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The possibilities and challenges in providing pediatric spiritual care

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Article

Journal of Child Health Care

2017, Vol. 21(4) 435–445
The possibilities and challenges ª The Author(s) 2017
Reprints and permission:
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DOI: 10.1177/1367493517737183

spiritual care journals.sagepub.com/home/chc

Willyane de Andrade Alvarenga1,

Emilia Campos de Carvalho1, Sı́lvia Caldeira2,
Margarida Vieira3 and Lucila Castanheira Nascimento1

Abstract
The purpose of this article was to present discussions on how pediatric nurses can perform
spiritual care to children and adolescents and discuss the challenges of integrating such care in
health-care settings. Based on the literature, the article presents an overview of spiritual care in
pediatric settings highlighting the assessment of spirituality, expected outcomes, and the corre-
sponding nursing interventions. Spiritual care provided to children and adolescents should take
into account all aspects of the developmental stage, life experiences, and familiar and sociocultural
contexts. Different approaches can be used to perform spiritual care. However, lack of knowledge
and time are highlighted as the main challenges in integrating spiritual care into the clinical practice.
Spiritual care is crucial to the well-being of children and adolescents in times of illness and hos-
pitalization when the goal is to provide holistic care.

Keywords
Adolescent, child, nursing, nursing care, spirituality

Spirituality is considered the search and expression of meaning in life, purpose, transcendence, and
the relationship or connection experience with self, family, others, nature, and the significant or
sacred (Puchalski et al., 2014; Weathers et al., 2016). It is considered to be present in every human

1
PAHO/WHO Collaborating Centre for Nursing Research Development, University of São Paulo at Ribeirão Preto
College of Nursing, Ribeirão Preto, São Paulo, Brazil
2
School of Nursing, Instituto de Ciências da Saúde, Universidade Católica Portuguesa, Lisbon, Portugal
3
School of Nursing, Universidade Católica Portuguesa, Instituto de Ciõncias da Saúde, Porto, Portugal

Corresponding author:
Lucila Castanheira Nascimento, Department of Maternal-Infant and Public Health Nursing, University of São Paulo at
Ribeirão Preto College of Nursing, Bandeirantes Avenue, 3900 Ribeirão Preto, São Paulo, Brazil.
Email: lucila@eerp.usp.br
436 Journal of Child Health Care 21(4)

being throughout his life span (Ramezani et al., 2014). Thus, children are regarded as spiritual
beings with a natural ability to have spiritual experiences (Hay and Nye, 2006; Mueller, 2010).
Attending the spiritual needs of patients is part of the nurse’s duties to provide a holistic and
humanized care (Yilmaz and Gurler, 2014). However, there are challenges in attending spiritual
needs, and this aspect of care has been considered as neglected, especially in pediatric patients
(Nascimento et al., 2016). Nevertheless, some questions have been raised by health-care profes-
sionals and researchers about how to provide spiritual care to children and adolescents.
Given the relevance of implementing integrative health-care practices, the spiritual dimension
of children and adolescents still requires discussion, and some challenges deserve to be underlined.
From the researchers’ experience and current literature, this discussion article aims to present
discussions on how pediatric nurses can provide spiritual care to children and adolescents and to
discuss the challenges of integrating such care in health-care settings.

Data sources
The discussion presented in this article was based on relevant articles identified in the literature as
published from 1990 to 2016 using the following keywords: ‘spiritual’, ‘child’, ‘adolescent’, ‘reli-
gion’, and ‘health’. The search included literature in English and Portuguese, books or journals
focused on pediatric studies that were theoretical or research based. The databases searched using an
iterative process were CINAHL, PubMed, SCOPUS, PsycINFO, and Google Scholar. In addition,
several publications were identified in the reference lists of articles through the search. Thus, this
study aimed at identifying and using these articles as sources to develop a discussion on the subject.
The selected articles and the professional experiences of our authors have led us to this dis-
cussion article about the potential that the nursing care has to support and facilitate the expression
of children’ spirituality in the context of health; however, highlighting that this potential is cur-
rently underused in health care.

