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Article

Religious Bodies–Lutheran Chaplains Interpreting and Asserting Religiousness of People with Severe Dementia in Finnish Nursing Homes

by
Jari Pirhonen
1,2,*,
Auli Vähäkangas
3 and
Suvi-Maria Saarelainen
4
1
Faculty of Social Sciences, University of Helsinki, 00014 Helsinki, Finland
2
Faculty of Social Sciences, Tampere University, 33014 Tampere, Finland
3
Faculty of Theology, University of Helsinki, 00014 Helsinki, Finland
4
Philosophical Faculty, School of Theology, University of Eastern Finland, 80100 Joensuu, Finland
*
Author to whom correspondence should be addressed.
J. Ageing Longev. 2023, 3(1), 92-106; https://doi.org/10.3390/jal3010008
Submission received: 26 November 2022 / Revised: 25 February 2023 / Accepted: 26 February 2023 / Published: 2 March 2023
(This article belongs to the Special Issue Change and Continuity in Ageing—The Selected Papers from the 26th Nordic Congress of Gerontology (NKG))
Review Reports Versions Notes

Abstract

:
The prevalence of dementia is increasing globally as populations grow older. Moderate and severe dementia are the main reasons for older people entering long-term care in Finland, and the vast majority of nursing home residents have it. Regarding mild dementia, religiousness is known to slow the progress of the disease, offer solace, and maintain a life-long identity. However, we know practically nothing about the religiousness of people with severe dementia. This study sought to fill the gap by interviewing Lutheran chaplains working in Finnish nursing homes. The data were subjected to qualitative content analysis to understand: (I) how people with severe dementia may express their remaining religiousness and (II) how the chaplains asserted the religiousness of people whom their words often did not reach. The clearest expressions of religiousness found were bodily, including expressions of emotions and fumbling liturgical movements. The chaplains utilized prayer services, active presence, and generational intelligence to respond to residents’ religiousness. The main conclusion is that people with severe dementia can express their faith and are eager to practice it when opportunities are provided to do so. Our research challenges care providers and religious communities to better acknowledge the religiousness of people with severe dementia.

