Serenity Spirituality Sessions: A Descriptive Qualitative Exploration of a Christian Resource Designed to Foster Spiritual Well-Being among Older People in Nursing Homes in Ireland

: This paper reports on a descriptive qualitative study that explored the value and benefit of Serenity Spirituality Sessions programme for older nursing home residents. The research was carried out in six nursing homes in the Republic of Ireland. The facilitators of these sessions, who worked in the nursing homes, were interviewed about their experiences of delivering the programme and their views on the impact that the programme had on resident participants. Emergent themes revealed benefits of the intervention for clients, including inducing a calming effect, increased sense of belonging and benefits of ritual use. The programme yielded positive results, and appears suited to the predominantly Christian population, and as such is deemed a useful adjunct to holistic and spiritual care in these settings.


Introduction
There is emerging consensus that spiritual care forms an important role in overall care of older people [1][2][3].For many older people, religion and/or spirituality play an important role in their lives [2,3].It is generally accepted that most people have spiritual needs as well as physical and emotional needs [4].Spirituality is often a very important coping mechanism when dealing with difficult circumstances or major changes in life, such as moving from independence to dependent care or facing death [2,3].It is often a core part of the older person's identity and as a result many residential settings for older people support clients' spiritual needs [2].There are currently more than 20,000 people living in residential nursing home care in Ireland, within more than 450 nursing homes providing care.Many of these provide spiritual care to clients through the use of chaplaincy services.Additionally, a small number of homes also provide access to religious services and/or spiritual care interventions provided by nursing or activities staff.While no national standards exist to support this intervention there is acceptance and recognition that clients have spiritual needs to meet while receiving care (Health Service Executive, and that responsibility for this lies with all health care staff) [4].

Providing Spiritual Support to Older People
There is growing consensus that health care can be maximized by providing spiritual care [5].Reasons for this are outlined in Box 1.

Box 1.
Reasons for the provision of spiritual and religious support to patients [6].
(1) Many patients are religious, and the majority would like their faith to be considered in their health care.(2) Religion influences patients' ability to cope with illness.
(3) Religious beliefs and practices may influence medical outcomes.(4) Patients are often isolated from other sources of religious help.(5) Religious beliefs and rituals may conflict with or otherwise influence the medical decisions that patients make, particularly when they are seriously ill.(6) Religious beliefs and commitments influence the type of health care and monitoring that a patient receives in the community.(7) Medical, nursing and psychiatric training programs are now required to ensure that all graduates provide culturally sensitive health care, which includes care that is sensitive to deeply held religious beliefs.
Spiritual needs of older adults are manifestations of the ageing process [7].It is therefore recommended that that spirituality can be integrated into care in a sensitive and sensible manner by taking a brief spiritual history at the time of admission to a nursing home.Identifying patient needs in this way can provide vital information for the care of the patient [6].As people age they begin to consider more fully issues of ultimate meaning about life and to prepare for their death [1].For many, this means a growing concern with responding to ultimate meaning, developing means of transcendence and growing intimacy with God and/or others [1].There is also a need for forgiveness, to prepare for dying and death and to feel useful [8].
Old age is a life stage where meaning-making is vitally important, a time when the older person can potentially stand back and come to terms with all that has gone before, a time when transcendence is possible.It is suggested that: Creating a spiritual life that provides a sense of ultimate meaning gives a resource for putting life events, both positive and negative, in to context, transcending losses and disabilities, creating a sustaining sense of connection with the sacred, and developing the capacity for deep inner peace ( [9], p. 116).
There is also a proposed notion of gerotranscendence, which suggests that: Spiritual development gradually and steadily increases from middle age onward and results in a shift from materialistic, role-oriented life philosophy to a transcendent, spiritual perspective in late old age ( [9], p. 33).
As such it seems that for some spirituality and aging go hand in hand.This means for some, that healthy aging, requires support to meet the spiritual needs of older people, known as the spiritual tasks of ageing [1] (Box 2).Box 2. Spiritual tasks of ageing [1].
 Finding ultimate meaning for themselves-through relationship, reconciliation with family and/or God, dealing with guilt//loss, etc.  Assisting a person in moving from self-centredness to self-transcendence-through acceptance of self, of ageing, of chronic conditions, of anger/grief, etc.  Responding to ultimate meaning with spiritual strategies-through worship, prayer, sacred reading, music, art, etc.  Being "with" the older person, developing intimacy in relationship-though listening, connecting, trusting, caring, honouring, etc.  Moving from provisional life meanings to final meanings-through reminiscence, life-review, finding meaning in growing older, in suffering, in death, etc.  Giving hope-through genuine care, affirmation, support in the dying process, etc.However, while spiritual needs in older people are being recognised more, there is often reticence around providing or facilitating spiritual care and a focus on doing so in life limiting circumstances [10].At the same time, recent studies show that older people engage regularly in spiritual activity while at home [11].
In many nursing homes, caregivers, such as facilitators, can often play a very important role in the life of the resident.They may form very close relationships with residents through daily interaction, often on an intimate level, in terms of bathing, dressing, feeding, sharing concerns, etc.They may also provide an intimate listening space to allow residents to relate their personal stories, as form of spiritual reminiscence.
For many older adults in care, ritual has played a huge part in their lives.Ritual provides a sense of continuity, a link with the past, but also to culture and faith [12].Rituals can take various shapes and forms.For many, the ritual of a Catholic Mass or a similar service can have a dual purpose: it can provide an opportunity to connect with or respond to the resident's concept of the Divine in a familiar setting and provide a space where the resident can feel a sense of community and belonging [1].While prayer and other rituals may seem quite a religious intervention, these nursing interventions have been found to be popular in other settings [13,14].
This project aims to explore the usefulness of a pre-designed spiritual care programme-the Serenity Spirituality Sessions-that was developed by Sonas apc Ireland [15].Sonas apc is a charitable (not-for-profit) organisation whose primary aim is to train healthcare staff and family to provide therapeutic support for older people with communication challenges, particularly those with Alzheimer's and dementia.They provide a range of training resources for this purpose, which provide a huge resource in a country that is economically challenged, under resourced, and like the rest of the developed world, has an increasing aging population.The Serenity Spirituality Sessions programme was developed in 2011 in response to a growing awareness of the need to provide additional spiritual support to older people.As the majority of people admitted to nursing homes in Ireland are Christian, the package was designed to suit the needs of the majority at this time.

