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Paley asks why there has been a shift in focus from religious to non-religious spiritual care within nursing in the UK. He argues that this shift has resulted from an organised movement within academic nursing to assume control over 'a newly invented sphere of work'. I would like to make three points in response to his article: 1 Whilst nursing may be adopting a broader understanding of spirituality, this is not because of a movement within academic nursing to take control of a new area of work, but rather in response to patient demand and evolving healthcare policy. I would agree with Paley that there has been a shift in focus within nursing where the spiritual dimension has come to be viewed in a wider context than purely religion. Traditionally, medical and nursing care were provided within religious orders. Early definitions and models of nursing referred to addressing patients' religious needs. For example as far back as 1892 Florence Nightingale described nursing as a 'fine art' dealing with 'the living body – the temple of God's spirit' (Colliton 1981, p. 492). In 1977, Virginia Henderson included religion in her model of nursing considering it the duty of the nurse to assist the patient to 'worship according to his faith' (p. 13) and 'practice his religion or conform to his concept of right and wrong' (Henderson 1977, p. 19). The latter part of Henderson's statement perhaps highlights a shift to widening the concept of spirituality within nursing to include non-religious spiritual care. Around this time Ruth Stoll, one of the earliest nurses to publish on spiritual care wrote: humankind is incurably religious…what varies among people is what they are religious about. Whatever a person thinks to be the highest value in life can be regarded as his god, the focus and purpose of his time and life (Rinear & Buys 1985, p. 867). Here again we see a wider understanding of spirituality emerging extending beyond religion. This broader concept of spirituality features in current nursing codes of ethics (Nursing and Midwifery Council 2004) and nurse education guidelines (Quality Assurance Agency for Higher Education 2001) where nurses on qualifying are expected to be competent in assessing patients' spiritual needs and, planning, implementing and evaluating spiritual care to address these needs. Therefore, whilst I would agree with Paley that there has been a broadening in understanding of spirituality within nursing, I would disagree that this shift has occurred because of an academic 'project' within nursing to assume control over 'a newly invented sphere of work'. If this had been the case perhaps more progress would have been made. In actual fact the nursing research within the field has, on the contrary, been uncoordinated and piecemeal, with individual researchers carrying out small-scale studies in single institutions dotted across the UK and abroad. Such a scenario hardly smacks of careful collusion and undercover planning. As will be shown below, healthcare policy has adopted a broad understanding of spirituality, so have nurses been working behind the scenes trying to twist the arms of international [e.g. World Health Organisation (WHO)] and national bodies [e.g. National Institute for Clinical Excellence (NICE)] and government health departments to move in this direction? I think not. I would suggest that the move to widen the concept of spirituality, rather than resulting from collusion within academic nursing, has occurred for two reasons; in response to patient demand and in response to healthcare policy. In my view, Paley's greatest shortcoming is his failure to acknowledge the voice of the patient. The patient is at the heart of our National Health Service (NHS) in the UK and as nurses our remit is to provide individualised, patient centred, holistic care. We must, therefore, be responsive to patient need and to changing patient need. Whilst patients' in the UK may struggle to define the term 'spirituality' (McSherry et al. 2004), when asked about their lived experience of being a patient they tell us that religious needs as well as non-religious spiritual needs are important to them during illness and hospitalisation (e.g. Simsen 1988, Narayanasamy 1995, 2004, Ross 1997, Murray et al. 2004). They would also value spiritual care and help from members of the healthcare team with whom they have established rapport, including nurses and chaplains (e.g. Ross 1997, Murray et al. 2004). Further, the fact that much of the nursing research into spirituality has arisen from the clinical field with a desire to improve patient care through working with other healthcare professionals (in particular chaplains) suggests that nurses are more concerned for patient welfare than in assuming control over spiritual care. Most nursing theses have been triggered by critical incidents from practice as evidenced by the content of the introductions. Many of the studies included in the review of nursing research to date (Ross 2006) are authored by clinicians (e.g. Charters 1999, Thomas & Retsas 1999, Walton 1999, Carroll 2001, Strang & Strang 2001, Lundmark 2006). These nurses have chosen to publish their findings in clinical as well as academic journals, but they are working to a patient-led agenda, rather than an academic one. They are in touch with patient need and are driven by the desire to improve patient care. Paley would have us believe that society is becoming increasingly secular, but I am not sure that it is secularising quite in the way he would make out. He focuses on a certain form of institutional religion (e.g. Methodist and Anglican) based upon statistics, but seems to be unaware of experience on the ground. For instance, he fails to mention the independent and evangelical Christian churches and movements which are flourishing (e.g. Hillsong, Alpha, New Wine, Soul Survivor) and the rise in other religions, such as Islam, within our multi-faith society. Whilst we may be seeing more non-religious expressions of spirituality within our society, religion is still a significant force within the UK. As discussed in more detail below, significant changes in healthcare policy have taken place to meet the spiritual needs of an increasingly religiously diverse society better, as well as the spiritual needs of people with no religion; both are important. As indicated above, patients also tell us that both religious and non-religious spiritual