1. Introduction

Since the Second World War, freedom of religion has been a key principle for organizing human coexistence. It is in the Declaration of Human Rights [1] and is valued enough in Finland to be recorded in the Constitution—every citizen has a right to express and practice their religion [2]. For several decades, the World Health Organization (WHO) has acknowledged that human wellbeing has spiritual and religious aspects [3]. The WHO’s view is confirmed by a vast amount of knowledge on the effects of spirituality and religiousness on human wellbeing and even health [4,5].
Previous research shows that religiousness is more personally important among the older generation [6]. We understand the term “religion” following Kenneth I. Pargament’s definition as “a process, search for significance in ways related to the sacred” [7] (p. 32). Therefore, religiousness of an individual is seen as a personal search linked to the sacred that includes both experience and action. We focus here on lived religion, which Suvi-Maria Saarelainen defines in the health care context as “a combination of practices that assist in making sense of daily life, a biographical process that changes over a lifetime” [8] (p. 71). Among the aging population, Lars Tornstam has introduced the concept of gerotranscendence to capture the shift of life orientation in old age, where people tend to turn to the transcendent when entering the final stages of their lives [9]. It is also known that religious beliefs may help people in adjusting with age-related deterioration of functional abilities, cognitive abilities included [10]. Religiousness may slow the progress of early-stage dementia by offering cognitive activity and social support [11]. Studies of Christians with dementia show that belief in God gives them comfort and maintains their identity [12,13]. Reviews indicate the need to acquire more knowledge about how people with dementia express their spiritual needs and to identify the possible barriers to spiritual care in dementia [10,14].
Less is known about people with severe dementia, who usually reside in nursing homes. Dementia is an umbrella concept for diseases characterized by progressive loss of cognitive functions and other abilities [15]. For simplicity, we use the terms dementia and dementing illnesses in this paper to cover diseases that negatively affect the nervous system, such as Alzheimer’s. Although no two people with dementia have identical symptomatic spectrums, they share many features. Dementing illnesses cause cognitive symptoms such as difficulties in remembering things and in perceiving space and time correctly. At some stage, dementia may change a person’s behavior or even personality [16]. As the disease progresses, it weakens a person’s functional abilities, so they need assistance in all their daily activities [17].
The progressing disease does not, however, frustrate the basic human need for affection. Tom Kitwood has presented a model of interrelated emotional needs to better understand the situation of people with dementia [18]. To maintain a sense of self, people need comfort, attachment, inclusion, occupation, and identity. In other words, people need others to ease anxiety, to reach affiliation, to be socially engaged in a meaningful way, and to be recognized as persons. These affectional needs emphasize the importance of interaction, and in the final stages of dementia, people usually lose the ability to communicate verbally [19]. Unfortunately, people who have stopped speaking are often at risk of being cast out of social groups because they tend to be seen as incompetent or even unwilling to connect with others. Bowie and Mountain observed 110 people with dementia in a long-stay hospital ward and found that they were socially active only on 5.5 percent of their days, and then only when nursing staff provided assistance [20]. Yet, nursing intervention activities, such as reminiscence therapy, carries multiple positive impacts that support quality of life among older people who suffer from cognitive impairment [21]. As these types of interventions gently induces a recollection of memories from the past and are efficient as regular small group activities, reminiscence activities are found to support meaningful aging and may revive cognitive capacities [22,23].
We argue that older people with loss of cognitive capacities should not be perceived as incapable of engaging socially, otherwise their chances of living their lives according to personal values is jeopardized, e.g., they cannot engage with meaningful activities such as religiosity. Especially when religion is seen as a private matter in Finland [24], which, with the other Nordic welfare states, has been pictured as a highly secular society [25]. Yet, among older Finns, religiosity and religious participation has been found as highly meaningful [26,27]. Even today, 66.5% of the Finnish population belong to the Evangelical Lutheran Church of Finland [28]. The size of the majority church ELCF is seen when comparing it to the second largest Christian community in Finland, The Finnish Orthodox Church, which had only 57,613 members in 2022 [29]. Older people are more active members in the ELCF, both in terms of membership and participation [30]. The importance of the ELCF is also seen in that all Chaplains in the hospitals are employed by the ELCF [31].
One solution is to shift attention into the body. Pia Kontos, who has studied people with dementia in nursing homes, perceives the body as a fundamental base of human selfhood that does not derive its agency from cognitive capacities [32]. Kontos argues that “the body itself is an active, communicative agent, imbued with its own wisdom, intentionality, and purposefulness” [33] (p. 558). Stephen Katz problematizes traditional classifications of agency in nursing homes by introducing “anti-activity activities,” such as napping and watching television [34]. Jari Pirhonen and Ilkka Pietilä suggest that even people whose functional abilities have declined substantially may feel more or less agentic depending on their surroundings in nursing homes [35]. This all suggests that the human body, when provided with appropriate conditions, may itself be perceived as a source of human action or agency.
In addition, researchers have acknowledged the importance of the body in dementia care. The importance of senses in communication in dementia is widely acknowledged [36,37]. Touching is crucial for the wellbeing of people with severe dementia [38]. Music is known to relax people with dementia and to improve their self-expression [39], and dance therapy has been introduced to holistic dementia care [40,41]. When words fail, there still are numerous ways to enhance wellbeing. Could the religiousness of people with severe dementia also be approached through the body?
Theologians have traditionally concentrated more on the soul than on the body, until the 1990s [42,43]. Disability theology has focused on how the bodies of people with severe dementia and their chaplains could be better utilized in pastoral care [44,45]. An important part of embodied pastoral theology is emotions and how they are utilized in the pastoral encounter [46,47]. Emotions—from hope to hopelessness, from joy to sorrow and bereavement, from desire that provides motivation for personal goals to apathy that prevents wishful thinking—are all encountered in meetings with chaplains [47,48,49,50].
The aim of this study is twofold, to find out: (I) how, according to chaplains working in nursing homes, people with severe dementia express their potential religiousness and (II) how chaplains affect the potential religiousness of these individuals. Our working hypothesis is that religious convictions of people with severe dementia might be interpreted and influenced less through words and more through the body.