Aims
To explore the use and value of the Serenity Spirituality Sessions programme for older nursing home residents.

Objectives
The research aimed to:  To oversee the delivery of the Serenity Spirituality Sessions programme to a sample of older nursing home residents. To explore the value of using the Serenity Spirituality Sessions programme with older nursing home residents from the perspective of the facilitators.

Method
The Sample Purposive sampling was used to identify six spiritual care facilitators from six nursing homes in the Republic of Ireland.All participant nursing homes were approved by the Health Information and Quality Authority [16] and were members of Nursing Homes Ireland (NHI).All were privately run.The nursing home residents were generally accepted to be older people and no provision was made to determine or select a nursing home based on demographics.
Purposive sampling determined those nursing homes which appeared to have openness to spiritual care as evidenced from observation of their websites as well as the Nursing Homes Ireland website (NHI 2014).As such, they indicated that spiritual care was important and/or that they offered regular services/visits from various clergy for their residents, and/or that they had an oratory on site.As the intervention is primarily a Christian one, consideration was given to the suitability of its use, namely that residents taking part were Christian and such intervention was deemed consistent with the usual spiritual care component of holistic care at the home.
The nursing homes were either already running the Serenity Spirituality Sessions programme for older nursing home residents (n = 4) for a short time period (less than one year), or were in agreement to do so.In those four sites where the programme had been running, this was for periods of between seven months and eighteen months.The other two nursing homes ran on a trial basis for the duration of the intervention (four weeks).Inclusion criteria were that both the nursing home and the facilitator needed to be willing to participate and the facilitator needed to provide written consent to take part.Six activity co-ordinators/facilitators in charge of spiritual time/activities were interviewed.
A dedicated activity co-ordinator/facilitator in charge of spiritual time/activities was required to run the intervention.All six facilitators were women.No particular training in either spiritual care delivery or using the programme was required, as the intervention is deemed to be suitable to be used by any adult family member, staff or carers with the capacity to read, understand and conduct sessions.The facilitators self-trained using the "how-to" DVD provided.