needs are important to them and as nurses we have a duty to respond to both. The fact that nursing is constructing a wider understanding of spirituality indicates a willingness to adapt to changing patient need and to shape service provision accordingly. The second reason nursing is broadening its understanding of spiritual care is in response to healthcare policy. These policy documents stress the importance of addressing both religious and non-religious spiritual needs and indeed the remit of hospital chaplaincy is to respond to the spiritual needs of people of all faiths and none. Internationally, we have seen bodies such as the World Heath Organisation including the spiritual dimension, in its broadest terms, within health impact assessment (WHO 2002). At European level, the Department of Constitutional Affairs (2006) has resulted in the needs of diverse religious groups being catered for within healthcare provision. Within the UK numerous documents have been produced by the Department of Health and the Scottish Executive Health Department (2002) providing guidance on both religious and non-religious spiritual care within our NHS, the most recent of which again stresses the importance of providing multi-faith support in a religiously diverse society (Department of Health 2003). One of the key recommendations of the NICE Guidance on Cancer Services is that cancer sufferers should have their religious and non-religious spiritual needs addressed (NICE 2004). This recommendation similarly features in National Service Frameworks for Mental Health (Department of Health 1999), Older People (Department of Health 2001) and people suffering from Coronary Heart Disease (NHS Modernisation Agency –Department of Health. Coronary Heart Disease Collaborative 2004). All of this healthcare policy stresses the importance of both religious and non-religious spiritual support provision within our NHS. It is hardly surprising, therefore, that such policy development has served to widen nurses' understanding of spirituality and their practice of spiritual care. 2 Contrary to Paley's claim, UK clinicians can identify with a broader understanding of spirituality and they want to be involved. Paley claims that the wider understanding of spirituality that is emerging within nursing is one that few clinicians can identify with and are unwilling to be involved in, unlike their North American counterparts. He is clearly misled in this respect. Again he fails to cite any evidence for these claims and appears to be unaware of what is happening in practice. Clinical nurses in the UK not only have a broad view of spirituality, seeing it as something more than religion (e.g. Narayanasamy 1993, Ross 1994, McSherry 1998, Carroll 2001, Narayanasamy & Owens 2001, Narayanasamy et al. 2002), but they also see spiritual care (attending to the religious and non-religious spiritual needs of patients) as part of their role and are willing to work with other healthcare professionals in bettering patient care (e.g. Ross 1994, McSherry 1998, Carroll 2001, Narayanasamy & Owens 2001, Narayanasamy et al. 2002, 2004). Such a scenario is hardly indicative of trying to assume control. Whilst nurses were not always comfortable with giving spiritual care, they did, however, acknowledge the need for more education for preparing them for this role (Narayanasamy 1993, Ross 1994, 1996, Charters 1999, McSherry et al. 2004). This is a similar sentiment encountered by many of us across the UK involved in educating tomorrow's nurses. For example in an in-house survey of a cohort of final year nursing students at Glamorgan University (n = 160) just under 60% said they would like further education, a strange finding if nurses have no intention of showing greater involvement in this aspect of care. In addition, there are an increasing number of articles being authored by clinical nurses in the UK seeking to implement spiritual care in their practice and questioning how this can best be done (e.g. Oldnall 1996, Kenny 1999, Govier 2000, Hancock 2000, Thompson 2002, Hammond 2003, MacLaren 2004). Current research studies on spiritual care in the UK are also being led by clinicians. For example two current studies, one on spiritual needs and care preferences of heart failure patients and the other on the spiritual impact of witnessing resuscitation of a loved one, have been initiated by Consultant Nurses in Heart Failure and Acute Medicine, respectively, where they are seeking to improve patient care within their hospitals. All of this activity, contrary to Paley's view, provides evidence that clinical nurses in the UK identify with a broader understanding of spirituality and want to engage with spiritual care. 3 There is a need for careful interpretation of research findings. One point I would agree with Paley on is the need for careful interpretation of research findings in this field, as in any other. He refers to the very obvious differences that exist between the UK and the USA and goes on to say: So it is unfortunate that the nursing literature on spirituality routinely lumps together UK and USA sources (most recently, Ross 2006), in a way that can easily lead to misconceptions. (p. 4) But why should literature which discusses research on a common topic (in this case spirituality) from different countries be a problem and lead to misconceptions? Is Paley suggesting that people reading such literature are unable to judge for themselves the strengths and limitations of individual studies? The particular article he cites as an example (Ross 2006) is exactly what it says it is: an overview (not a critique) of the published nursing research on spiritual care from 1983–2005. The article lists the studies conducted and was intended as a resource, not a critique of this research. It would be the reader's responsibility to obtain the original articles and make judgements about the strengths, limitations, quality and usefulness of the studies cited, something that most people would do as a matter of course. In conclusion, it would seem that the move within nursing to adopt a wider understanding of spirituality, rather than being driven by an academic agenda as Paley suggests, is in fact a timely response to changing patient need, backed up by healthcare policy and as such is to be welcomed. The patient, however, receives little acknowledgement in Paley's discussion – therein lies his greatest error.
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