Discussion
Spiritual care: A necessary practice in pediatric nursing care
Spirituality may be one factor that usually contributes to physical, emotional, and psychological
well-being in children and adolescents (Jackson, 2012). Children have rich spiritual lives, which
are evident primarily in traumatic life situations such as illness, death, and abuse (Pfund, 2000).
Children, whether religious or not, seek to understand events in their life through religious
experiences, spiritual values, or other potential sources of explanation (Coles, 1990). This search
for meaning is related to their spirituality and, for example, it can influence how they accept
diseases and cope with treatment or hospitalization (Neuman, 2011).
Similar to adults, children and adolescents need to find meaning in illnesses, to transcendence
beyond suffering, and to feel a sense of connectedness with self, others, or something significant,
particularly during hospitalization. The most valued aspect of spirituality in adolescents is the
human connection (Jackson, 2012). The experience of illness and hospitalization is traumatic
events that cause fears and preconceptions about family separation, isolation, and fear of death in
children (Smith and McSherry, 2004). Furthermore, it can damage the connectedness with self and
the sense of unity that children and adolescents celebrate with family and friends at school. This
situation can promote spiritual crises, (Mueller, 2010) similar to those experienced with bullying
(Hay and Nye, 2006).
Alvarenga et al. 437

Figure 1. Key components for spiritual assessment in children and adolescent.

The experiences of pediatric cancer, palliative care, or living with a long-term treatment due to a
chronic disease are examples of situations in which children and adolescents can experience
spiritual distress. Most of the challenges they face include spiritual, religious, and existential issues
such as dealing with the fear of the future, disease symptoms, hopelessness, intense suffering,
separation from significant others due to health conditions or subsequent hospitalizations, anger
toward God, and changes in self-image and self-concept. This discussion highlights the importance
of spirituality being integrated into the care. Spiritual care is ‘the art of ‘‘being with’’ patients that
helps the development of the current nursing theories in the area of spiritual care’ (Ramezani et al.,
2014: 217). It is not separated from the physical, social, or psychological care (McSherry, 2008).
However, it requires that children and adolescents be perceived as bio-psycho-social-spiritual
beings by health professionals.

Key components of the spiritual assessment in children and adolescents

The assessment of spirituality and the spiritual needs of children and adolescents are the first step
in delivering spiritual care (Petersen, 2014). A diagram was developed to help to elucidate the key
components of the spiritual assessment in children and adolescents (Figure 1), which includes
verbal communication and the observation of behaviors and the child’s life context. This requires a
particular approach for each child and adolescent considering their individual and contextual
aspects such as age, developmental stage, life experiences, and family and sociocultural contexts.
Age and developmental stage can influence the meaning given to situations and how religious
or spiritual beliefs are expressed by children and adolescents (Smith and McSherry, 2004). The
knowledge of the cognitive, psychosocial, and developmental moral theories and faith’s stages
according to James Fowler can provide nurses with additional information to help to understand
expected behaviors, thoughts, and religious and spiritual beliefs (Neuman, 2011). According to
that author, there are six faith stages (and one pre-stage) that provide a theoretical perspective of
how people develop spiritually over their life span and focus on a generic understanding of faith
(Fowler, 1981). An overview of the stages from infancy through adolescence, such as undiffer-
entiated faith, intuitive-projective faith, mythic-literal faith, and synthetic-conventional faith is
illustrated in Table 1. Although children or adolescents can anticipate the latter stages, flexibility is
needed to consider the developmental stages in order to avoid mistakenly considering children at
the early stages of development as spiritually immature (Coles, 1990; Hay and Nye, 2006).
438 Journal of Child Health Care 21(4)

Table 1. The faith’s stages according to James Fowler and developmental aspects from infancy to adolescence
(Fowler, 1981).

Undifferentiated faith (infancy to age 2) Intuitive-projective faith (3 to age 6)

 The individual begins to develop a sense of  Fantasy-filled or imagination

trust in others
 Relational experience of mutuality with the
mother and other intimate caregivers
 The basis for courage, autonomy, hope, trust,
and strength to prepare for subsequent stages
 Egocentric self-awareness
 Imitative phase with the use of symbols in speech and
ritual play determined by culture
 God is conceptualized in the way in which society
has represented it
 A style of meaning-making based on an emotional
and perceptual ordering of experiences

Mythic-literal faith (7 to age 12) Synthetic-conventional faith (adolescent)

