
picture 1 picture 2
thoughts and feelings about prayer, and thoughts
about God (Wilson 1994).
Pendleton et al (2002) recruited a convenience
sample of 23 patients aged five to 12 years, and
their parents, in a cystic fibrosis clinic. They used
in-depth interviews, children’s drawings and self-
administered parental questionnaires and concluded
that children with cystic fibrosis reported a variety of
religious/spiritual coping strategies.
It is not possible to state how well the findings
of these US studies would translate into European
culture. Further, the focus of all three was on
children’s religious understanding and in particular
their views about God; the researchers did not seek
the children’s views about their spiritual needs as
they are defined by NHS Scotland.
Aim of the study
To explore the spiritual needs of school-aged
children with complex healthcare needs in hospital.
Method
The three US studies mentioned above informed
the methods used in this study. Ebmeier (1991)
used the four pictures in Figure 1 to stimulate story
telling, enabling children to talk about concepts that
may not have emerged through direct conversation.
With permission, the same pictures were used for
this study and the storytelling technique was also
employed.
The story was created to include a beginning,
middle and end, starting with admission to hospital
and ending in discharge home. Using identical
pictures to those from the Ebmeier study meant that
a previously tested model for this specific age group
was used. However, a new set of questions was
formulated to focus the discussion. A convenience
sample of hospitalised school-aged children between
the ages of eight to 11 years with complex health
care needs was recruited. The sample was intended
to include patients of all faiths or none. Although
the target was 20 children, recruitment difficulties
and time constraints meant that only five children
participated.
Permission was obtained to approach families on
the ward from the consultant and the registered
35
research
(Reproduced children in the study
permission from Myra Huth, one of the co-authors of
picture 3 picture 4
nurse. Separate information leaflets were provided
for the parent and child and 24 hours after the initial
approach, the researcher returned to seek consent
from both parent and child. Interviews based on
storytelling then took place at mutually convenient
times. Recruitment required parental insight
into the child’s belief system and understanding
about whether the child had any faith or none.
Parents were asked: ‘What is the term that is most
commonly used in your culture/community to
speak about a god or a faith figure?’ This enabled the
researcher to use the most familiar term.
Pictures were presented one at a time and with
each one there were several open-ended questions
asked, for example:
● What might the child be thinking about in this
picture?
● How does the child feel inside in this picture?
● What do you think the child will do to feel strong
in this picture?
One question, specifically reserved for the end of
the story, was ‘What do you think this child would
want to say to God about what has happened in the
story?’.
Interviews took place while the children were
still in hospital, mainly to enable children to
draw from their current experience. Interviews
were audio taped and transcribed. Data analysis
involved identifying emerging themes from the
transcriptions. Triangulation was employed: there
was independent identification of the same themes
by the researcher, the chaplain and the research
supervisor but the low recruitment rate made data
saturation impossible. The literature was used
concurrently to test and validate the findings and
the analysis was also reviewed by a multidisciplinary
research steering group which was set up to oversee
the study.
Findings
When asked what word their child used to describe
‘god’, all the parents opted for the title of their
god as ‘God’. This should not be assumed to be a
Christian reference, but merely a statement of their
cultural reference point that could be described as
a monotheistic view of god (a belief system that
36
research
holds to one god such as Christian, Muslim, Jew and
Sikh). The terms the children used did not differ
from their parents.
The main themes to emerge from the data analysis
were as follows:
● the role of the child’s relationships with family,
friends and healthcare professionals
● the impact of the hospital environment on the
child
● coping with invasive procedures
● belief – children’s views about their health and
belief system.
Relationships
Relationships with people was an important theme
to emerge from all five interviews. The presence of
a parent made a particularly positive difference: ‘I
would just like having your Mum or Dad with you
…helps.’ At each stage in the journey of the child
in the story, at least one interviewee mentioned the
presence of a parent. The fact that parents play a
strong supportive role was highlighted by one child,
whose sense of achievement was determined by what
his parents thought of him: ‘Now I don’t think my
parents are proud of me for being in here [What do
you think they are feeling about you, then?]. Angry …
[Feeling angry. Why?] ‘Cos I’m not coping with this.’
The children also referred to the value of friends,
including other patients, staff, toys, visitors or
playmates at home. One child described how she
acquired friends once she was out of physical
isolation, while another child offered advice to a
fellow patient before receiving an injection.
Another aspect of a stay in hospital is the
relationship children have with healthcare
professionals. Even prior to picture 3, which
shows the specific role of the nurse involved in an
invasive procedure, the children talked about their
relationships with the staff. In relation to picture
2, reference was made to healthcare professionals
conveying a sense of safety: ‘I suppose there’s people
there to help her and, if anything went wrong, so
she’s quite safe … and … I just think if she needed
anything she could probably just get someone – just
where she is.’