2. Materials and Methods

The research is based on thematic interviews conducted with ten chaplains of the Evangelical Lutheran Church of Finland in 2020. To recruit participants, the Church Council provided us with some contact details of large joint parishes where they supposed some chaplains would work mainly in nursing homes. These joint parishes were contacted, given research information, and asked if they employed any suitable informants. Four informants were reached this way, and another six were found using snowball sampling [51], i.e., interviewees gave us names of chaplains who worked with residents in nursing homes. Ten names of chaplains in total came up and all of them were interviewed, resulting in data saturation. All interviewees were ordained ministers of the Evangelical Lutheran Church of Finland. For simplicity, from here on we will call the interviewees chaplains. Basic information about the interviewees is presented in Table 1 below.
As expected, the chaplains worked in large joint parishes around Finland. In smaller parishes, pastoral care, counseling, and visits to nursing homes are taken care of by temporary members of parish clergy. Nine out of ten chaplains were women, which was quite comparable with the wider situation. In 2020, 70 percent of chaplains in Finnish Lutheran parishes concentrating on pastoral care and counseling were female [52]. Seven of the chaplains worked mainly in nursing homes (one had just retired after 40 years in nursing homes). One worked in rehabilitation hospital where most of the residents were older adults with dementing illnesses, and two worked in central hospitals, also visiting nursing homes nearby. The interviewed chaplains had worked among people with dementia for 115 years in total. All the interviews were conducted by phone and audio recorded. The duration of the interviews varied between 53 and 114 min, totaling 755 min. Audio records were transcribed verbatim, totaling 197 pages of text.
The themes of the interviews were broad, enabling us to utilize the data for various topics. Themes included COVID-19 restrictions in nursing homes from the chaplains’ point of view, encountering dying people and people with severe dementia, the nature of pastoral care in nursing homes, and religious expressions and activities in nursing homes. In this research, we have concentrated on the chaplains’ interpretations of residents’ religious expressions on one hand, and the chaplains’ work among people with severe dementia on the other.
We utilized data-driven qualitative content analysis to identify repeated patterns in the data [53,54]. In this case, the analysis aimed to categorize: (I) situations where the chaplains anticipated that the residents were expressing their religiousness and (II) situations where the chaplains were affecting the residents’ religiousness. In the first phase of the analysis, the first author (who had conducted the interviews) studied the entire data carefully and isolated extracts dealing with points (I) and (II) above. Before becoming a researcher, the first author worked in nursing homes as a practical nurse. As a researcher, he has studied constituents of good life in nursing homes [55]. While conducting this research, he studied alongside work to finalize his master’s degree in theology. This background offered him a solid viewpoint to evaluate the chaplains’ accounts of life in nursing homes. Although the other two authors have previously been ordained as ministers of Evangelical Lutheran Church in Finland, they both have worked as full-time researchers for many years. Thus, both the authors’ substantial knowledge on the topic and their academic experience speaks for the validity of the analysis.
After the first author had finalized the first stage of analysis, 54 pages of data remained from the original 197 pages. This smaller data set was reviewed by all the authors, after which it was discussed. The consensus was that expressions of religiousness were very bodily. The chaplains were quite certain that people who had totally lost the ability to express themselves with words still expressed their religiousness through their bodies, expressions of emotions, and attempts to participate in prayer services. These three then became subcategories under the main category “Expressions of religiousness”. Regarding the situations in which the chaplains were influencing the interpreted religiousness, longer discussion was needed. We agreed that prayer services were the most visible means to influence the residents’ religiousness, but the less visible, more private action needed to be analyzed further. Thus, we read the data again and had another discussion. The corporeality of residents’ religious expressions and their communication in the first place seemed to build the frameworks for chaplains’ actions. The data included several descriptions of situations where a resident was not able to communicate with words due to the progression of dementia. By analyzing these pieces of data, we noticed that the chaplains carried out pastoral encountering (see [46,47]) utilizing means such as speaking gently, touching, and humming, which formed the category of active presence. In addition, the chaplains were perceived to employ generational intelligence with the residents by utilizing knowledge of previous stages of older generations. The form of the analysis is presented in Table 2 and Table 3 below.

Ethical Considerations

The Research Ethics Committee in the Humanities and Social and Behavioral Sciences, located at the University of Helsinki, provided us with ethical approval, and the European ethical guidelines for research were followed accurately. The chaplains were provided with information about the research beforehand and they had an opportunity to ask questions. Their right to terminate the interview or to withdraw from the study at any time was discussed, and information on data protection and anonymity was delivered. Since the chaplains were interviewed by phone, their oral consent was audio recorded, and they were fully informed about the recording. All the names mentioned in this paper are pseudonyms to secure anonymity of the people involved in the research.