 Concerns about knowing how things are
 Ability to narrate one’s experience
 To take the perspective of others
 To internalize stories, beliefs, and observances
offered by the community or groups
 Anthropomorphic image of God
 Beliefs are appropriated with literal
interpretations of religion or doctrines
 World based on lawfulness and reciprocity
 Capacity for reflection on one’s own thoughts and
ways of experiencing life
 Mutual interpersonal perspective
 Intimate relationship outside the family and the
influence of significant others
 God takes a new meaning, which allows the
establishment of a relationship that provides support
during a time of crisis.
 Tacit character of identity, values, and beliefs
One’s ideology or worldview is lived and asserted,
but it is not an object of critical reflection

Children are capable of understanding events from the standpoint of meanings, including their
life experiences and sociocultural contexts. The spiritual expression can be influenced by the
person’s ethnic origin or cultural and environment (Lepherd, 2015). Cultural environment and
social interactions influence the children’s worldview and their behavior such as the use of the
language of faith, religious practices, and symbolisms (Hay and Nye, 2006; Mueller, 2010).
Therefore, it is important for nurses to listen to what children say and relate to their life experi-
ences, culture, family, and significant others (Mueller, 2010). The family represents a rich source
of information for spiritual assessment because family members can identify the child’s needs. In
addition, some aspects of religion, spirituality, or the child’s worldview can be perceived from
family members (Hexem et al., 2011). In addition, school, media, peers (Moore et al., 2012),
hospital, and health-care professionals can influence the spirituality of children and adolescents.
The spirituality of a child can be recognized in his activities in the hospital setting because
spirituality is manifested through behaviors (Lepherd, 2015). However, this requires observing his
means of body communication such as looks, laughs, cries, paintings, gestures, and facial
expressions (Champagne, 2003). This is important for the identification of signs of spiritual dis-
tress that can be reflected through intense crying, insomnia, nightmares, prolonged silence, and
resistant or regressive behaviors (Mueller, 2010).
Nurses must be attentive to everything that provides meaning in the life of their pediatric
patients, whether it is existential, religious, personal, or secular (Pfeiffer et al., 2014). The presence
of important people, a symbolic object, a pet, and religious practice are all examples of significant
aspects for a child. In order to identify these and other aspects, it is fundamental to consider the
Alvarenga et al. 439

different dimensions of the spirituality in children such as (a) contexts where spirituality appears
(relationship with self, others, the world, and God); (b) conditions for the expression of behaviors
(e.g. from a religious and autobiographical language or languages of games, fiction, or science); (c)
strategies to maintain a sense of spirituality that might not be associated with the behavior of adults
such as going to church (e.g. physically or mentally withdraw, focus on something particular,
prayer, exploring aesthetic and sensory experiences, imagination, dreams, and search for mean-
ing); (d) the changing presentation of spirituality over time (e.g. avoidance, magnification, and
changefulness); and (e) consequences, which are the effects of spirituality (e.g. calmness, peace,
oneness, wonder, gratitude, inner conflict, and desire to seek) (Hay and Nye, 2006).

Spiritual assessment tools and instruments

There are tools available to guide conversations about the patient’s spiritual history understood as
‘a set of questions designed to invite patients to share their religious or spiritual beliefs to help to
identify spiritual issues’ (Borneman et al., 2010: 165). Most available tools are not clear about the
target audience, and few are specific or suitable to pediatric patients (Lucchetti et al., 2013). Two
assessment tools for use in the pediatric setting are:

 BELIEF (B—Belief system; E—Ethics or values, L—Lifestyle, I—Involvement in a spiri-

tual community, E—Education, and F—Future events). It is a simple and broad guide with
18 subjects that can be used in the clinical practice during routine visits with parents and
children, including babies. The influence of parents on the spirituality of children and their
involvement with religious groups can be observed as well as the effects of religious or
spiritual beliefs on future events such as dietary restrictions, immunization, birth control,
abortion, blood transfusion, and death (McEvoy, 2000). Some examples of questions are
as follows: ‘Does your family belong to a religious group?’, ‘Are certain ethics or values
important in your family life?’, ‘What are these ethics or values?’, ‘Does your family
observe any dietary restrictions?’, and ‘Does your family say prayers or meditate together?’.
 A small interview guide of eight questions used with children between 6 and 17 years of age
with advanced cancer (Kamper et al., 2010). The questions are based on a relationship with
a higher being, with self, and with others, and it is an interesting guide to be used. Some
examples of questions are ‘What makes you feel good or happy?’, ‘What helps you to feel
better when you do not feel good or are unhappy?’, ‘Some children do things to feel close to
God (or a higher power) when they are sick. Have you done anything like that? If so, what
did you do?’, ‘Is there anything you do to help people in your family to feel good or happy?
If so, what do you do?’.