The Serenity Spirituality Sessions
The study comprised the delivery of a specifically devised Serenity Spirituality Sessions programme.This programme was developed by Sonas apc [15] under the guidance of its founder Sr. Mary Threadgold, a speech and language therapist.Content was selected based on an in-depth expertise in the field and expert advice on other aspects (such as appropriate music) was sought during its development.Sr. Mary Threadgold developed the Sonas programme in 1990.She had seen the value of music and touch when working with young people with intellectual disabilities and wanted to design a therapeutic activity for older people who had communication impairment that built on that knowledge.The resultant Sonas programme incorporates multi-sensory stimulation within a structured session that involves cognitive, social and emotional stimulation and is now being used frequently in Ireland for people with dementia.The Serenity Spirituality Sessions is a specifically designed Christian spiritual support mechanism that can be easily used by staff, family or volunteers who are involved in caring for older people.It is available to purchase at cost of 80 euro [15] and the operation of it is self-explanatory.Those who wish to facilitate spiritual support for older people need only watch the "how-to"-DVD provided with the package.The sessions come as a complete package, which includes a box set of CDs, an information booklet, and a DVD.These materials are visually appealing (Figure 1) and were provided free of charge by Sonas apc [15] to participating nursing homes who were not already in possession of the programme.The Serenity Spirituality Sessions box set is a turn-key solution to support the continual nurture of Christian Spirituality for older people in care.A checklist is provided to prepare the way for a successful session.The facilitator is encouraged to keep the group size small (maximum of 8) in order to ensure quality interaction.Sessions last between 35 and 45 min and consist of 6 guided sections: (1) Let's begin, (2) Praying with Scripture, (3) Prayers and Reflections for Others, (4) God's Presence in Nature, (5) Personal Prayers, (6) Final Blessing and Hymn.
The CDs are played during each session, which gives opportunity to participants to listen to a range of scripture readings, liturgy and music selected by the facilitator.An example of CD content is provided in Box 4. All the material contained in the box set has been carefully selected for older people to be reminiscent of their own Christian prayer throughout their lives.There is a focus on familiar readings, psalms and prayers to facilitate comfortable and easy participation.
In the current study, the facilitator/activities co-ordinator was requested to run the six sessions over a period of three to four weeks, and to participate in a follow-up interview.How the facilitators ran the session varied.Two of them ran the programme on a regular weekly basis, one ran it twice a week and one did not run it on a regular basis at all.All except one nursing home ran it on the same day at the same time in the same place each week.The two facilitators using the programme for the first time ran it once a week for four weeks.In all six cases it was conducted in a sitting room or day room, in the home.Attendance varied from 7 to 12 in general, with up to 20 included in one session in one home.Participants were self-selecting.This choice of numbers was not dictated by the programme but rather according to the needs and facilities of each service.Box 4.An example of CD content of the Serenity Spirituality Sessions.Hymn-Amazing Grace Track 9

CD1 Track
Scripture reading Track 10 Music

Data Collection Measures
Data were collected in 2012.Semi-structured interviews were used to collect data.These interviews comprised a number of open-ended questions, the responses to which were recorded.One-to-one interviews were held in a convenient quiet room in each nursing home site at a time convenient to the participants.Data collection included a seven-item interview schedule.These questions were formulated following consultation with the designers/promoters (Sonas apc, 2014) and in accordance with literature on the topic.Proposed questions were also discussed with some academic peers not participating in the project, in order to establish face and content validity.The questions were sent out to each interviewee in advance to allow time to prepare and contemplate responses.Four of the participants opted to write down some initial preliminary notes to use as an aid in the interview.

Ethical Considerations
The local College Research Ethics Committee (LCREC) granted ethical approval to conduct the study.A formal request to each nursing home manager determined access.As the nursing homes were already providing Christian spiritual services that residents chose to attend or not, and as the majority of residents at the site were Christian, the ethos of the materials was not deemed inappropriate.Additionally the provision of such a programme, voluntarily attended by residents, was not viewed as coercive by either the managers or the LCREC, as it comprised an extension of usual spiritual service provision.Anonymity and confidentiality, of both the respondents and the sites, were preserved.The method of data collection preserved both of these, and this fact was made clear to respondents.Written information on the study was provided to both the nursing home managers and the facilitators.The nursing home managers acted as gatekeepers and recruited facilitators.Participants also signed a consent form, and were given time in advance to consider and provide consent.Participation in the programme by residents was encouraged in all nursing homes but was voluntary, always respecting the wishes and well-being of the resident.