3. Results

3.1. Interpreting Religiousness

3.1.1. Bodily Manifestations

According to the chaplains, the majority of nursing homes did not systematically find out residents’ religious convictions, in line with secular Finnish policies [24]. Since many of the residents had lost their ability to communicate verbally, the chaplains could not simply ask residents about their religious views. Thus, they had become quite skilled in interpreting bodily signals, as Pekka expressed:
PEKKA: When I am with a person with dementia, I observe whether their lips or eyes or heads move. Things like that … or if they smile. Or maybe they try to move their fingers, or take my hand. I mean, communicating with them becomes bodily. Physicality becomes important, touch and all, even the Holy Communion is physical then, the taste of the wine, lack of taste of the bread. If someone cannot drink, you moisten her lips with the wine to offer some taste.
Pekka described communication as a holistic phenomenon that is rooted in the body. Gestures, postures, and even eye movements told him if the resident was willing to encounter him. During the interview, inspired by St. Francis of Assisi, Pekka also stated that the gospel should not be proclaimed by words but by actions. Taking care of other people and treating them with dignity is not dependent on spoken words. This is an appropriate starting point for the chaplains’ work among people with severe dementia.
Some of the chaplains had learned the validation method [56] to better understand people with severe dementia. The central idea of the method is to genuinely listen to people with dementia, showing respect and appreciation, and not to deny their prevailing reality [57,58]. Helena utilized the method in nursing homes:
HELENA: So back in the day, I took part in a validation training for this when I started in 2001. That’s why I’ve also become acquainted with body language and facial expressions, and what meaning they take on after conceptual terms start to gradually lose their meaning.
RESEARCHER: That must certainly have been a huge help for you to have knowledge of the validation process.
HELENA: Yes, it has. And I’m also sensitive, in the way that I am attuned to feelings, emotional settings, and also kinds of expressions, gestures, and messages. As such it is of value in this job to be sensitively perceptive. And that training, of course, also helped me focus on it.
As the passage shows, embodied experiences are intertwined to the personhood of an individual. When one loses capacity to express individual thoughts with words, embodied gestures take a more central role in communication [59,60]. Essential in embodied pastoral encounters is, thus, the ability to recognize emotions and to create an atmosphere in which people with dementia may express their emotions, for example, with small gestures as Helena explained above [44]. Chaplains’ ability to support the religiousness of an individual seems to be linked to willingness and training to see and understand more than immediate events and actions. A carer who has this knowledge and skill to be present can support people with dementia to experience meaningfulness [61].

3.1.2. Strong Expressions of Emotions

All the interviewees had witnessed how residents often got very emotional during prayer services. Anneli gave an apt example:
ANNELI: But then something that often occurs is that it invokes feeling or memories, even if they don’t find words otherwise, they may burst into tears having heard a particular song… But they are the kinds of situations where you feel it deep in your heart, what you’re supposed to say or do in such a situation, so yeah.
RESEARCHER: Yes, so this kind of devotional moment clearly arouses, or can arouse, deep emotions even in patients suffering from severe memory disorders?
ANNELI: Yes, yes, yes. These kinds of memories come up, and may be awoken by a certain Bible passage. But, often it is song which awakens this.
Anneli affirmed fervently that people with severe dementia could react emotionally to religious situations. She described her own reactions in such situations—it was touching to see a person awakening and reacting to things in the outer world. Pekka referred to situations when he had emotionally reached a person that usually was unable to communicate at any level as mystical experiences. Thus, the chaplains reacted emotionally to residents’ emotional reactions.
People who were unable to express themselves with words were able to express themselves with crying. Sometimes residents cried out loud, sometimes a silent tear fell on their cheek. The chaplains interpreted religious content such as a familiar hymn or prayer as the cause of the tears, and perceived this as a sign of a person’s religiousness. Crying was not the only way to react to religious matters—sometimes restless residents calmed down and, more rarely, calm residents got restless during prayer services.
In emotional moments such as these, an individual with dementia may have connected with something familiar from the past. For a moment, one might remember passages from an earlier life [61]. Familiar rituals may create feelings of being listened to and being accepted but not always, because the reaction can also be the opposite. Chaplains to nursing homes have to be ready for a wide range of emotions [62].

3.1.3. Fumbling for Liturgical Rituals

One clear clue regarding residents’ potential religiousness was their fumbling for liturgical rituals. By liturgical rituals, we mean customary habits connected to the practice of a religion. In the Finnish Lutheran context, the rituals are mainly based on services that contain repeated elements. People are used to clasping their hands for prayer, holding a hymn book, singing together, sitting and standing according to the liturgy, kneeling for Holy Communion, and so on. Residents with severe dementia were able to at least fumble these rituals, as Tiina expresses:
TIINA: For example at Communion, when you can’t really tell from a person if they are here or there, but when it gets to it, or when they have made the utterances of Christ’s body and so forth, the mouth will open like young chick’s, for example. If they had been asked if they would like to take Communion they would not have understood, but these certain things trigger this in a way.
Tiina’s account shows the power of religious rituals. She tells how a person who is unable to express herself with words is able to join in the Holy Communion in her own way. The resident here may not know anymore what Holy Communion is, but she still knows how to participate. As Kontos stresses, the body itself may be seen as an agent [33]. The body knows what is going on. The interviewees told us how residents tried to clasp their hands for prayers. Sometimes a resident held a hymn book upside down, but it still seemed important to have the book. Residents tried to sing by moving their lips if the actual singing was too difficult. Pekka recalled another case regarding liturgical rituals:
PEKKA: There have been cases where a person has been reached by singing “in the name of the Father, the Son, and the Holy Spirit” [to a tune used in Finnish Evangelical Lutheran liturgy]. Then the person has responded singing “amen, amen, amen.” That is rather remarkable. And they have felt very good and grabbed [my] hand. I remember, one person grabbed me by the hand each time they encountered something familiar as everything was so foreign to them. Suddenly something familiar appeared.
At the beginning of a Lutheran liturgy, the priest sings “In the name of the Father, the Son, and the Holy Spirit” and the parishioners respond by singing a triple Amen. In Pekka’s account, the responsory offers a resident a way to connect to Pekka and the whole situation. The liturgical rituals may open familiar paths for people who have been active churchgoers. At the same time, they provide chaplains with valuable information regarding residents’ religiousness. The above examples show that rituals are strongly embodied experiences and they carry symbolic and existential meaning [63]. Rituals that can be touched and smelled invite people with dementia to participate more easily than rituals performed by words alone [64,65].

