Spiritual Support in Advanced Heart Failure

A Randomized Controlled Feasibility Study


  • Jackie Miles Aneurin Bevan University Health Board
  • Linda Ross University of South Wales
  • Paul Jarvis University of South Wales
  • Sara Pickett Swansea University




heart failure, spirituality, spiritual interventions, randomized controlled trial


Heart failure is a complex, progressive disease with an uncertain trajectory. Those with advanced heart failure (AHF) experience substantial spiritual needs. Spiritual interventions may enhance quality of life and reduce anxiety and depression, but studies are limited and none have focused exclusively on the AHF patient population. This is the first feasibility randomized controlled trial (RCT) to ascertain the clinical and cost effectiveness of a spiritual intervention (spiritual support) in AHF patients. A total of 47 AHF patients were randomized to control (standard care, n = 25) or intervention (standard care plus spiritual support, n = 22) groups. Spiritual support consisted of a one-hour discussion facilitated by trained volunteers using a “Spiritual Enquiry Tool” at two-monthly intervals over six months. Participants completed validated measures of spiritual well-being, depression/anxiety, and health-related quality of life (QoL). Purpose-designed questionnaires gathered information on demographics, NHS resource use, confounding factors, and satisfaction with spiritual support. The new information was to help researchers design an RCT to determine the clinical and cost effectiveness of spiritual support within a holistic model of care for AHF patients. Future trends worthy of further investigation include (i) the possible positive effect of spiritual support on QoL and anxiety, and (ii) possible lower NHS resource use and cost savings in patients receiving spiritual support. Overall, the key message of this study is that researchers must evaluate whether the cost of running a well-designed trial of this nature is justified in the current economic climate, where funding bodies are looking for value for money.

Author Biographies

Jackie Miles, Aneurin Bevan University Health Board

Jackie Miles (nee Austin) is Lead Nurse for Heart Failure and Cardiac Rehabilitation Research at the Department of Research and Development, Aneurin Bevan University Health Board, Newport, South Wales, UK, and is Visiting Professor at the School of Care Sciences, University of South Wales.

Linda Ross, University of South Wales

Linda Ross is Professor of Nursing (Spirituality) at the School of Care Sciences, University of South Wales, and a Visiting Professor at Staffordshire University, UK.

Paul Jarvis, University of South Wales

Paul Jarvis is a Statistician and Lecturer in computing in the School of Computing and Maths, Faculty of Computing Engineering and Science at the University of South Wales.

Sara Pickett, Swansea University

Sara Pickett is a Health Economist Researcher, who at the time of the research was at the Swansea Centre for Health Economics (SCHE), Swansea University, UK.


Abu, H. O., Ulbricht, C., Ding, E., Allison, J. J., Salmoirago-Blotcher, E., Goldberg, R. J., & Kiefe, C. I. (2018). Association of religiosity and spirituality with quality of life in patients with cardiovascular disease: A systematic review. Quality of Life Research, 27(11), 2777–2797. https://doi.org/10.1007/s11136-018-1906-4 DOI: https://doi.org/10.1007/s11136-018-1906-4

Austin, J., Williams, R., Ross, L., Moseley, L., & Hutchinson, S. (2005). Randomised controlled trial of cardiac rehabilitation in elderly patients with heart failure. European Journal of Heart Failure, 7(3), 444–417. https://doi.org/10.1016/j.ejheart.2004.10.004 DOI: https://doi.org/10.1016/j.ejheart.2004.10.004

Balboni, T. A., Fitchett, G., Handzo, G. F., Johnson, K. S., Koenig, H. G., Pargament, K., … & Steinhauser, K. E. (2017). State of the science of spirituality and palliative care research part II: Screening, assessment, and interventions. Journal of Pain and Symptom Management, 54(3), 441–453. https://doi.org/10.1016/j.jpainsymman.2017.07.029 DOI: https://doi.org/10.1016/j.jpainsymman.2017.07.029

Boero, M. E., Caviglia, M. L., Monteverdi, R., Braida, V., Fabello, M., & Zorzella, L. M. (2005). Spirituality of health workers: A descriptive study. International Journal of Nursing Studies, 42(8), 915–921. https://doi.org/10.1016/j.ijnurstu.2004.11.007 DOI: https://doi.org/10.1016/j.ijnurstu.2004.11.007