Data Analysis
The interviews were audio recorded, transcribed and analysed using thematic analysis [17].The interview recordings were listened to several times in order to become totally immersed in the data gathered.All recordings were then transcribed in full detail, read through and analysed carefully and finally coded in a thematic manner.The approach used to analyse this data in this research project can be described as one of thematic content analysis.This is an approach widely used in social science research that is useful for identifying rich patterns and trends within the data [18] It follows the 16-step method developed by Burnard [19], with the aim of producing "a detailed and systematic recording of the themes and issues addressed in the interview and to link the themes and interviews together under a reasonably exhaustive category system".The employment of this method meant that notes were taken after each interview regarding the general topic discussed.Interview recordings were listened to several times.Transcripts were then completed and read through several times in order to become immersed in the data and enter the other person's "frame of reference".Unnecessary and repetitious text was removed.Another reading of transcripts identified and noted general headings/themes to categorise the content of the interviews (open coding).The list of categories was then grouped under higher-order headings so as to "collapse" or reduce the number of headings overall and a final list was produced.The next stage involved colour-coding categories and sub-headings.The coded sections were then arranged in appropriate groups.Multiple copies of transcripts were used to ensure the context of the coded sections was maintained.

The Findings
Three main themes emerged which can be summarised as follows, benefits and challenges of the sessions, rituals/beliefs to support faith, and a sense of community and belonging.