There are tools to assess the parents’ spirituality such as the FICA (F—Faith or beliefs, I—
Importance and Influence, C—Community, and A—Address) and FACT (F—Faith and beliefs,
A—Active or Availability, Accessibility, Applicability, C—Coping or Comfort, Conflicts or Con-
cerns, and T—Treatment plan). FICA is organized into 11 questions that open the dialogue about
the presence and importance of spiritual beliefs in one’s life and how they are expressed (Puchalski
and Romer, 2000). FACT is organized in 13 questions and evaluates the patient’s faith or beliefs,
participation, availability, and access to a community of faith; the experience of faith and its influ-
ence on coping and comforting; and the existence of conflicts or concerns; FACT includes an
appropriate treatment (LaRocca-Pitts, 2009). This tools may not be suitable for children and
440 Journal of Child Health Care 21(4)

adolescents because they require a certain level of development to understand and answer the fol-
lowing questions: ‘Do you consider yourself spiritual or religious (or a person of faith or a spiritual
person)?’, ‘What are the things you believe give meaning to your life (or purpose)?’, and ‘What
role do your beliefs play in regaining your health?’. Formal tests are required to confirm its con-
tribution to children or adolescents of different ages and backgrounds. Aspects related to the cog-
nitive, social, and emotional development should be considered in instruments used for the
assessment of the spiritual dimension (Cotton et al., 2010).
There are also instruments to measure spirituality. The five instruments in the literature that are
most frequently used with adolescents are the Brief Multidimensional Measure of Religiousness/
Spirituality, Spiritual Well-Being Scale, versions of the RCOPE, Religious Orientation Scale, and
the Systems of Belief Inventory (Cotton et al., 2010). Feeling Good, Living Life (Fisher, 2004) is
an instrument geared to children that measures spiritual well-being in children between 5 and 12
years old; it has 16 items with a Likert-type response scale of five points about the perception of
well-being (Feeling Good) and expression of life (Living Life) in four areas of spiritual well-being:
the quality of relationships with self, family, the environment, and God.
There are still other strategies for assessing spirituality, which can be used alone or combined
with an interview, with the observation of drawings, photography, puppets, and storytelling.
Examples of these activities are (Moriarty, 2011) as follows:

 The use a visual stimulus, for example, a photo of a child alone. Question: ‘What is this
child thinking?’
 The reading of a story about family, land, or spirits. Question: ‘Who are the most important
people and things in your life?’
 Asking the child to draw herself and discuss the drawing. Question: ‘What does it say about
you?’

These are interactive approaches that allow deepening spiritual matters and other matters
related to the life experiences of children or adolescents. These are flexible and ideal methods for
pediatric patients in their early stages of development and limited communication skills when they
do not have the ability to read, write, or respond to instruments or those with any developmental
issue. Some of these techniques were used in studies with children and adolescents investigating
their spirituality (Baring, 2012; Champagne, 2003; Hay and Nye, 2006; Kamper et al., 2010;
Moore et al., 2012).
To select the best approach when assessing the spirituality of children and adolescents, nurses
should consider age and developmental stage, ability to respond, time to conduct the assessment,
and skills to engage patients and families. Through assessing verbal and nonverbal communication
in children and adolescents, nurses are able to understand the patients’ spirituality and identify
spiritual needs and the presence of spiritual distress through clinical reasoning. However, the
recognition of spiritual distress can come from the acknowledgment of expressed feelings and
concerns; this demands nurses to become familiar with the various aspects of expressions of
spirituality in children and adolescents (Petersen, 2014).