Boyle, D., Crilly, T., & Malby, B. (2017). Can volunteering help create better health and care? Commissioned by the HelpForce Fund, London South Bank University. https://­helpforce.community/wp-content/uploads/Helpforce-Can-volunteering-help-create-better-health-and-care.pdf

British Heart Foundation (2020). Heart failure. Retrieved August 2020 from https://heartfailure.bhf.org

Cockell, N., & Mcsherry, W. (2012). Spiritual care in nursing: An overview of published international research. Journal of Nursing Management, 20(8), 958–969. https://doi.org/10.1111/j.1365-2834.2012.01450.x DOI: https://doi.org/10.1111/j.1365-2834.2012.01450.x

Craig, P., Dieppe, P., Macintyre, S., Michie, S., Nazareth, I., & Petticrew, M. (2008). Developing and evaluating complex interventions: The new Medical Research Council guidance. British Medical Journal, 337, a1655. https://doi.org/10.1136/bmj.a1655 DOI: https://doi.org/10.1136/bmj.a1655

Curtis, L., & Burns, A. (2015). PSSRU: Unit costs of health & social care 2015. Retrieved 13 April 2017 from https://www.pssru.ac.uk/pub/uc/uc2015/full.pdf

Curtis, L., & Burns, A. (2016). PSSRU: Unit Costs of Health & Social Care 2016. Retrieved 13 April 2017 from https://www.pssru.ac.uk/pub/uc/uc2016/full.pdf

CV Outcomes, Inc. (2017) Kansas City Cardiomyopathy Questionnaire (KCCQ-12). Retrieved 7 June 2017 from http://cvoutcomes.org/pages/3214

Department of Health (2016). NHS reference costs 2015 to 2016. National schedule of reference costs: The main schedule. Retrieved 9 March 2020 from https://www.gov.uk/government/publications/nhs-reference-costs-2015-to-2016

European Commission (2010). Europe 2020: A strategy for smart, sustainable and inclusive growth. Brussels: European Commission. http://hdl.voced.edu.au/10707/89925

EuroQol Group (1990). EuroQol – a new facility for the measurement of health?related quality of life. Health Policy, 16(3), 199–208. https://doi.org/10.1016/0168-8510(90)90421-9 DOI: https://doi.org/10.1016/0168-8510(90)90421-9

Goebel, J. R., Doering, L. V., Lorenz, K. A., Maliski, S. L., Nyamathi, A. M., Maliski, S. L., & Evangelista, L. S. (2009). Caring for special populations. Total pain theory in advanced heart failure: Applications to research and practice. Nursing Forum, 44(3), 175–185. Malden, USA: Blackwell Publishing Inc. https://doi.org/10.1111/j.1744-6198.2009.00140.x DOI: https://doi.org/10.1111/j.1744-6198.2009.00140.x

Gwent Healthcare NHS Trust (2006). Clinical futures strategy. Wales: NHS.

Higginson, I. J., Evans, C., Grande, G., Preston, N., Morgan, M., McCrone, P., Lewis, P., Fayers, P., Harding, R., Hotopf, M., Murray, S. A., Benalia, H., Gysels, G., Farquhar, M., & Todd, C. (2013). Evaluating complex interventions in end of life care: The MORECare Statement on good practice generated by a synthesis of transparent expert consultations and systematic reviews. Bio Med Central Medicine, 11, 111. https://doi.org/10.1186/1741-7015-11-111 DOI: https://doi.org/10.1186/1741-7015-11-111

Hsu, P., Krageloh, C. U., Shepherd, D., & Billington, R. (2009). Religion/spirituality and quality of life of international tertiary students in New Zealand: An exploratory study. Mental Health, Religion & Culture, 12(4), 385–399. https://doi.org/10.1080/13674670902752920 DOI: https://doi.org/10.1080/13674670902752920

Joint Formulary Committee (2017). British National Formulary, March 2017. London: BMJ Group and Pharmaceutical Press. Retrieved 9 March 2017 from http://www.medicinescomplete.com

Koenig, H. G. (2009). Research on religion, spirituality, and mental health: A review. Canadian Journal of Psychiatry, 54(5), 283–291. https://doi.org/10.1177/070674370905400502 DOI: https://doi.org/10.1177/070674370905400502

Koenig, H., King, D., & Carson, V. B. (2012). Handbook of religion and health. New York: Oxford University Press.

