Nurses often work with people who are dying and facing a challenging journey of private suffering one that can also leave a lasting impact on friends and families (Lewis and Hoy, 2011). For the bereaved person, this experience often involves anxiety, despair, sadness, guilt, and even relief as part of the grieving process. However, dying or bereaved people often find comfort, and the ability to cope, through the use of rituals and the creation of legacy.
What is ritual?
A ritual is the undertaking of specific activities or behaviours that express symbolic, often culturally influenced, meaning, whereby specific thoughts and feelings are experienced individually, or as a group, by its performers (Rando, 1985). End-of-life (EOL) rituals serve an important purpose as they enable people to express their ongoing grief and maintain connections between the dying person and their friends and family (Rothaupt and Becker, 2007); EOL rituals are also considered distinct from habitual ritual activities as they continuously develop across the initial, liminal and later stages of the grieving process (Reeves, 2011).
Beginning with Freud, grief theory was chiefly concerned with the idea of supporting the bereaved person in emotionally detaching themselves from the person they have lost and with the notion of recovering through ‘grief work’ (Rothaupt and Becker, 2007). Linear stage models would later emerge from Kübler-Ross's seminal Five Stages of Grieving, while subsequent theorists Worden and Parkes would develop this further with their respective Tasks of Grieving and Phases of Grief models (Bayliss, 2008). From here, ensuing theories, such as Tonkin's (1996) Growing around Grief model, Stroebe and Schut's (1999) Dual Process model and Neimeyer's (2001) Constructivist model would offer an understanding of grief as an assimilation process that develops positively from continued attachment.
Ritual as a rite of passage
Rituals enable people to transition through significant events, or crises, that they experience throughout their lifetime, where cultural practices surrounding ‘rites of passage’ take place (Van Gennep, 1960). The developmental psychologist, Erikson (1995) proposed that successful transition through life stages involves completion of cultural roles and rituals. Rituals surrounding entry into adulthood are commonplace, such as the Coming of Age Day in Japan, or military conscription at the age of 18 in Finland; marriage is perhaps the most commonly practised and universally understood of all life-stage rituals.
Erikson's work suggests that at the end of life, people experience a final crisis of psychosocial identity, characterised as ‘ego integrity versus despair’, as they transition from terminal diagnosis to death (Nyatanga, 2008). It is here, at the threshold before death, that people often turn to religion and ritual in order to facilitate this final passage, as death and dying often draw out profound questions of spirituality, even among those who would not normally consider these questions (Bayliss, 2008).
Function and importance of ritual
A person's sense of self-identity and meaning in life can be challenged by the crisis of bereavement, where Neimeyer and Anderson (2002) have suggested that people undertake a two-stage process of meaning reconstruction in order to process this experience. The first stage involves conservation of the bereaved person's identity and understanding about their relationship with the person who has died, as well as the nature and meaning of life, while the second stage involves the construction of new meaning and understanding that adapts the person's past identity to their new reality; a process that Cobb (2008) described as spiritual suffering. Rituals can aid in this process, as they act to maintain the dying person's and the bereaved person's sense of identity, as they face the transition from life to death. They also offer permission for the bereaved person to experience feelings of grief in a safe place over time (Reeves, 2011). Rituals are performed in order to restore a feeling of control (Norton and Gino, 2014) by providing structure and stability for honouring the person who has died and allowing the bereaved person to move forward in life throughout an uncertain time.
Spirituality lacks a universally accepted definition, although attempts commonly reference an accompanying sense of hope, purpose, meaning, faith and belonging (Gijsberts et al, 2019). Nolan et al (2011) described spirituality as a quality that encompasses the individual or communal need for meaning, purpose, inspiration and reverence in life, as well as the need for connection with people, nature, or with the divine. It has also been proposed that spirituality is a concept distinct from religion and that it is present in all human beings, although it may lie dormant until a person is faced with a challenge to their sense of self (Greenstreet, 2006).