3.2. Asserting the Discovered Religiousness

3.2.1. Prayer Services

Since the chaplains interpreted that severe dementia did not, at least totally, defeat residents’ religiousness, they utilized several measures to influence it. The most traditional and visible measure to affect residents’ religiousness was to deliver prayer services in nursing homes. They adjusted both subject matter and duration of the occasion to residents’ cognitive capacities, as Tarja expressed:
RESEARCHER: Yeah, so you can’t give a normal sermon.
TARJA: No, it can’t go like that. No. It can’t be the same sermon you gave at the church the previous Sunday. And you need a more activating approach from the pastor, so that one’s attention is focused on the present, so that someone, the pastor must have some kind of bridge to the person with a memory disorder when providing a devotional at a care home. Some kind of bridge must be built in order to provide some kind of joy to the resident or… Well, joy or providing that sacred experience. It can’t be expected that the residents acclimatize themselves to such a state. The pastor must wisely build this rapport with the listener.
Tarja had learned that when people with dementia attended religious services, prayer services needed to be present-oriented. Theological brilliance was replaced with strong presence, as another chaplain put it. Tarja talked about bridging as a chaplain’s special skill in these situations. Listening to people with dementia needs special skills and active presence, as previous studies also stressed [62,66,67].
Earlier in the interview, Tarja described how people with severe dementia recognized religious symbols. A candle, a cross, and a Holy Bible on the table told people that something religious was happening. The clerical clothing, which Tarja wore, helped residents to orient themselves in the situation. When they were not fully cognitively capable of comprehending the situation, embodied cues helped people to follow the occasion.

3.2.2. Active Presence

Since residents manifested their religious convictions mainly through their bodies, the chaplains had learned to respond bodily. Pekka gave an almost poetic description of pastoral care for a person with severe dementia:
PEKKA: And if you encounter someone with warmth, a giving embodied touch, using kind words, it feels good. You acquire a gentle tone in your voice if your touch is respectful, generous, and unintrusive, as well as your voice. If a person has hearing, you can speak to them from very nearby. And they might even join you in song if it’s familiar to them…So some of the songs and the oldest ones remained. It was possible to recall even three songs even though one had been removed from their home. At the care home there was only one, a lullaby that their mother had sung. And there it was, spirituality could be humming that lullaby and grasping onto mother’s memory, using a mother’s touch, stroking the head and gentle touch.
Pekka thought that while people with severe dementia were unavoidably approaching physiological death, simultaneously, at some level, they were returning to their early childhood. Kaisa described the same phenomenon in other words: as longing to be on their mother’s laps again. These accounts highlight the residents’ need for a sense of security. When words do not offer security, bodies may. Pekka talks about warmth—a gentle voice and touch or humming a lullaby—as asserting the sense of security. The loving presence which chaplains showed their frail fellow human beings respected the person’s human value [62].
An interesting finding was the importance of social conventions. While a person with severe dementia should have lost the ability to tell coherent stories, she could still have conversations, as Tiina expressed:
TIINA: I remember conversations where the person with memory loss who is sitting by me, perhaps holding my hand if it is that kind of a situation, and the person wants to, or may speak for a long time, I’m stuck in between often not having a clue what they mean, although they may utter some real words as well, but…the kind of interaction that is hard to grasp even with validation methods, but it rather becomes a case where one nods their head a bit and indicates that they are in the same emotional state as the speaker, and at the end they might thank me for listening. I have no idea what they have been talking about but they are very happy.
The excerpt shows the deep social fiber of human nature. The social convention of having a conversation was clear for the resident, even though the logic in her use of words was lost. Once again, the chaplain’s skills of active presence are highlighted. Tiina was not able to validate the resident’s words, but she was able to validate her emotions. In addition, the excerpt highlights the concept of epistemic justice [68]. Even if the resident was not able to express herself logically, she still had the basic need to be heard. Robbing her of fulfillment of that need could be considered as epistemic injustice. Care and support of people with dementia is very much about the ability to endure chaotic situations and narrations. Through this endurance, a carer may truly capture a moment of deep encounter where inner pain and difficult emotions are alleviated [61].
All the interviewees strengthened their presence in nursing homes by using visible signs of chaplaincy, just as Tarja did:
TARJA: Then when they realized that I was wearing a pastor’s clothes, so they recognized that I’m a pastor, they didn’t necessarily invite me to their room, but when I met patients or residents in the lounge or dining room we usually held a devotional in that public space, then they may have even grabbed my hand and asked for a particular song or…expressed homesickness, asked about when they can go home, or asked for advice on what to do. Or they would start telling me about some pastor they know, as I had awoken some kind of memory in them by being a pastor.
All the interviewees wore clerical collars when visiting a nursing home to offer residents a clue of their role. Residents recognized the chaplains from their clothing and approached the chaplains with various subjects, providing the chaplains with chances to affirm the residents’ religious convictions or give them comfort. The chaplains being visible was one more aspect of corporeality in affirming religiousness among people with severe dementia.