Providing spiritual care

Nurses formulate a care plan based on the spiritual needs identified in order to nurture the well-
being of children and adolescents and strengthen factors that promote the expression of
Alvarenga et al. 441

spirituality. Briefly, the expected results include the development of quality relationships with
themselves, others, the world, and a transcending power leading them to the feeling of spiritual
well-being (Hay and Nye, 2006). Other outcomes to be pursued are as follows:

 reduction of guilt and anxiety, increased religious and spiritual satisfaction, a positive new
approach to the meaning of self-existence and current condition, and positive behaviors
(Moorhead et al., 2013);
 comfort, peace, hope, dignity, and joy (Pfeiffer et al., 2014); and
 the promotion of a peaceful death, spiritual growth, and a trusting relationship at the end of
life (Petersen, 2014).

To demonstrate how this might play out, some interventions can be used with children and ado-
lescents in response to the patient’s spiritual needs. The empathetic dialogue is described as ways
to open space for the patients’ spirituality and promote spiritual support (Neuman, 2011). Some
aspects can be considered in proving spiritual support such as (1) respecting individuality, (2)
establishing confidence and intimate relationships, (3) creating a safe environment for the child
to talk and think about their spiritual experiences and reflections on life, and (4) encouraging chil-
dren and adolescents to explore different ways to understand certain experiences or situations and
emphasize their positive aspects (Hay and Nye, 2006; Nye, 2009; Ramezani et al., 2014).
Re-establishing positive relationships and minimizing separations are other interventions that
nurses can perform with children and adolescents (Ramezani et al., 2014). The search on social
networks in which children and adolescents are inserted as well as the influence of family, friends,
and even other patients with whom they interact are important. Visits, exchanges of messages and
letters, and the recall of pleasant moments are some ways to connect them with significant others
(Elkins and Cavendish, 2004). Children perceive others around them; therefore, the presence of
parents or others who are references could be maintained, especially with young children who
count on adults to feel protected and find meaning in their surrounding world (Champagne, 2003).
It is important to include the family as the focus of the spiritual intervention. The suffering of
family members can affect children or adolescents (Mueller, 2010). Therefore, communicating with
family members and seeking to meet their spiritual needs can minimize the suffering of children or
adolescents (Nascimento et al., 2016). Leading family members to understand the child’s diagnosis
and prognosis, and giving them the time needed to process this information, seems important in
reducing suffering. Similarly, it is important to empower families in the decision-making process,
which will certainly be based on cultural, spiritual, and religious beliefs that nurses can seek to know
(Rosenbaum et al., 2011). The nurse can also help families to find new meanings of hope; however,
caution is needed regarding the promotion of false hope (Rosenbaum et al., 2011).
Some actions that characterize the spiritual care include opening the space for children and
adolescents and their families to express their values and beliefs with no censorship and judgment
(Rosenbaum et al., 2011). Interventions may include providing or allowing the visit of religious
leaders according to the faith traditions followed by the child and family, (Neuman, 2011;
Rosenbaum et al., 2011) encouraging Bible readings, and praying if this is in agreement with the
family’s and child’s belief system and is a source of support. Parents reported that their main
religious and spiritual practices are praying and reading the Bible because these helped them to
reorganize life, practice patience, and find peace and comfort in their faith in God (Hexem et al.,
2011; Rosenbaum et al., 2011). Studies with children and adolescents showed that most do
442 Journal of Child Health Care 21(4)

something to feel closer to God and/or a higher power and that prayer is their primary resource,
especially when they are feeling sad or abandoned (Kamper et al., 2010; Moore et al., 2012).
Spirituality is not limited to the religious dimension or a relationship with God (Nascimento
et al., 2016). Nevertheless, research shows that at least 90% of the world’s population is currently
involved in some form of religious or spiritual practice (Koenig, 2009) and that parents influence
on the religiosity of children (Baring, 2012). Other forms of expression of spirituality can also be
explored, especially with secular children and adolescents. Some possible interventions with
infants, older children, and adolescents include creating a cozy atmosphere (Ramezani et al.,
2014); performing specific physical care (Elkins and Cavendish, 2004); offering comfort, safety,
toys, and familiar objects (Mueller, 2010); and encouraging the use of imaginative faculties (Nye,
2009). The use of art through paints, clay, stone, fabric, and yarn, as well as of theater, music,
dance, and videos are resources that nurses can widely explore for the expression of spirituality. In
addition, poetry, written texts, and storytelling are other ways to guide the imagination for the
promotion of well-being (Elkins and Cavendish, 2004; Ettun et al., 2014; Pfund, 2000).
The outcomes of spiritual care are not immediate or are necessarily measurable and might lead
to a happy effect. However, attention to changes in the spiritual state of their pediatric patients and
families is as important as knowing that spirituality is complex, intimate, and the expected results
may not be achieved or maintained with timely interventions. In the dynamics of the spiritual state,
‘spiritual life is a piece of continuous work; it is not something to be concluded’ (Nye, 2009: 46).
The transforming power of the spiritual care for patients and nurses, in addition to improving
nurse–patient professional relationships, is emphasized aspects related to the relevance of per-
forming spiritual care (Puchalski et al., 2014; Ramezani et al., 2014).