Benefits and Challenges of the Sessions
All facilitators expressed the view that the integrated package was a very useful tool to support clients' spirituality.One stated that ( [20], p. 39): The package is very good.It's very helpful because if I need to do a spiritual session, like praying, I wouldn't know where to start…it's a very good tool to do it.
Another described it as "brilliant, because it's just compact, you know".One facilitator stated that ( [20], p. 39): It was very easy to follow…because everything is already prepared for you, it cuts out on your preparation time and [having] everything under the one roof is great in an environment like this…it's good to have everything and you can just lift the case and go with it.Put it in your CD player and you know that you've got all the ingredients for a successful group.
Another facilitator mentioned that "an integrated package works, but it needs to kind of stand alone", while another mentioned how it would be a very good tool for someone who was not a native English speaker or not so familiar with Irish culture.Another facilitator expressed the view that the intervention was: …easy to manage and to run and it's all there and it explains how to run it.If it wasn't for that, I think it would be quite difficult to kind of come up with something like that yourself, that would be effective and that would have the same impact on older people really ( [20], p. 39).
All facilitators found it had a huge calming and relaxing effect on the residents.One reported that: Two ladies actually on two occasions were very agitated.One of them was looking for home and she wanted her daughter and this, that and the other, and when I brought her up, she sat and she had her hands clasped like this (hands clasped as in prayer) and she tapped in time with the hymns and music and she sang along and she prayed and she became completely, (pause) her whole countenance just changed once she was away from that busy environment, she was just completely calm and relaxed ( [20], p. 38).
The same facilitator also shared: The same with another lady, she would pull herself along in the wheelchair, and she was totally out of sorts and when I brought her in here, and just, I think the quiet room, the environment, and she got a lot of joy from it, definitely did and she sang along.She has very poor communication.Now she would have had a stroke and that, and she could only repeat the same words over and over again…and she can sing every word of the hymns, and she can sing along with them, so it just taps in to a different part of her memory or her brain…very effective for her, particularly her, like I could see just the benefit she got out of that and the other lady that was very restless as well, do you know, it had a great calming effect on them ( [20], p. 38).
One interviewee stated that "residents really feel calm, calm and peaceful after the session".She went on to give a very pertinent example of one lady attending the sessions "who is usually quite agitated…and most of the time she settles down, you know".She described another resident who was in another nursing home and was all the time on his own, eating in his room, never out of his room.But that changed: In our nursing home, with the good work of the care assistants…that man is going to have his meals downstairs in the dining room.He comes to Serenity and to Mass.But when you see that he never got out you know, for these things before, it's a great achievement.And he has really enjoyed it ( [20], p. 40).
The same facilitator gave a similar example of another female resident: she was at home, for a couple of years, she had dementia, she was sitting alone looking at the wall, from day to day…When she came here she couldn't participate in anything…then Serenity brought her out and then Sonas…now she's communicating, she's taking part in all activities, which she would never before.It's just amazing!...she's so happy doing something and not just sitting ( [20], p. 42).
Another facilitator felt "the benefit was the comfort", while a third saw "real benefits in terms of two ladies that were agitated, that were stressed.They calmed down, they were able to sit through the session, they didn't look to leave, which, in other sessions they quite often would look to leave, or still remain agitated.But this they didn't.They stayed calm and remained calm afterwards" ( [20], p. 41).
A similar lasting benefit was reported by a fourth facilitator, which underlines the relaxing effect of the sessions: "We've noticed that during the session, as the session is progressing, people become very relaxed.And we noticed that that relaxation carries on then for the rest of the day" ( [20], p. 41).Another observed that: You don't know what effect it has on somebody deep down, really you don't know.It could be subtle…it could be something you don't even realise, but tomorrow somebody might notice a change in the person, or that the person is calmer or what have you, so you know, still waters run deep ( [20], p. 41).Other direct feedback from the residents given by two more facilitators included comments such as, "That was just beautiful!","That was lovely", and "When can we do it again?","Can we do it every evening?" ( [20], p. 42).
Several facilitators observed that residents really valued and needed relationship and intimate sharing.A good example of how relationship and intimate caring can benefit the resident was described by one facilitator who felt hymns were so important: We've a woman in here, she's blind, but she has her hearing and if you go up to her and sing with her, she'll rock with you, you know, which is brilliant...that's where you need the songs."Another reported that "I think it's nicer because you're giving them more attention, it's more close [sic], there's more closeness, there's more intimacy in it definitely, yeah" ( [20], p. 48).This emphasis on intimacy resonates with the opinion of Elizabeth MacKinlay ([1] p. 81), who states that "Intimacy is just as important in later life as at any time along the lifespan; perhaps even more so in the frailty of later life, having lost physical or cognitive abilities, the person is even more in need of relationship and love.""For people with dementia" she declares, "relationship is almost synonymous with meaning".Eileen Shamy ([21], p. 61) also stresses the importance of relationship in her definition of spiritual well-being: "Spiritual well-being is the affirmation of life in a relationship with God, self, community and the environment that nurtures and celebrates wholeness." This relatedness and connection is illustrated in another facilitator's observation during the trial-run of the Serenity programme: I think as a group we all feel very connected, at that time, so allowing myself to connect with the residents in that time, at that level.So including myself as a member of that group, offering my prayers with the residents and sharing something of myself within that group as well, I think that, for me, that is important, that I feel and that the residents feel that we are connected ( [20], p. 48).
The importance of the programme for building up relationships and intimacy is demonstrated by another facilitator who reported that "I do feel since I've started this, my relationship with the residents, it's got closer, you know that kind of way.They are opening up a little more about their fears and things like that, which is good."( [20], p. 48).
All facilitators appeared to be very aware of the importance of honouring the personhood of each resident.One stated, "I think before attending to the physical needs of a person, you have to remember that he is a person (emphasis participants own)" She went on to describe a common example of carers under time pressure, rushing a resident to get dressed, etc.She remarked that carers need to ask themselves if they are performing the task for the resident or for themselves, and declared, "Often you're doing it in your own way, how YOU are used to doing it…so before starting any physical needs you should ask how HE would like to do that…the main thing to remember is that it's not a piece of meat you're taking care of, you're taking care of a person" ( [20], p. 49).
Another facilitator described how her spirituality helps her be a presence for others in the nursing home.She spoke of one man whose wife had died and whose grief was triggered when certain hymns were played; "He'd get upset because it brings back memories, you know which is good, and I'd put my arm around him and say 'but you know it's OK to cry'."( [20], p. 49).
Henri Nouwen ( [22], p. 19) describes the importance of this compassion when he states, "Yet perhaps our greatest gift is our ability to enter into solidarity with those who suffer.Compassion can never coexist with judgement because judgement creates distance and distinction, which prevents us from really being with the other".
A third interviewee felt that, when caring for older people, being present and giving reassurance in the Serenity Spirituality Sessions was vitally important: "older people need an awful lot of reassurance that their life was worth-while, that they spent it well, that we give them a value and a worth at the end of their lives".She understood the importance of being a listening and reassuring presence for those "in spiritual pain"; those worried or even close to death.Her personal experience of watching her own father dying in pain made a deep impact, but also gave her great insight into pain as he revealed to her; "It's all part of the process…the beautiful process of dying."She shared that this made her "so conscious, so conscious from that day, that there actually is a process going on for the person who is dying…because there isn't a person I sit with that I don't think of him and keep my mouth shut most of the time and just say, 'Listen, I'm here, you're not on your own'."This is a deeply touching example of understanding Personhood and gifting Presence.( [20], p. 49).
The theme of presence was prominent in the literature reviewed and also emerged as a significant theme in the interview data.This is illustrated in a story related by one interviewee concerning a resident who shared after a Serenity session that she was feeling sad and alone.The facilitator recounted how she told the resident "you're not on your own, we're one big family in our community here.We are all here for each other and we're all friends, OK and you're not on your own ( [20], p. 50)."She added, "So I was giving her a lot of reassurance, so I told her I loved her and I gave her a big hug, and if she ever needed to talk to somebody, that I was here for her."Then she described how the reassured resident "gave me a big hug and said 'Thank you so much.I feel so much better after that!'"This is another significant example of the healing power of presence.This facilitator showed particular awareness of being present as she declared: "I think it's important, sometimes you know, just sitting there and listening to somebody, it's very important, they need to be able to express how they're feeling."( [20], p. 50).
There were also some challenges with the programme materials.One facilitator mentioned a difficulty she encountered when she noted that "it doesn't really give you a guide as to how do you encourage people to reflect on scripture".This facilitator felt that a template of "just maybe four points on how to reflect" would be useful, because "…initially it's difficult to grasp an understanding of what and how you are supposed to say, what do you say?What do I say to a group of elderly people that makes sense to them and that respects their beliefs…that was meaningful?" ( [20], p. 40).Some facilitators felt that four weeks was too short a time-frame in which to really come to grips with everything involved in running the programme.
In regards to the prayer/hymn booklet, five facilitators felt the format could be improved in various ways for residents with poor eyesight and for those with motor difficulties.For example one wanted to "make it bigger; well make it clearer and [use] bigger font and once you do that, I think that's perfect."( [20], p. 39).