3.2.3. Chaplains’ Generational Intelligence

Generational intelligence may be defined as a capability to take a viewpoint of another generation [69,70]. The concept entails both a critical and an empathetic aspect [71]. One needs a critical attitude to understand that their own perceptions of other generations are, at least partly, socially produced. Empathy, then, may build a bridge from one’s own preconceptions towards another person’s viewpoint and help one to perceive the world through their eyes. The chaplains acknowledged residents as representatives of a different generation to their own, and they had made the effort to understand residents’ generational experiences. They were familiar with the culture of the residents’ youth. Further, it is crucial for carers to be aware of a reminiscence bump: the autobiographical memory of an individual is particularly strong between ages six and thirty [72]. Therefore, people with loss of memory are also most likely to have episodic memories before the age of thirty. For example, Anneli knew that, since the residents were mainly born in the 1930s and 1940s, they had been young in the 1950s. She had played Elvis music to residents with success, and in the next excerpt, she describes a prayer service she had executed with a cantor:
ANNELI: And with the church organist we had moments where they might have played hymns followed by even “a summer night’s waltz” [an old Finnish evergreen] as an interlude between hymns in the devotional [chuckles], that’s how it is, they are currently folks born in the 30 s and 40 s, so a little something from that time may be played between, Olavi Virta or Forest Flowers [Finnish artist and song]. So many recalled, oh that was my wedding waltz and may through that recall things from their youth.
In addition to becoming familiar with the popular culture from the residents’ youth, the chaplains acknowledged that the church had much greater societal power in residents’ childhood and youth. Kaisa talked about older Finnish customs:
KAISA: And when you think about the fact that these people who are in their eighties and nineties, in their lives, even if they weren’t particularly spiritual, in their context spirituality will have been present in a different way to them than to us, it has also been the kind of habitual culture where it has been a thing to go to church, hymns are far more closely tied to phases of life in this way.
In residents’ youth, Finland was mainly agricultural. People lived in close-knit village communities, in which religious activity was expected. In a way, the chaplains were able to base their actions on the residents’ generational experiences. They knew that old hymns would resonate more with older than younger generations, as Kaisa stated above. Anneli anticipated that confirmation classes were stricter then than today, and most of the residents had learnt by heart many prayers, hymns, and other Christian content. As the chaplains had seen, people with severe dementia were able to join prayers and hymns even when they did not talk anymore in their everyday life. Thus, the chaplains utilized the work of their past colleagues, making their interactions intergenerational. When carers know the life history of an individual, it is easier for them to provide meaningful engagements—religious rituals and more broadly enjoyable moments—for an individual with dementia [61].