A healthcare professional was viewed by one child
as a role model; he named a favourite nurse who was
referred to as ‘my best nurse here’. Another child
added a different aspect to the role of the healthcare
professional: when asked by the researcher if
someone in the hospital could offer comfort, this
child commented, ‘Well, if you got to know the
person.’ This child also minimised the supportive
role of the healthcare professional, saying of the
intrusive treatment, ‘all they can really do is put a
plaster on it’. However, this child, along with one
other, did add a note of thanks to the staff at the end
of the story.
Hospital environment
It was evident from the children telling the story that
the hospital placed physical demands on them, even
paediatric nursing November vol 19 no 9
prior to the presentation of the picture of invasive
treatment. For example, discomfort during travel
to hospital, being thirsty, disruptive noise, being
cold at night and tiredness. Aspects of the children’s
home life were not discussed in detail but contrasts
were mentioned, for example, nice dinners, their
own bed, the household pet or family events such
as Christmas. The children had varying views of the
hospital: one contrasted hospital and home; another
described hospital more in terms of stopping a bad
experience, while a third child viewed his or her time
in hospital as normal routine.
Anxiety and uncertainty of the unknown caused
one child, in his story, to mention being ‘dead
scared’. The children based anxiety on a lack of
knowledge: ‘actually, not knowing what’s going to
happen. . . I think they’re quite worried about what
the doctor or nurse is going to say.’
The picture of the child in the bed (picture 2)
revealed different perceptions about this piece of
hospital furniture. One viewed the bed as a place to be
examined and a place to worry. Another child saw the
bed as their personal space to listen to music or play.
Others saw it as a means of escape; one child was
using sleep, not for rest, but as place of retreat and an
escape from the boredom and pain. Another child
viewed bed as a place of necessity, due to illness.
Coping with invasive procedures
The response to picture 3, which depicts a nurse
giving an injection, drew a reaction from all of
the children. Some provided a reason why such
treatment was administered. A ten-year-old referred
to his own experience of ‘blood being taken’. An 11-
year-old rationalised it further by saying that it would
‘help me in the future’. One child provided a couple
of coping mechanisms such as physically looking
away, or thinking, ‘it doesn’t take that long, it will be
over and done with soon’. This child also said that
her initial experience was quite scary: ‘the first time
round’s worst’, and while it was still scary, it was at a
level she felt she could handle. An 11-year- old said:
‘He could maybe think about something he enjoys
doing . . and it might take his mind off the needle
so he could feel happy about something he enjoys
doing rather than feeling anxious.’
However, a ten-year-old also suggested a The research sought
different strategy in which the child could look at to test and develop
the treatment being administered. The thinking the NHS definition of
being that she would ‘make sure they’re not doing spiritual care – one that
anything wrong’. An eight-year-old described how he adopts spirituality as the
would resort to physical resistance such as kicking. primary concept over
Another issue raised by a ten-year-old boy and above religion
concerned the management of his treatment, which
could determine when he would leave the hospital
for a period of time. This child expressed concern
that if the timing did not work ‘they would give
me into trouble’. Whoever ‘they’ were, either from
hospital or home, this was a possible trigger for
conflict and concern in the child’s mind.
One child referred to her own poor experience of
administering of an injection which then had an
paediatric nursing November vol 19 no 9
impact on the way she told this part of the story.
This child found it hard to understand why the
child in the picture was showing no emotion. The
interviewee was quite meticulous in checking the
detail of the picture to find a reason. She described
the emotion of the child in her story as sad and
angry. Another child contributed a different
observation about picture 3 by noticing that it was
only the nurse that was present and that the child
was not accompanied by anyone else: ‘There’s only
a nurse there, and . . there’s no-one there from his
family or friends to hold his hand, so he’s probably
feeling even more anxious.’ This child explained
the difference it would make in this situation: ‘but
with some family member or friends, they could,
like, help you through it, sort of mentally… make
37
research
ian dodds
you feel a lot better.’
Three of the children found comfort through
playing with toys and games. While one made a
general comment, another was quite specific, for
example, citing crafts and painting. One child did
indicate a sense of achievement through play and
attachment to the toys they owned. For example, one
of them described his or her toy as a ‘best friend’.
Another child said, ‘He (the child in the picture)
must be awful bored …cos there’s no sort of books
or games… so he’s probably feeling very alone’.
This child felt that the child in the story would feel
stronger if someone visited and played with him: ‘I
mean, being alone like that would make you think
about all… the negative things that are going on
around you …If you had a visitor that would maybe
38
‘Play appears
to be a means
of instinctive
connection that
enables them
to experience a
sense of security’
Acknowledgements
This research project was
funded by Yorkhill Children’s
Foundation.
References
Ebmeier C et al (1991)
Hospitalized school-age
children express ideas,
feelings and behaviours
toward God. Journal of
Pediatric Nursing. 16, 5,
337-349.
Hart D et al (1997) Spiritual
care for children with cancer.