The Use of Rituals to Support Existent Faith
Maltby [23] maintained that "religious symbols can facilitate the tasks of aging persons by providing a link with the past as well as being a concrete reminder of hope in the future.Even those who have language impairment can frequently sing familiar hymns and become involved in a community ritual".
This view appears to be illustrated well by the Serenity Spirituality Sessions experience in terms of examples given by some interviewees.One facilitator described a resident who "has full blown Alzheimer's and she could shout at you and all.And she has her beliefs, so I like her in the group, even if she shouts, but I think it's important that she is in it as well, even though she wouldn't communicate with you, coz there is something there.And yesterday we were singing…she was down from me…and she was singing along to the CD, and that's great feedback to tell her family."( [20], p. 50).
Another felt the prayers gave great reassurance.She stated, "It gives comfort and they are looking forward to it…it gives hope and meaning, yes!"A third facilitator talked about the ritual of weekly prayer together and how "some would pray for their families and praying for this and that and everyone is sharing.I think it brings this feeling of closeness...I think it's very important."( [20], p. 47).
The benefit of ritual prayer and song as a support for clients' spirituality and faith resounded through the findings.One facilitator stated: I think a lot of our residents have got very strong faith and they like to practise…they like to come together as a group to pray, it means so much more if you're praying with other people.( [20], p. 42).
Another facilitator said that "the benefit was as well that they knew the hymns…they were calm and they were getting some peace and joy from it" ( [20], p. 41).Another felt that while there was a good Mass service and Communion service in the nursing home, the residents also benefitted from a more informal praying together: And I think all of the people…feel very connected when they're together and practising their faith together.So something like this really supports this…it isn't like an organised religious ceremony or anything, it's kind of quite informal…and we're coming together to pray because we want to and because they enjoy it ( [20], p. 43).
Another facilitator mentioned the importance of residents being able to express their spirituality during the sessions and how the nursing home provides that continuum of spiritual care: And they're expressing their spirituality…it's a ritual they are doing and they need that.They do…coz religion is very important in peoples' lives you know….Like say for example a resident goes to church every morning at 10 o' clock, and you know maybe did the rosary every morning and stuff like that.When they come into a residential home, that option should be there…that they get that.It's very important, because it was part of their life…they were doing this ritual all their lives…You don't come into a residential home and next of all it all stops!([20], p. 43).
The benefit of ritual prayer and song as a support for clients' spirituality and faith resounded throughout the findings.