Challenges in pediatric spiritual care

Although spirituality is explored through various aspects, it remains one of the most complex objects of
study, especially in children and adolescents. The establishment of a broad definition of spirituality
capable of contemplating religious and non-religious people is challenging because of the diversity in
spirituality concepts (Koenig, 2009). Pluralistic definitions are unanimously recommended in health
care (Puchalski et al., 2014). Hence, it is necessary to conceptualize spirituality without disregarding
human diversity in order to approach its purpose in the clinical practice. However, when conducting
research on spirituality and health, the concept needs to be adequate to the object of study because it
facilitates comparisons with other studies, contexts, and measures to assess spirituality (Koenig, 2009).
There is a need for empirical studies that point to the spiritual expressions of children and
adolescents in situations of illness and hospitalization as well as to the appropriate and validated
tools to measure spirituality and religiosity in this population. Some existing perspectives and
instruments are developed for the adult population (Cotton et al., 2010; Lucchetti et al., 2013).
Other challenges relate to the integration of spiritual assessment and interventions in the clinical
practice. Nurses identify lack of time for dialogue, work overload, rapid shifts, lack of continuity in
the spiritual care, and lack of competency to address spiritual needs and promote adequate
interventions as barriers to providing spiritual care (Edwards et al., 2010; Nascimento et al., 2016).
The overcoming of a reductionist and dualistic paradigm in the biomedical model of health care
that affects the nursing practice has been described as challenging to the provision of a holistic care
(McSherry, 2008; Timmins et al., 2015).
There is evidence that nurses feel discomfort and difficulties in talking about spirituality with
patients (Rosenbaum et al., 2011; Taylor et al., 2014). The discomfort may be associated with the
Alvarenga et al. 443

required emotional effort (Edwards et al., 2010) and a cultural process of reprimand and deva-
luation of spirituality, which have also contributed to lead 10-year-old children to show discomfort
or shame when talking about these issues (Hay and Nye, 2006). Education has been identified as a
major changing mechanism through the training of professionals in spiritual awareness, emotional
resources, and skills to meet the spiritual needs of children (Pfund, 2000). Therefore, the inclusion
of spirituality in textbooks and use of simulation scenarios in the nursing curricula are necessary
(Timmins et al., 2015; Yilmaz and Gurler, 2014).
Ethics in the performance of spiritual care deserves to be highlighted because it concerns the
imposition of beliefs or the nurse’s spiritual practices on children and adolescents who are vul-
nerable individuals. Spiritual care is related to the nurse’s spirituality (Pfeiffer et al., 2014).
However, when providing this type of care, nurses’ should be reflecting on their own spirituality
(religious or spiritual beliefs or world view) and how it influences the way they provide the care
(Taylor, 2011). This is based on an ethical endeavor toward the promotion of the patients’ dignity
by respecting their beliefs and worldviews (Taylor, 2011).

Conclusion
Nurses can provide spiritual care in pediatric settings. Observational and listening skills are
required to understand the expression of spirituality in these patients. The assessment and planning
of spiritual care should consider aspects related to the developmental stage, life experiences, and
family and sociocultural contexts.
Nurses can use different approaches and some tools to assess spirituality, particularly in chil-
dren and adolescents. We emphasize the importance of developing specific instruments to assess
spirituality in pediatric patients and their validation in different contexts of care.
Little evidence was found in the literature about the effectiveness of clinical interventions to
provide spiritual care. However, some spiritual interventions for children and adolescents, such as
active listening; minimizing their separation from significant others; allowing the manifestation of
spiritual values and beliefs; offering comfort, safety, and toys; and using art and music, are
underscored in the literature. Moreover, the inclusion of these interventions and spiritual eva-
luations in the clinical practice presents challenges that include the lack of knowledge and time and
the reductionist paradigm of the biomedical model that still influences the nursing care.
Much has been conducted toward including and rescuing holistic care in the nursing practice; some
strategies including professional education have been identified. Nurses face a challenging journey before
they can consider establishing spiritual care for children and adolescents as a reality in their practice.