McClain, C. S., Rosenfeld, B., & Breitbart, W. (2003). Effect of spiritual well?being on end?of?life despair in terminally-ill cancer patients. Lancet, 361(9369), 1603–1607. https://doi.org/10.1016/S0140-6736(03)13310-7 DOI: https://doi.org/10.1016/S0140-6736(03)13310-7

McIlvennan, C. K., & Allen, L. A. (2016). Palliative care in patients with heart failure. British Medical Journal, 353, i1010. https://doi.org/10.1136/bmj.i1010 DOI: https://doi.org/10.1136/bmj.i1010

Murray, S. A., Kendall, M., Boyd, K., Worth, A., & Benton, T. F. (2004). Exploring the spiritual needs of people dying of lung cancer or heart failure: A prospective qualitative interview study of patients and their carers. Palliative Medicine, 18(1), 39–45. https://doi.org/10.1191/0269216304pm837oa DOI: https://doi.org/10.1191/0269216304pm837oa

Murray, S. A., Kendall, M., Grant, E., Boyd, K., Barclay, S., & Sheikh, A. (2007). Patterns of social, psychological and spiritual decline toward the end of life in lung cancer and heart failure. Journal of Pain and Symptom Management, 34(4), 393–402. https://doi.org/10.1016/j.jpainsymman.2006.12.009 DOI: https://doi.org/10.1016/j.jpainsymman.2006.12.009

Murray, S. A., Kendall, M., Boyd, K., Grant, E., Highet, G., & Sheikh, A. (2010). Archetypal trajectories of social, psychological and spiritual wellbeing and distress in family care givers of patients with lung cancer: Secondary analysis of serial qualitative interviews. British Medical Journal, 340, c2581 https://doi.org/10.1136/bmj.c2581 DOI: https://doi.org/10.1136/bmj.c2581

National Institute for Cardiovascular Outcomes Research (2012). National heart failure audit April 2010–March 2011. NHS Digital IC17110110. London: University College London.

National Institute for Health and Care Excellence (2013). Guide to the methods of technology appraisal 2013. https://www.nice.org.uk/process/pmg9/resources/guide-to-the-


National Institute for Health and Care Excellence (2015). Care of dying adults in the last days of life. Retrieved 7 June 2017 from https://www.nice.org.uk/guidance/ng31

National Institute for Health and Care Excellence (2016). Guidance on loneliness in older people. Nice.org.uk/guidance/qs133/resources/mental-well-being-and-independence-for-older-people-pdf-7554542081349

NHS Education for Scotland (2009). Spiritual care matters. An Introductory resource for all NHS Scotland Staff. Edinburgh; NHS Education for Scotland. 2068KB. https://www.nes.scot.nhs.uk

NHS Education for Scotland (2020). Spiritual care. Edinburgh: NHS Education for Scotland. Retrieved July 2020 from https://www.nes.scot.nhs.uk/education-and-training/by-discipline/spiritual-care/areas-of-education/ccl-scotland.aspx

Nolan, S., Saltmarsh, P., & Leget, C. (2011). Spiritual care in palliative care: Working towards an EAPC task force. European Journal of Palliative Care, 18(2), 86–89. https://www.eapcnet.eu/Portals/0/EJPC18_2_EAPC_update_Spiritual.pdf

Nursing & Midwifery Council (2018). Future nurse: Standards of proficiency for registered nurses. NMC: London. https://www.nmc.org.uk

Park, C. L. (2008). Estimated longevity and changes in spirituality in the context of advanced congestive heart failure. Palliative and Supportive Care, 6(1), 3–11. https://doi.org/10.1017/S1478951508000023 DOI: https://doi.org/10.1017/S1478951508000023