Sense of Community and Belonging
This theme did not appear prominently in the literature reviewed; however, it did surface as a significant theme in all the interviews conducted.All facilitators felt that through the Serenity programme, residents experienced a great sense of community and belonging to the nursing home community, and they felt this was of vital importance to the residents and their sense of spiritual well-being.The fact that all facilitators felt the same way is evidence to support the view of any one of them.These views were illustrated in their comments.One facilitator reported that "I think the programme is a good addition to what's already existing and it's nice for them to come together, there's a sense of community as well, being in a small group."Another felt this sense of community was of great importance because "when you get that sense of belonging you are more brave to go, to step out into the world to do things."( [20], p. 43).
This sense of belonging that facilitators feel is associated with the Serenity programme, and the security and comfort it brings, could also be linked in with Robert Atchley's continuity theory.In this he advocates that "The external aspects of worship-ceremony, music, and religious symbols-all can provide satisfying continuity.It is a repetition that can produce a feeling of comfort and security."( [20], p. 46).
One facilitator found in her experience that the prayers give a lot of comfort; "it gives them some reassurance...it gives comfort and they are looking forward to it…it gives hope and meaning".She also felt that praying together "brings this feeling of closeness…and for people who don't have relatives very near, I think this sense of belonging is very important" ( [20], p. 47).
Another facilitator commented on the importance of residents being able to participate and share verbally in the Serenity programme.She observed that "the more it went on, they started to give feedback" and while it was different to the ritual of a Mass, she felt that "to actually have to think and then to share, was kind of different…interesting to see what everyone said, and not often things you're expecting."( [20], p. 47).She added, "They're bringing to mind a family member that they're praying for, which is nice for them to have the opportunity to do that which they mightn't have in a Mass or a Holy Communion service, which I think is nice."( [20], p. 47).
This significance of the practice of sharing was echoed by another facilitator, who found that "what we really liked about the Serenity actually is sharing.Learning a little bit more about each other and sharing something of ourselves, maybe about our family, you know.
When we wanted to pray for a family member or friend, we were able to share that with the group and that was, the residents really enjoyed that.Somebody this morning prayed for a sick relative…and obviously that was on their mind, so we learned a little bit more about that resident today and their family and where they lived… and we really learned different things about each other which was nice." ( [20], p. 47).
She also commented later on some residents who had shared intimate sufferings and loss with the group during prayers and the comfort she felt they received within the group; "He obviously felt comfortable enough to show the group that he did miss his parents and we prayed for them and he got a lot of comfort from that then, when we prayed for his parents and mentioned them in the prayers."Another lady who opened up about the death of her brother "seemed to get a lot of comfort from the fact that we prayed for her brother as a group…I think they do feel comfortable with each other and it always seemed quite respectful as well.People were allowed the space to talk." ( [20], p. 47).
The ability of the sessions to provide a sense of community and belonging among the older residents surfaced as a significant theme in the interviews conducted.All facilitators felt that by using the programme regularly, residents experienced a great sense of community and belonging to the nursing home community.They felt this was of vital importance to the residents and their sense of spiritual well-being.