Acknowledgement
The authors would like to thank the Coordination for the Improvement of Higher Education Per-
sonnel to the first author.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship,
and/or publication of this article.

Funding
The author(s) disclosed receipt of the following financial support for the research, authorship,
and/or publication of this article: The first author received funding from the Coordination for the
444 Journal of Child Health Care 21(4)

Improvement of Higher Education Personnel as a PhD’s scholarship (PDSE 99999.010691/

2014-06).

References
Baring R (2012) Children’s image of God and their parents: explorations in children’s spirituality. Interna-
tional Journal of Children’s Spirituality 17(4): 277–289.
Borneman T, Ferrell B and Puchalski CM (2010) Evaluation of the FICA tool for spiritual assessment. Journal
of Pain and Symptom Management, Elsevier Inc 40(2): 163–173.
Champagne E (2003) Being a child, a spiritual child. International Journal of Children’s Spirituality 8(1):
43–53.
Coles R (1990) The Spiritual Life of Children. Boston: Mariner Books.
Cotton S, McGrady ME and Rosenthal SL (2010) Measurement of religiosity/spirituality in adolescent health
outcomes research: trends and recommendations. Journal of Religion and Health 49(4): 414–444.
Edwards A, Pang N, Shiu V, et al. (2010) The understanding of spirituality and the potential role of spiritual
care in end-of-life and palliative care: a meta-study of qualitative research. Palliative Medicine 24(8):
753–770.
Elkins M and Cavendish R (2004) Developing a plan for pediatric spiritual care. Holistic Nursing Practice 18(4):
179–186. Available at: http://search.ebscohost.com/login.aspx?direct¼true&db¼rzh&AN¼106767324&site
¼ehost-live&scope¼site.
Ettun R, Schultz M and Bar-Sela G (2014) Transforming pain into beauty: on art, healing, and care for the
spirit. Evidence-based Complementary and Alternative Medicine, Hindawi Publishing Corporation 2014.
Fisher J (2004) Feeling good, living life: a spiritual health measure for young children. Journal of Beliefs and
Values 25(3): 307–315.
Fowler JW (1981) Stages of Faith: The Psychology of Human Development and the Quest for Meaning. San
Francisco: HarperOne.
Hay D and Nye R (2006) The Spirit of the Child: Revised Edition, Rev ed. London: Jessica Kingsley Publishers.
Hexem KR, Mollen CJ, Carroll K, et al. (2011) How parents of children receiving pediatric palliative care use
religion, spirituality, or life philosophy in tough times. Journal of Palliative Medicine 14(1): 39–44.
Jackson SA (2012) Children, spirituality, and counselling. American Journal of Applied Psychology 1(1): 1.
Kamper R, Van Cleve L and Savedra M (2010) Children with advanced cancer: responses to a spiritual quality
of life interview. Journal for Specialists in Pediatric Nursing?: JSPN 15(4): 301–306.
Koenig HG (2009) Research on religion, spirituality, and mental health: a review. Canadian Journal of Psy-
chiatry. Revue Canadienne de Psychiatrie 54(5): 283–291. Available at: http://www.ncbi.nlmnih.gov/
entrez/query.fcgi?cmd¼Retrieve&db¼PubMed&dopt¼Citation&list_uids¼19497160.
LaRocca-Pitts MA (2009) FACT: taking a spiritual history in a clinical setting. Journal of Health Care Cha-
plaincy 15(1): 1–12.
Lepherd L (2015) Spirituality: everyone has it, but what is it? International Journal of Nursing Practice 21(5):
566–574.
Lucchetti G, Bassi RM and Lucchetti ALG (2013) Taking spiritual history in clinical practice: a systematic
review of instruments. Explore: The Journal of Science and Healing, Elsevier Inc. 9(3): 159–170.
McEvoy M (2000) An added dimension to the pediatric health maintenance visit: the spiritual history. Journal
of Pediatric Health Care 14(5): 216–220.
McSherry W (2008) The Meaning of Spirituality and Spiritual Care within Nursing and Health Care Practice,
1st ed. London: Quasy Book.
Moore K, Talwar V and Bosacki S (2012) Canadian children’s perceptions of spirituality: diverse voices.
International Journal of Children’s Spirituality 17(3): 217–234.
Alvarenga et al. 445

