Advancing Spiritual Care Through Research

Assessing and Communicating the Spiritual Needs of Children in Hospital

Allison Draper, MDiv BCC

Manager of Spiritual Care Services and Chaplain Maternity/ L&D and NICU

Stanford Children’s Health, Palo Alto, CA

Alister Bull. Assessing and Communicating the Spiritual Needs of Children in Hospital. London UK and Philadelphia: Jessica Kingsley Publishers 2017

Every once in a while, something I read will bring immediate clarity to an issue that has long been clouded. Alister Bull’s short book, Assessing the Spiritual Needs of Children in Hospital, parted the clouds and revealed a brilliant vision for how to language and practice pediatric spiritual care. For any healthcare chaplain who, like me, has struggled with how to explain to patients, families, or interdisciplinary colleagues what it is we do, or how we do it, I encourage you to read Bull’s book. With clear language and a no-nonsense approach, Bull pinpoints what pediatric chaplains are looking to assess and shore up with a hospitalized child. He proposes practical inventions, based on well-established child development models.  Indeed, the proposed methods and precise, practical language offer healthcare clinicians of all disciplines a way to access, support and incorporate the spiritual needs of a child into their plans of care.

In his introduction, Bull reflects on his own questions, what is “spirituality” and “what does spirituality mean to a child?” Bull’s beginning premise is that the word “spirituality” is just too imprecise a term for clinical use in the predominately secular, pluralist environment of a UK hospital. Here in the United States, the terminology around what a chaplain is and does is more firmly rooted in Christian theology and language. Religiously affiliated organizations still account for an estimated 20% of acute care beds in the U.S. even though the number of religiously identified adults is on the steady decline. Conversely, the percent who identify as “spiritual but not religious” is steadily increasing (  This dynamic away from overt religious identity is likely the driver for fledgling efforts to change the potentially exclusionary language of healthcare chaplaincy. As a chaplain in a secular, academic hospital in the culturally diverse Bay Area of California, I resonate with Bull’s observation: the term “spirituality introduces a language that make some suspicious, gives academics plenty to argue about and leaves practitioners ambivalent to what it means to both the carer and the patient.” Rather than continue to debate the meaning of a fundamentally undefinable word (“spirituality”), Bull proposes “connectedness” as the domain of the pediatric chaplain. This word immediately telegraphs an internal, personal, and context-specific arena of practice. Bull also points out the “strong physical imagery” of the word and why it has such strong appeal across many professional fields.

Within the realm of spiritual care, connectedness speaks to an inner experience and an outer relational expression of that experience. I found myself intrigued by the inherent simplicity of Bull’s idea to use a continuum of connectedness-disconnectedness to collect consistent child-based ratings about their experience. This continuum scale can become the basis for assessing, resourcing, and documenting changing spiritual needs throughout a child’s hospital experience. 

Bull calls upon four theories of early childhood development in shaping his ideas about connectedness. From the foundation work of Jean Piaget, Erik Erikson, Urie Bronfenbrenner, and James Fowler, Bull constructs four “dimensions” of connectedness: momentum of connectedness; resilience of connectedness; awareness of connectedness; evaluative nature of connectedness. Each of these areas can be assessed by the spiritual care provider, and in the process of the evaluation, increase the child’s felt experience of connectedness.

After explaining how to understand child development through the lens of connectedness, Bull organizes the book with concrete examples that illustrate how children connect. Chaplains will immediately recognize the themes elicited from children in Bull’s care as spiritual and existential in nature. Bull provides practical ideas for how to connect and communicate with children through their natural “language” of play and storytelling. He calls this initial phase of engagement “building the Zone of Proximal Connectedness” or ZPC. In creating a liminal safe space for a child to talk about their hospital experience, Bull notes that the chaplain’s role fundamentally shifts. The chaplain becomes a facilitator and documenter. The chaplain, as a trusted adult, is allowed to lay out how the assessment will be conducted, setting the rules of the game. The child in playing the game is free to decide what they want to share about themselves during this encounter. The chaplain becomes an observer rather than an initiator. The focus, Bull says, becomes receiving and documenting information from the child. The child is free to share in more detail about their felt experience within the given immediate context of the hospital setting.

Bull provides examples of “tools” such as a Fruit Tree Exercise that enable the child to prioritize what is most important to them while hospitalized. A Likert Scaling Exercise allows the child a way to state degrees of preference. These tools are offered to the child to place on a bigger board representing the hospital. The tools and structure offered by the chaplain facilitate the child’s storytelling. The chaplain, as assessor, may ask open ended questions about why a particular card is placed in at the top of the tree (of highest importance) or why something has greater preference? Through this child-driven narrative, the chaplain can assess the degree of connectedness vs. isolation a child is experiencing on a particular day, and document to the care team what this child has identified as resources that help them feel most connected in the hospital. 

In concluding the book, Bull returns to his initial premise that the term “spirituality” is too imprecise to be useful in understanding the dynamics of a child’s moment to moment hospital experience. “It is a distraction for a healthcare professional to try and identify an individual’s spiritual profile; a greater freedom is created when they are released to explore connectedness and disconnectedness… and how this contrast relates to children’s perceptions of their situations.” A chaplain’s unique role in healthcare is engaging directly with the outer expression of the inner, “spiritual” world of another person. We find out where another person finds comfort and connection to support their healing. This may or may not involve religious faith.  Our role is that much more difficult to do and explain to other clinicians when it involves a child. A child may not be able to articulate their inner experience and needs because of their age and developmental stage, illness, and personal history.

If you are a healthcare professional who has ever struggled to explain “spiritual care” to children, families, or interdisciplinary colleagues, I wholeheartedly recommend Alister Bull’s book.  Bull’s clear language and simple approaches remove the “distraction” of overt spiritual and religious framing. I’m intrigued to see how the language and facilitation of connectedness might lead to more reflective practice for individual chaplains. I’m curious how this approach might lead to greater clarity and growth for the profession, as we seek to meet people of all ages and backgrounds, to facilitate their voices in guiding their own healing journeys.

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