Discussion
Older people residing in nursing homes in Ireland were raised in a society where religion played an important role right throughout their lives.Given the fact that care of older people has changed somewhat over recent years, the appropriateness of religious or spiritual care in these care centres is often unclear.However, these findings shows that spiritual care of older people is not only considered an important aspect of overall care, but that the Serenity Spirituality Sessions programme played a very important role within the context of spiritual well-being of older people.The intervention clearly had benefits for older people concerned.Studies of nurses from older people settings reveal that nurses see a clear role in providing spiritual care to their clients.This role is believed to include supporting clients to find meaning and to make connections with others; comfort and reassurance and respect for and/or facilitation of religious beliefs [24].In keeping with other religious interventions [7] the Serenity Spirituality Sessions programme appeared to have beneficial effects.
One unexpected finding was that the intervention seemed to create a space where residents had an increased sense of community and belonging.This was evidenced when facilitators reported that residents sharing and praying with and for each other felt deeper connections within the group.This inherent sense of belonging created a greater sense of peace and well-being.MacKinlay ( [1], p. 225) describes the intimate relationship with God and/or others as one of the spiritual tasks of ageing.She states that "relationship is an important aspect of being human" and that "the human spirit longs for connections with others".This is something that was very much evidenced by findings, with several facilitators demonstrating how important they found the development of relationships with and among residents.They all felt this had a very beneficial impact on overall spiritual well-being.
Findings of the research also indicated that rituals of hymn-singing and praying together had a positive impact on the spiritual well-being of residents in nursing homes.Most facilitators described the feedback from residents as extremely positive, with many expressing great joy and peace as a result.Rituals of music and liturgy are identified as playing an important role in how humans may respond to others and can help create a sense of hope [1].Similarly Atchley's [9] continuity theory indicates the importance of residents having a sense of continuation of spiritual or religious practices while in residential care, which "helps one discover the symbols and themes that are significant and meaning-giving…and that can serve as resources in adapting to changes", thereby promoting a greater sense of spiritual well-being.Additionally in The external aspects of worship-ceremony, music, and religious symbols-all can provide satisfying continuity.It is a repetition that can produce a feeling of comfort and security.
For many older adults in care, ritual has played a huge part in their lives.As Fischer [12] states: Ritual is important because it provides a sense of continuity, a link not just with our individual past, but with that of our culture and our faith…The enactment of ancient ritual brings renewed awareness of where we have come from and who we are.It can help us establish profound emotional connections in terms of our identities as individuals and members of families.In this way we capture the feeling of an old self or a partial self.Ritual is one of the paths to integrity as we age.
Rituals can take various shapes and forms.For many, the ritual of a Catholic Mass or a similar service can have a dual purpose: it can provide an opportunity to connect with or respond to the resident's concept of spiritualty and provide a space where the resident can feel a sense of community and belonging.While overtly religious, older people are drawn towards both the religious and spiritual as they near their end of life and often gain great support from familiar childhood religious ritual [7].

Limitations
Although qualitative research makes no claim to generalizability limitations that apply to this approach need to be considered.This is a small-scale study and as such the findings are both limited and context dependent.A follow up larger-scale project that quantitatively measured intervention outcomes using controlled situations would be useful to strengthen preliminary outcomes.The Serenity Spirituality Sessions programme was also not used consistently across the homes, a factor which would need to be addressed in any future studies.Another factor that may influence the interpretation of findings is that the residents were self-selecting and chose voluntarily whether or not to attend the sessions.It is likely, therefore, that those attending were more positively disposed towards the concept than those who did not.The use of private nursing homes, homes already using spirituality interventions may have further biased the findings.As four of the six homes were already using Serenity Spirituality Sessions this further compounds this bias.The study yielded the facilitator views only, but it would have been useful to also know the residents' views.While the frequency and length of sessions varied from one site to another is an acknowledged limitation of the study, this study was not aiming for methodological rigour or control.This flexibility permitted the Serenity Sessions to be adapted locally to suit each particular group.Obviously, generalising from these findings is difficult; however, the contextual information that arose suggests that the Serenity Sessions is a useful support for older people in residential care, and this study, albeit qualitative and thus subjective, had resoundingly positive results.

Conclusions
In an increasingly secular age, it is all too common to see a public diminishing interest in issues of spirituality and religion.However, within the health care setting, and particularly within the care of older people, the aging, those living with chronic illness and nearness of death incline people towards seeking spiritual support.For those with a background of religiosity, solace can be sought in the return to religious rituals.The provision of spiritual support to clients in care is gaining increased international recognition, and in this context the provision of interventions such as the Serenity Spiritually Sessions can be a useful adjunct to care.While there are ethical concerns about "omission" (not providing spiritual care) and "commission" (providing spiritual care that might appear coercive) ( [25], p. 2099), the provision of faith-based supports to clients who subscribe to, or agree to subscribe although not extensively researched, can be useful [26].As well as benefits to spiritual well-being there is some emerging evidence that such interventions can improve understandings and control of [25].As the findings are very positive about the programme's usefulness, we believe that the spirituality sessions ought to be recommended for use in residential settings, for older people and those with dementia, who are willing to participate.However, given the diversity of religious faiths, and increasing secularism, diverse religious interventions are recommended for the sake of meeting the needs of people of other religions.Clearly a one size fits all model may not be the most suitable, so more adaptable and flexible approaches, perhaps using intelligent technology, may be more helpful in this particular domain.development of the manuscript.Fiona Timmins managed the planning and design of the manuscript.Suzanne Kelly, Mary Threadgold, Michael O' Sullivan and Bernadette Flanagan were involved in manuscript development.Each author has participated sufficiently in the work to take public responsibility for appropriate portions of the content.All authors have read and approved the final version of the article.