Moorhead S, Johnson M, Maas ML, et al. (2013) Nursing Outcomes Classification (NOC), 5th ed, St. Louis,
MO: Elsevier.
Moriarty W (2011) A conceptualization of children’s spirituality arising out of recent research. International
Journal of Children’s Spirituality 16(3): 271–285.
Mueller CR (2010) Spirituality in children: understanding and developing interventions. Pediatric Nursing
36(4): 197–203, 208.
Nascimento L, Alvarenga W, Caldeira S, et al. (2016) Spiritual care: the nurses’ experiences in the pediatric
intensive care unit. Religions 7(3): 27. Available at: http://www.mdpi.com/2077-1444/7/3/27.
Neuman ME (2011) Addressing children’s beliefs through fowler’s stages of faith. Journal of Pediatric Nur-
sing, Elsevier Inc. 26(1): 44–50.
Nye R (2009) Children’s Spirituality: What It Is and Why It Matters. London: Church House Publishing.
Petersen CL (2014) Spiritual care of the child with cancer at the end of life: a concept analysis. Journal of
Advanced Nursing 70(6): 1243–1253.
Pfeiffer JB, Gober C and Taylor EJ (2014) How christian nurses converse with patients about spirituality.
Journal of Clinical Nursing 23(19–20): 2886–2895.
Pfund R (2000) Review?: nurturing a child’s spirituality. Journal of Child Health Care 4(4): 143–148.
Puchalski C and Romer AL (2000) Taking a spiritual history allows clinicians to understand patients more
fully. Journal of Palliative Medicine 3(1): 129–137. Available at: https://courses.washington.edu/
bh518/Articles/ takingaspiritualhistory.pdf.
Puchalski CM, Vitillo R, Hull SK, et al. (2014) Improving the spiritual dimension of whole person care:
reaching national and international consensus. Journal of Palliative Medicine 17(6): 642–656. Available
at: 10.1089/jpm.2014.9427.
Ramezani M, Ahmadi F, Mohammadi E, et al. (2014) Spiritual care in nursing: a concept analysis. International
Nursing Review 61: 211–219. Available at: http://ovidsp.ovid.com/ovidweb.cgi?T¼JS&PAGE¼reference
&D¼psyc11&NEWS¼N&AN¼2014-20882-010 NS -.
Rosenbaum JL, Smith JR and Zollfrank R (2011) Neonatal end-of-life spiritual support care. The Journal of
Perinatal and Neonatal Nursing 25(1): 61–69. Available at: http://content.wkhealth.com/linkback/open-
url?sid¼WKPTLP:landingpage&an¼00005237-201101000-00014.
Smith J and McSherry W (2004) Spirituality and child development: a concept analysis. Journal of Advanced
Nursing 45(3): 307–315. Available at: http://search.ebscohost.com/login.aspx? direct¼true&db¼rzh&AN
¼106715965&site¼ehost-live&scope¼site.
Taylor EJ (2011) Spiritual care: evangelism at the bedside? Journal of Christian Nursing 28(4): 194–202.
Taylor EJ, Park CG and Pfeiffer JB (2014) Nurse religiosity and spiritual care. Journal of Advanced Nursing
70(11): 2612–2621.
Timmins F, Murphy M, Neill F, et al. (2015) An exploration of the extent of inclusion of spirituality and spiri-
tual care concepts in core nursing textbooks. Nurse Education Today 35(1): 277–282.
Weathers E, Mccarthy G and Coffey A (2016) Concept analysis of spirituality: an evolutionary approach.
Nursing Forum 51(2): 79–96.
Yilmaz M and Gurler H (2014) The efficacy of integrating spirituality into undergraduate nursing curricula.
Nursing ethics 21(8): 929–945.

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