Spiritual suffering can involve damage to a person's sense of purpose, identity and wholeness and often occurs following a terminal diagnosis (Cobb, 2008). It comes as no surprise then that the term ‘palliative’ is associated with a loss of hope across many cultures (Wiener et al, 2013). Such damage presents a challenge for the dying person and the bereaved to find meaning in irreconcilable loss (Cobb, 2008); for many, religion offers a vehicle through which meaning and hope may be restored (Puchalski, 2006). As such, people commonly find engagement in prayer ritual helpful when faced with such crises as death.
Ritual structure
Understanding ritual structure can help clarify what is important for people when undertaking rituals. Van Gennep (1960) proposed that all rites of passage consist of three stages: separation, transition and incorporation rites. Separation rites involve a person's removal from their current life stage, while transition rites denote a temporary state whereby a person exists outside normal societal structure and roles; finally, incorporation rites involve the person's reintroduction into society under a new societal status. Rituals that accompany life-stage transitions, therefore, serve to symbolise passage through these three stages (Froggatt, 1997).
Rappaport (1999) proposed four core elements that provide a basis by which rituals can be built and understood (Box 1). Most funeral rituals, for example, reflect Rappaport's elements. They involve a formal performance, which follows a recognisable pattern of behaviour reflecting the cultural background of its participants, where a prosperous afterlife or rebirth is wished for on behalf of the person who has died; and collective strength to cope with the grieving process is sought among the bereaved.
The individual elements of funerals also reflect Van Gennep's (1960) three stages. Separation rites commonly include covering, encasing, burying and/or cremation of the body. Transition rites include the process of funeral planning and preparation, as well as the ceremony itself. Finally, incorporation rites involve the process of collective mourning, following the end of the funeral ceremony; a process that may continue for as long as the grieving process itself does (Fowler, 2004).
Life stages are commonly met by rituals that symbolise passage from one stage to the next, with rituals such as the Jewish Bar Mitzvah or the Australian Aboriginal Walkabout commonly representing celebration of passage through adolescence, whereas university graduation represents a change in societal status. All these different cultural rituals symbolise movement from one life stage to the next through formalised performance (Van Gennep, 1960; Rappaport, 1999).
Prayer as a ritual
Religion provides a structure through which our otherwise incomprehensible world may be understood. Taking an example from Christianity, Frye (1982) noted that the male image of God as depicted in the Bible may have been written to rationalise the patriarchal society that preceded and followed its writing. He also noted that humanity's loss of immortality, as depicted in the Book of Genesis, may have been written to justify primal feelings of death as being an unnatural force that was the fault of an external evil. As such, people often turn to religious belief and prayer ritual in order to make sense of the otherwise incomprehensible nature of death (Nyatanga, 2008).
Although prayer rituals may differ in form, practice, and behaviours (Table 1), most EOL prayer rituals feature a common theme of preparation for a form of life, reincarnation or achievement after death (Green, 1991). As such, they are often of great importance in the acceptance of death and in providing hope for family and friends left behind. It must be remembered, however, that all forms of religious experience are heavily influenced by the person's cultural background; meaning that prayer rituals may be re-sculpted and uniquely interpreted (Watts, 2002).