Ross, L. A. (1997). Elderly patients’ perceptions of their spiritual needs and care: A pilot study. Journal of Advanced Nursing, 26(4), 710–715. https://doi.org/10.1046/j.1365-2648.1997.00393.x DOI: https://doi.org/10.1046/j.1365-2648.1997.00393.x

Ross, L. A. (2006). Spiritual care in nursing: An overview of the research to date. Journal of Clinical Nursing, 15(7), 852–862. https://doi.org/10.1111/j.1365-2702.2006.01617.x DOI: https://doi.org/10.1111/j.1365-2702.2006.01617.x

Ross, L. A., & Austin, J. (2015). Spiritual needs and spiritual support preferences of people with end-stage heart failure and their carers: Implications for nurse managers. Journal of Nursing Management, 23(1), 87–95. https://doi.org/10.1111/jonm.12087 DOI: https://doi.org/10.1111/jonm.12087

Ross, L., & Miles, J. (2019). Spirituality in heart failure: A review of the literature from 2014 to 2019 to identify spiritual care needs and spiritual interventions. Current Opinion in Supportive and Palliative Care, 14(1), 9–18. https://doi.org/10.1097/SPC.0000000000000475 DOI: https://doi.org/10.1097/SPC.0000000000000475

Royal College of Nursing (2011). Spirituality in nursing care: A pocket guide. Retrieved 27 March 2020 from https://www.rcn.org.uk

Saunders, C. (1996). A personal therapeutic journey. British Medical Journal, 313(7072), 1599–1601. https://doi.org/10.1136/bmj.313.7072.1599 DOI: https://doi.org/10.1136/bmj.313.7072.1599

Scottish Government (2009). Spiritual care and chaplaincy. Edinburgh: The Stationery Office.

Spertus, J. A., & Jones, P. G. (2015). Development and validation of a short version of the Kansas City Cardiomyopathy Questionnaire. Circulation: Cardiovascular Quality and Outcomes, 8(5), 469–476. https://doi.org/10.1161/CIRCOUTCOMES.115.001958 DOI: https://doi.org/10.1161/CIRCOUTCOMES.115.001958

Thorn, J. C., Coast, J., Cohen, D., Hollingworth, W., Knapp, M., Noble, S. M., … & Hughes, D. (2013). Resource?use measurement based on patient recall: Issues and challenges for economic evaluation. Applied Health Economics and Health Policy, 11(3), 155–161. https://doi.org/10.1007/s40258-013-0022-4 DOI: https://doi.org/10.1007/s40258-013-0022-4

van Reenan, M., & Oppe, M. (2015). EQ?5D?3L user guide: Basic information on how to use the EQ?5D?3L instrument. Version 5.1. Rotterdam, EuroQol Research Foundation: 1–25.

Welsh Government (2005). Designed for life. A world class health service for Wales. http://new.wales.gov.uk/topics/health/health_social_care_strategies

Welsh Government (2015). Health and care standards. Cardiff: Crown.

Welsh Government (2017). Heart conditions delivery plan. Retrieved 18 July 2017 from http://gov.wales/topics/health/nhswales/plans/heart_plan/?lang=en

World Health Organization (2002). WHOQOL?SRPB field-test instrument. Geneva: WHO. https://www.who.int/mental_health/media/en/622.pdf

WHOQOL SRPB Group (2006). A cross-cultural study of spirituality, religion, and personal beliefs as components of quality of life. Social Science and Medicine, 62(6), 1486–1497. https://doi.org/10.1016/j.socscimed.2005.08.001 DOI: https://doi.org/10.1016/j.socscimed.2005.08.001

Zigmond, A. S., & Snaith, R. P. (1983). The Hospital Anxiety and Depression Scale. Acta Psychiatrica Scandinavica, 67(6), 361–370. https://doi.org/10.1111/j.1600-0447.1983.tb09716.x DOI: https://doi.org/10.1111/j.1600-0447.1983.tb09716.x



How to Cite

Miles, J., Ross, L., Jarvis, P., & Pickett, S. (2021). Spiritual Support in Advanced Heart Failure: A Randomized Controlled Feasibility Study. Health and Social Care Chaplaincy, 9(2), 191–215. https://doi.org/10.1558/hscc.41171

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