4. Discussion

The main result of this study is that, according to chaplains working in nursing homes, people with severe dementia come to express and express religiousness in quite a bodily way. The chaplains interpreted religiousness from residents’ body language, expressions of emotions, and attempts to follow liturgical customs. Furthermore, since the expressions of religiousness were bodily, the chaplains utilized their bodies and the residents’ bodies to express their religiousness. Previous theological studies have criticized the theorization of the body in which the physical body is forgotten [43]. When the body is present, it is pictured as an ideal, as a source of abstract dimensions such as embodiment, while the actual, physiological body is forgotten. Our results show that Finnish chaplains do not forget the body when encountering people with dementia. In these encounters, the actual body is at the center.
The chaplains had learned the importance of active presence: eye contact, active listening, touching, using a gentle voice, and utilizing visual elements when providing residents comfort. It is not too far-fetched to say that the body dominates the religiousness of people with severe dementia. When a person loses capacity to think religiously, the body may remain religious. The embodied encounter between the caregiver and the care receiver is essential, as it stresses on relational personhood despite the vanishing self of a person with dementia [44]. The aim of an encounter is to give people with disabilities back their human value and status in the community [73]. Disability theology has criticized relational theory for overly stressing a person’s ability to be in a relationship [58]. It is, thus, important that the chaplains encounter people with dementia with friendship and by showing their human value. For people with dementia, experiences of meaning in life contribute to experience of personhood [59].
Our findings show that rituals help people with dementia to show their emotions. Religious rituals can be an important tool of pastoral care for people with disabilities [64]. The fuller our liturgical symbols are, the better they will be appropriated [64]. Additionally, rituals help dementia patients connect to their memories [65]. Activities such as listening to music and watching photographs or videos have shown to provide significant tools to assist people with mild or moderate cognitive impairment to connect with their past [22,23].
Personal religiosity can support older people encountering difficulties in life. For instance, religion may provide sources of stability and resilience when personal strengths are tailing off, as well as sources of power and control in changing life situations [74]. As Emery and Pargament state, God or a Supreme Being can be seen as a protective force to turn to in the hardships of life [74] (p. 7). Furthermore, religious communities may form significant networks of belonging for older people [74,75]. As such, practicing religion alleviates loneliness among older people [76].
Yet, none of these cited studies take a direct stand on the religiosity of people with dementia. We have identified only passing references to experiences such as those our informants described, that chaplains need to give more guidance to support religiosity as such, and meet the religious needs of people with dementia. Embodiment played a crucial role when inviting older people to express their religiosity. As Saarelainen has defined, religion is a biographical process that changes over a lifetime [8]. Our findings show that even severe dementia does not end the process, instead, as noted above, expressing and practicing one’s religion becomes more bodily and dependent on others. The chaplains of this study showed their wisdom in taking time to listen to people with dementia with respect. Listening skills are important because communication is often problematic, both for the person with dementia and for the listener [62].
We would also like to highlight the role of generational intelligence in the chaplains’ work in nursing homes. Understanding the history and experiences of the generation residing in nursing homes has now helped chaplains to connect with them. If a Finn was a child in the 1930s, the church played a bigger role in her childhood than it would today. If she was a teen the 1950s, it is safe to assume that she knows who Elvis Presley is. Generational intelligence provided the chaplains a viewpoint to residents’ societal history. As studies have shown, autobiographical memory forms a reminiscence bump that seems to lead to situations where people with mild or moderate memory loss are more likely to remember events from their youth [72].
Our findings further indicate that people undergoing severe dementia seemed to connect with their episodic memories through religious rituals. The article highlights that being able to follow personally meaningful values such as religiosity is also important for those individuals who live with severe cognitive impartments. Earlier studies focusing in reminiscence therapy point out that being able to connect with one’s memories impacts positively in quality of life, decreases depression [21,22] and neuropsychiatric symptoms, and improves general wellbeing [23] among older people with mild or moderate memory issues. Our findings bring forth that a similar type of alleviation may also be discovered among people with severe dementia.
For care providers and religious communities, our findings highlight the importance of providing residents with chances to practice their religion. The chaplains pictured how cognitively disoriented people were instantly able to participate, in their own ways, in religious practice when they had the opportunity to do so. People who are no longer able to express their religious needs verbally do not automatically lack these needs. On the contrary, our findings lead us to think that not providing residents with regular opportunities to practice their religion may be seen as a form of religious violence. To avoid this, care providers could take residents’ religious needs more seriously and religious communities might intensify their presence in nursing homes. Especially since our results and Kitwood’s model of emotional needs [18] seem to be highly consistent, religious expression provides people with severe dementia chances of easing anxiety, reaching affiliation, being socially engaged in a meaningful way, and of still being recognized as a person. The chaplains did all this by their strong presence and delivering prayer services. In addition, previous studies have introduced spiritual assessment methods which could be used in Finland [77,78].
Based on our findings, one future research direction seems important. Secularization has been strong in Finland, where the policy is that religion is everyone’s private matter [8,24]. According to our findings, the secular courtesy of not asking a person about their religion may have vast negative implications when that person has dementia. Religious needs may be neglected and their wellbeing subsequently endangered. Thus, we need more research on the religiousness of people with severe dementia and their chances to practice their religion. All citizens have the constitutional right to express and practice one’s religion.

5. Limitations

Studying the religiousness of people with dementia is challenging in many ways and we acknowledge the limitations of our study. We have approached the topic via a third party, in our case the chaplains working in nursing homes. Our results point thus to the interpretation of these chaplains and not necessarily the actual religiousness of the residents. For example, the chaplains might interpret some actions of a person with dementia during a religious ritual as expressions of religiousness, even though she might be expressing her needs regarding sense of security. However, since our interviewees had, in total, 115 years of work experience among people with severe dementia, we trust that their perceptions at least point to the right direction. In addition, the interviewees had very similar observations, although they worked in separate nursing homes.