| Faith | Ritual performance | Separation rites | Transition rites | Incorporation rites | Recognisable formality (use may vary) |
|---|---|---|---|---|---|
| Judaism | Variable sequential prayers emphasising divine mercy | Reciting of the Vidui, a confessional prayer that emphasises the reality of death | Reciting of the Shema, an affirmation of Jewish faith | Surrounding of family and friends who must stay throughout final moments of life | May involve rabbi and removal of outside noise. Presence of Hebrew Bible |
| Muslim | Prayer five times daily, facing Mecca, with ablution prior to performance | Arrival of friends and family that recite various prayers from the Qur'an | Movement of the dying person to home or another location | Reciting of the Shahadah, the core affirmation of Islamic faith | May involve family or other practicing Muslims in their absence. May involve Sakrat, the offering, drinking and application of water from the Well of Zam Zam. Presence of Qur'an |
| Christianity | Eucharist/Holy Communion, reciting of various Bible prayers, Confession | Increased engagement in prayer and worship, request for Holy Communion | Gathering of objects of worship. Confession | Extreme Unction/Anointing of the Sick. Presence of priest ± family and friends | May involve priest and may use crosses, holy water, rosaries, pictures of Christ or other objects of worship. Presence of Bible |
| Sikhism | Reciting of various hymns and mantras from the Guru Granth Sahib | Recital of various mantras | Reciting of hymns such as Dukh Bhanjani and Sukhmani | Continuous recital of hymns and mantras by friends and family, who may also exclaim ‘Waheguru’ upon death | Presence of the 5 Ks: kesh (uncut body hair), kangha (wooden comb), kara (metal bracelet on right wrist), kirpan (short sword worn under outer clothing), kaccha (knee-length underwear). May repeatedly recite mantras for up to 40 days and use images of various Gurus and/or amrit (holy water) |
| Hinduism | Reciting of various mantras from the Bhagavad Gita | Recital of various mantras, presence of family and friends | Fasting and bathing; ganges water may also be applied to the dying person | The dying person is laid on the ground, as close to Mother Earth as possible; family may also chant | Ganges water (Gangajal) may be applied, oil lamps and incense may also be lit/burnt. Icons of the family deity may also be used as objects of worship and comfort |
| Buddhism | Meditation and chanting of various scripture | Settling of personal affairs. Creation of peaceful environment | Beginning of meditation and chanting | Representative acts of goodwill towards the living by Sangha | May involve removal of outside distractions (including noise and pain management). May involve presence of various scripture/sutta/sutra depending on the branch of Buddhism followed |
Prayer rituals of differing faiths and their significance
Prayer within the Jewish culture is often used to express grief and other emotions related to approaching death, while providing hope and comfort to the dying person and their friends and family (Levine, 2015). Although a rabbi's presence is not essential, it is often considered of great comfort, as they provide a sense of community gathering, appropriability and emotional/practical support throughout the process before and after death (Neuberger, 2004). The prayers in use may vary, but present family and friends often wish to be involved in joint prayer. The presence of a rabbi will often precede two specific prayers, namely the Vidui, a confessional prayer, and the Shema, a final proclamation of Judaist faith that may be the final words of the dying person before their passing. This process is said to aid the passing from life to afterlife and may act to comfort the family and friends who stay with the dying person during this time.
Similarly, Muslims often use prayer in comforting the dying person, whereby relatives, or any other practising Muslim in the absence of a relative, may whisper a call to prayer into the dying person's ear and then recite prayers around them (Green, 1991). As with Judaism, Islamic prayers are concerned with affirming one's relationship with God and aiding the transition from life to afterlife, with the similarities extending to a final proclamation of faith before death known as the Shahadah (Gatrad and Sheikh, 2006). The form of prayer is unique in that it is conducted five times daily, requires ablution before performance and is done facing the city of Mecca. Regardless, its significance is similar to that of prayer in Jewish culture as it provides hope for a prosperous afterlife and an opportunity to express grief, while offering emotional and spiritual comfort to the dying person and their family (Neuberger, 2004).
Christianity consists of many denominations, but all incorporate a belief in the death and resurrection of Christ, with an accompanying belief in an afterlife following victory over sin (Jupp, 2015). As such, most denominations incorporate the ritual of Holy Communion/Eucharist in comforting the dying person (Jupp, 2015). This ritual is not specific to the end of life but is often performed to remember Christ's death and resurrection, while also offering hope and reassurance of an afterlife to participants. Catholic and Eastern Orthodox ritual proceedings may additionally include Anointing of the Sick/Extreme Unction, a ritual that involves prayer alongside the application of sacred oil that symbolises purity and infusion of strength during passing from life to afterlife. The ritual of Confession is also particularly prevalent within Catholicism, where emphasis is placed on forgiveness of sin prior to acceptance to a Heavenly afterlife.