Seminars in Oncology
Nursing. 13, 4, 263-270.
Hay D (1998) The Spirit of
the Child. Fount Paperback/
HarperCollinsReligious,
London.
Pendleton SM et al (2002)
Religious/spiritual coping in
childhood Cystic Fibrosis: A
qualitative study. Pediatrics.
109, 1. E8.
Scottish Executive (2002)
Spiritual Care in NHS
Scotland. HDL (76) 2002.
Wilson CAM (1994)
Conceptualisation of
spirituality in critical ill
school-aged children.
Masters Thesis. University of
Mississippi.
play board games and things with you, then you
wouldn’t have time to think about all these things’.
Belief
The research also included the question: ‘What do
you think this child would want to say to God about
what has happened in the story?’ It was noticeable
that the children made no reference to a faith
community or God until asked about God in the
last picture. The children held mixed views of God’s
ability and motive to help the child in their story.
One stated: ‘Cos God doesn’t want anyone to be ill.’
God was described by another child as helpful: ‘He
tries his best to help them.’ However, this help was
viewed by the child as limited: ‘he (God) couldn’t
help me any more cos other people needed his help.’
The level of help from God appeared to be measured
by the child’s quality of health and if hospitalisation
was needed.
An 11-year-old child’s expectations of her God were
very similar to the relationships the child referred to
earlier in her story. She said that what she would have
expected from God was ‘more comfort and things
to do, like maybe just reading a book and things he
might have felt a lot better mentally as well so he
could . . .sort of . . .think about things a lot clearer’.
A ten year old focused on the parents praying for
the child in his story. There were two topics of prayer
mentioned: that the hospital stay to come to an end;
and that the child would be better. This child also
referred to a ‘lucky charm thing’ which he held onto
to bring luck. It was an image of Mary, the mother of
Jesus. An eight-year-old child, if given the opportunity
to speak to God, wanted to share the experience of
pain and the desire to get away from the hospital.
This same strength of feeling came through with a
nine-year-old child who also said she wanted to share
with God how she felt and what she thought of the
hospital: ‘It was scary . . it was like hell.’
Discussion
This research sought to test and develop the
NHS definition of spiritual care – one that adopts
spirituality as the primary concept over and above
religion. The ordering of these concepts meant
that the research focus was on the spiritual needs
of the child and would only include their religious
background if this were an expression of their
spirituality. The result was that ‘god’ and religious
expressions of all children were only described when
explicitly elicited by the researcher.
It is difficult to know what can be drawn from
this. Did they not have religious needs to express?
Further research could look at whether the concepts
and definitions of spirituality and religion used by
the NHS work well in meeting the spiritual needs of
children. Does the broader definition of spirituality
make support for a religious child less accessible if
they do not present their needs until asked?
Some practical implications can be drawn from
the findings. For one child it might have been
helpful for ward staff to find out what his or her
paediatric nursing November vol 19 no 9
views of their parental support were to facilitate
comfort rather than isolation because of feelings of
failure. Another child articulated developing logic
or reasoning that could be positively used by nurses
to help young patients deal with difficult situations.
Play was also an important aspect of these children’s
lives in hospital, to enable friendship, receive
support and to help engage with the environment.
Play appears to be a means of instinctive connection
that enables them to experience a sense of security.
In addition, the value that these children placed on
their home environment and family routine was
quite apparent.
The views expressed by the children about their
God in the story were mixed, however each child’s
views were consistent within their story. This question
drew out some of the children’s expectations of
relationships, their environment, care provision while
in hospital and discharge from hospital.
This study raises a number of research and
practice-based questions. How does the healthcare
team identify and respond to the child’s needs for
supportive relationships? How does the healthcare
team build up a child’s trust in the treatment and
care they offer? What lessons can be learnt in the
healthcare service, from the play service provision,
to incorporate age-appropriate play that would help
the child understand his or her healthcare journey
better? Should healthcare teams consider the
impact they have on the child’s view of their quality
of life? How does the chaplaincy service enable
the healthcare team to meet the spiritual needs of
children in hospital?
Conclusion
Although this was a small study, the information
from these five children provides some tentative
indicators of spiritual need in children in similar
circumstances. What came through the children’s
stories was how they valued good supportive
relationships that provided a sense of comfort
and strength, that could make a difference. The
children’s stories also revealed the need to have
confidence in the hospital environment, its
procedures and staff. 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
practically possible.
There is a need for all healthcare professionals to
recognise that children have spiritual needs that
can include religious beliefs, and that it is part of
their duty of care to attempt to identify and meet
such needs. Taking time to talk and listen with
each child enables a healthcare professional to
identify, and therefore try to meet, the needs of
children. One child summed up the spiritual voice
of hospitalised children with complex healthcare
needs when she commented on the last picture:
‘The best one of all, going home, where I would
like to be – going home’ PN