6. Conclusions

The aim of this study was twofold, to find out: (I) how people with severe dementia express their potential religiousness and (II) how chaplains affirm the potential religiousness of these individuals. The findings reveal that people with dementia express their religiousness in encounters with chaplains through rituals and emotions, and the chaplains influence their religiousness through the body. These findings challenge definitions of religiousness, which often focus on cognitive aspects more than the embodiment of people’s religiousness. Vanishing cognition does not necessarily erase a person’s religiousness, but our religious beliefs seem to go beyond our rationality. Hopefully, the religious bodies of the residents in this study will open new theological views and discussions.

Author Contributions

Conceptualization, J.P., A.V. and S.-M.S.; methodology, J.P., A.V. and S.-M.S.; validation, J.P., A.V. and S.-M.S.; formal analysis, J.P., A.V. and S.-M.S.; investigation, J.P., A.V. and S.-M.S.; resources, J.P., A.V. and S.-M.S.; data curation, J.P.; writing, original draft preparation, J.P., A.V. and S.-M.S.; writing, review and editing, J.P., A.V. and S.-M.S.; project administration, J.P.; funding acquisition, J.P. All authors have read and agreed to the published version of the manuscript.

Funding

This research was funded by the Academy of Finland, grant number 341519 and the Kone Foundation, grant number 201901669.

Institutional Review Board Statement

The study was conducted in accordance with the Declaration of Helsinki, and approved by The Research Ethics Committee in the Humanities and Social and Behavioral Sciences, located at the University of Helsinki (protocol code 5/2020).

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study.

Data Availability Statement

The data used during the current study are available from the corresponding author on reasonable request.

Acknowledgments

The authors would like to thank all the chaplains involved in the study. They made the study possible. Open access funding provided by University of Helsinki.

Conflicts of Interest

The authors declare no conflict of interest. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript; or in the decision to publish the results.

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Table
Table 1. Basic characteristics of interviewees.
Table 1. Basic characteristics of interviewees.
GenderPlace of Work (Mainly)Work Experience with People with Dementia (Years)Work Experience as a Chaplain (Years)
FemaleCentral hospital88
FemaleRehabilitation hospital512
FemaleSeveral nursing homes2.518
FemaleCentral hospital5.55.5
FemaleOne nursing home410
MaleRecently retired, worked in nursing homes4040
FemaleSeveral nursing homes320
FemaleSeveral nursing homes1824
FemaleOne large nursing home1820
FemaleOne nursing home1130
Working experience in total 115187.5
Table
Table 2. Analysis of chaplains’ interpretations of religiousness.
Table 2. Analysis of chaplains’ interpretations of religiousness.
Main CategorySub-CategoriesManifestations in the Data
Bodily manifestationsMoving eyes, lips and heads
Gestures and postures
Taking a hand
Looking towards or away
Interpretations of religiousnessStrong expressions of emotionsCrying
Calming down
Getting restless
Fumbling for liturgical ritualsClasping hands
Taking part in the Holy Communion
Holding a hymn book
Taking part in responsory
Table
Table 3. Analysis of asserting religiousness.
Table 3. Analysis of asserting religiousness.
Main CategorySub-CategoriesManifestations in the Data
Prayer servicesAdjusting the occasion to residents’ cognitive capacities.
Utilizing ritual symbols
Using liturgical clothing
Asserting religiousnessActive presenceGentle voice
Touching
Humming
Active listening
Validating emotions
Wearing clerical collars
Chaplains’ generational intelligenceUtilizing pieces of popular culture from residents’ youth.
Understanding the stronger societal presence of the church in residents’ childhood.
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Pirhonen, J.; Vähäkangas, A.; Saarelainen, S.-M. Religious Bodies–Lutheran Chaplains Interpreting and Asserting Religiousness of People with Severe Dementia in Finnish Nursing Homes. J. Ageing Longev. 2023, 3, 92-106. https://doi.org/10.3390/jal3010008

AMA Style

Pirhonen J, Vähäkangas A, Saarelainen S-M. Religious Bodies–Lutheran Chaplains Interpreting and Asserting Religiousness of People with Severe Dementia in Finnish Nursing Homes. Journal of Ageing and Longevity. 2023; 3(1):92-106. https://doi.org/10.3390/jal3010008

Chicago/Turabian Style

Pirhonen, Jari, Auli Vähäkangas, and Suvi-Maria Saarelainen. 2023. "Religious Bodies–Lutheran Chaplains Interpreting and Asserting Religiousness of People with Severe Dementia in Finnish Nursing Homes" Journal of Ageing and Longevity 3, no. 1: 92-106. https://doi.org/10.3390/jal3010008

APA Style

Pirhonen, J., Vähäkangas, A., & Saarelainen, S. -M. (2023). Religious Bodies–Lutheran Chaplains Interpreting and Asserting Religiousness of People with Severe Dementia in Finnish Nursing Homes. Journal of Ageing and Longevity, 3(1), 92-106. https://doi.org/10.3390/jal3010008

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