Sikhism and Hinduism share a belief in reincarnation and ultimately liberation from this cycle of death and rebirth through acquisition of good karma (Myrvold, 2006; Laungani and Laungani, 2015); likewise, their use of prayer ritual at the end of life is also similar. Sikhism is characterised by belief in a fated time of death, set by both divine will and by one's karma, that cannot be postponed nor hastened. As such, hymns such as ‘Dukh Bhanjani’ (‘destroyer of suffering’) and ‘Sukhmani’ (‘prayer of peace’) are often sung to comfort the dying person by granting strength and courage in this time of crisis. Hinduism also features the singing of hymns to grant strength and peace in the passage from this life to the next; so close is the link between these two faiths that Sikh priests are often summoned to perform Hindu funerals and EOL prayer rituals.
Buddhism generally does not use prayer as other faiths do, as it does not feature a central deity that is worshiped, nor an external paradise awaiting the faithful. Instead, Buddhist followers strive to achieve Nirvana, an internal mental and physical state whereby complete detachment from the physical world is achieved, liberation from a cycle of death and rebirth (Sam ․ sāra) is accomplished, and the state of suffering that comes from living ends (Neuberger, 2004). Mindfulness meditation is the faith's most common ritual and becomes of prime importance at the end of life. Whereas prayer in other faiths is used as an outward expression for support through the dying phase, meditation is used within Buddhism as an internal expression to achieve a similar result; performed to attain enlightenment and either ensure an improvement in status within the next Sam ․ sāra, or final release and achievement of Nirvana. Depending on specific denomination, the dying person may choose to invite others within the Sangha (Buddhist community) to begin chanting various scripture and sutta/sutra (discourse) in order to inspire a calm and joyful state of mind during meditation; such as Bardo Thödol within Tibetan Buddhism, or Heart Sutra within Zen Buddhism (Gouin, 2015). Devout Buddhists may also wish to forgo extensive pain management, to maintain clarity of thought and immersion in the full experience of suffering while undertaking meditation. Furthermore, release from Sam ․ sāra requires the dying person to detach from all material things; as such, it is imperative that the dying person is enabled to settle all personal affairs, and that their environment is made as peaceful and non-disruptive to meditation as possible. Buddhism also adopts the concept of merit transference, whereby acts of goodwill towards the living, in the name of the deceased, impart good karma on both the deceased person and the bereaved (Goss and Klass, 2006). As such, acts of goodwill towards others may become a focus for recently bereaved Buddhist followers.
Implications for nursing practice
Nurses who care for the dying person, their family and friends, seek to provide holistic care that recognises their physical, mental, social, emotional, societal and spiritual needs (Brooker and Waugh, 2013). Of these needs, spirituality is the most nebulous (Greenstreet, 2006) and the most often neglected within health care (Pentaris, 2018), though often the most important (Puchalski, 2006). A considered approach to spirituality can successfully inspire and maintain a sense of hope and wholeness that leaves a profound impact on those undergoing the grieving process (Greenstreet, 2006).
Hospitals and hospices present challenges to these therapeutic rituals through limited visiting hours, lacking facilities and space for prayer or meditation, interruption by healthcare staff and a lack of availability of rabbis or practicing Muslims/Sikhs to aid in prayer. Furthermore, these environments are often seen as alien and non-conducive to spiritual connections, particularly within Islamic culture (Gatrad and Sheikh, 2006), while the 2015 National Survey of Bereaved People (Office for National Statistics, 2016) also found that 81% of bereaved people believed that the person who had died would have chosen to die at home. These challenges must be overcome and the wishes of the dying must take precedence, including the chosen place of dying, in order to ensure that a good death can take place.
In all circumstances, people's preferences cannot be generalised based on their ethnicity or religion; as such, nurses need to consider people's wishes and preferences on an individual basis (Gunaratnam, 2008). Although cultural competence and perceived cultural knowledge may inadvertently act as a form of stereotyping, Neuberger (2004) noted that offers of cultural provision and enquiries regarding a person's wishes can make them feel cared for and valued as an individual, if handled with sensitivity. Furthermore, it should be noted that people may also not adhere strictly to cultural traditions, but instead may adapt them to fit their own individual beliefs and circumstances (Valentine, 2009), as such, an individualistic approach to nursing is key.
Death is considered a taboo subject that people are often unwilling to discuss, so nurses require strong communication and active listening skills to ascertain the needs of the dying person and open up conversations surrounding death (Dying Matters, 2020). Nurses may make use of active listening techniques such as paraphrasing and vocal mediation, as well as open questions, to encourage people to voice their concerns and feelings (McCabe and Timmins, 2013); the use of therapeutic silence may also aid in this approach (Bach and Grant, 2015). To further encourage conversation, nurses must also identify communication barriers, such as distracting noises, lacking privacy and their own fear-provoked blocking behaviour such as change of topic and distancing (National End of Life Care Programme et al, 2011).
Once this is done, conversation regarding the dying person's wishes can begin. The Spiritual Distress Assessment Tool (SDAT) and the Faith, Importance and Influence, Community and Address (FICA) tool may be useful aids for nurses and non-clinical staff in identifying un-met spiritual needs and facilitating conversation regarding how these needs can be met. However, although SDAT (Monod et al, 2012) and FICA (Borneman et al, 2010) have been found to have moderate and high reliability respectively (SDAT Cronbach's α = 0.60; FICA Cronbach's α overall score = 0.93), as well as moderate and high validity respectively (SDAT Spearman's Rank Correlation with FACIT-sp = -0.45) (FICA Spearman's Rank Correlation with FACIT = 0.78), it is worth noting that both studies primarily included participants who were of Christian faith. As such, questioning language may need to be adapted to fit the dying person's faith and individual needs.
Once a person's individual needs are established, nurses can put these wishes into practice; this may involve discharging the patient home or contacting the dying person's family, should consent be given, to pass on necessary information and allow them to visit. From here, provisions can then be made to allow desired rituals to take place, such as offering a Mecca-facing compass and a separate room for ablution before Islamic prayer (Gatrad and Sheikh, 2006), or the calling of a rabbi for those of Jewish culture (Neuberger, 2004). Sources of faith-based community support are often bountiful and invaluable for the dying and bereaved; examples from the Jewish faith are presented in Box 2. NHS Trust intranet sites will provide contact details for local sources of community support, such as the Imam of the local mosque for those of Islamic faith, and it is recommended that nurses make use of these resources.
Nursing rituals
Nursing's military and Christian origins continue to influence modern practice, as responses to the spiritual needs of patients are often still filtered through a Christian-centred lens (Pentaris, 2018). An example of this can be seen in the modern act of ‘Last Offices’, a term derived from the Christian sacrament of Last Rites (Quested and Rudge, 2003) and the Latin term ‘officium’, which means ‘service’ or ‘duty’ in English and implies sanctioned power, authority and responsibility from its original military context (Dougherty et al, 2015). This officium is reflected in the prescription of standard procedures of nursing care of the dead, as depicted by Dougherty et al (2015), and its Christian influence is visible in the ritual act of the closing of the eyes and mouth on death; an act that is not medically required before transport to the mortuary, but instead is chosen for its aesthetic qualities and accompanying Christian-inspired image of peaceful slumber among angels.
Given nursing's continued attachment to ritual, why should nurses be reluctant to support the ritual practices of the people they care for? In acknowledging their own use of ritual, nurses must seek to understand and support the rituals used by the people they are caring for.
Conclusion
Prayer rituals offer guidance throughout fearful times, where a person's sense of identity is challenged, while also offering spiritual and emotional comfort throughout the grieving process. With only one chance to get this care right, nurses need to offer authentic compassion and make use of all available skills and resources to ensure that desired rituals can take place, and that a good death can be followed by good care of those left behind.