The Challenges of Teaching Spirituality in Palliative Care

Dr Wilf McSherryProfessor in Dignity of Care for Older People

Centre for

Practice andServiceImprovement

Aim

Reflect upon the educational challenges associated with the teaching of spirituality within palliative care

Learning Outcomes

• Generate awareness of the educational challenges related to the teaching of spirituality within palliative care

• Consider strategies for the inclusion of the ‘spiritual dimension’ within programmes of education

• Discuss whether spiritual care competencies can assist the advancement of spirituality within EoLC

A Concern

McSherry (1997)• 84% of nurses identified patients with spiritual needs • Only 40% felt that they were able to meet their patients’

spiritual needs• 53.8% of the qualified nurses stated that they had not

received any instruction into the spiritual dimension• 72.8% who felt that they did not receive sufficient

training into this aspect of care

Nursing Times (NT 2009)• Should nursing practice automatically include a spiritual

element? Yes - 72% No - 28%

Challenges

The Educational Considerations

A Seminal Definition

“A Quality that goes beyond religious affiliation, that strives for inspirations, reverence, awe, meaning and purpose, even in those who do not believe in any god (good). The spiritual dimension tries to be in harmony with the universe, strives for answers about the infinite, and comes into focus when a person faces emotional stress, physical illness or death.”

Murray and Zentner (1989 pg 259)

Department of Health(2009 p19)

“Spirituality is difficult to define, as it can mean different things to different people, and its existence as a discrete phenomenon may be denied by some. In essence it is to do with making important connections which provide people with hope, purpose and comfort. This may also be confused with religion which relates to a belief system.”

What is Spirituality?

Patients’ Perceptions

“I have not a clue. I really don’t know what it means. To me it is just about religion. I don’t know how you describe it quite honestly. That’s why when you rung up I thought to myself, I don’t know what I am going to say to you because I don’t know what it means”

Patient Acute Trust

“Never has interested me even illness it’s never interested me has religion. It has done nothing for me.”

Patient Palliative Care

Patients’ Perceptions

“Well that’s what I thought when I got this letter you know. Well I thought well again were back to religion!”

Patient Palliative Care

“Spirituality I think it is personal, it depends on what the individual believes for example my mother believes spirituality to be psychic, ghosts and people coming back from the dead. Where as I think it to be what religion you believe in your own aspects towards god or however it is that you worship.”

Patient Acute Trust

Nurses’ Perceptions

“I think it’s different to every person, to me spirituality is what makes me feel what makes me! The emotional side, the essence of living! It makes somebody feel whole. It’s the sparkle. Yeah it’s just Je ne sais quoi! I don’t know?”

Nurse Palliative Care

Health Care Professionals’ Perceptions

“My current understanding is that it’s three-fold! The meaning purpose aspect which is most often talked about is only part of spirituality and I would say that equally at least relationships and I still struggle to find the right word a sense of transcendence awe, wonder, mystery are also important parts of spirituality and spiritual care.”

Chaplain

A Taxonomy of SpiritualityDESCRIPTORS

Theistic: belief in a supreme being, cosmological arguments not necessarily a ‘God’ but deity.

Religious: affiliation – belief in a God, undertaking certain religious practices, customs and rituals

Language: Individuals may use certain language when defining spirituality such as inner strength, inner peace.

Cultural; Political; Social ideologies: an individual may subscribe to a particular political position or social ideology that influences governs their attitudes and behaviours. dependent upon world faith – religious tenants.

Phenomenological: one learns about life by living and learning from a variety of situations and experience both positive and negative

Existential:a semantic philosophy of life and being, finding meaning, purpose and fulfilment in all of life’s events.

Quality of Life: although quality of life is not explicit in definitions it is implicit.

Mystical:relationship between the transcendent, interpersonal, transpersonal, life after death.

LEFT………………………………………………….........................................……………………………………………………………………………………..RIGHT

CONSIDERATION The order or sequencing of the descriptors present in the taxonomy are individually determined depending upon ones beliefs, values and life experience or worldview.The taxonomy is restrictive in that it implies the ability to intellectualise supporting the position that such definitions are exclusive and restrictive.The taxonomy implies that an individual's worldview will determine their definition of spirituality.The descriptors listed in the taxonomy are not exhaustive because they may well be infinite.The taxonomy suggests two form of spirituality the ‘old’ and the ‘post modern’. The old = religious and theist while the ‘The post-modern’ = Phenomenological and existentially focused.

McSherry (2009)Definition of Spirituality

Spirituality is universal, deeply personal and individual; it goes beyond formal notions of ritual or religious practice to encompass the unique capacity of each individual. It is at the core and essence of who we are, that spark which permeates the entire fabric of the person and demands that we are all worthy of dignity and respect. It transcends intellectual capability, elevating the status of all of humanity.

Why?

• It would appear that many statutory bodies, for example the Nursing and Midwifery Council (NMC) state both implicitly and explicitly that the spiritual dimension should be addressed

• International research suggests the teaching of Spirituality is left to individuals with an interest in the subject?

Why the interest in Spirituality?

• National Legislation/Guidance

• Codes of Ethics and Professional Conduct

• Educational preparedness

• Changing society

World Health Organisation

“Until recently the health professions have largely followed a medical model, which seeks to treat patients by focusing on medicines and surgery, and gives less importance to beliefs and to faith. This reductionism or mechanistic view of patients as being only a material body is no longer satisfactory. Patients and physicians have begun to realise the value of elements such as faith, hope and compassion in the healing process. The value of such ‘spiritual’ elements in health and quality of life has led to research in this field in an attempt to move towards a more holistic view of health that includes a non-material dimension, emphasising the seamless connections between mind and body.”

World Health Organisation (WHO) 1998

Patients’ Charter

“NHS staff will respect your privacy and dignity. They will be sensitive to, and respect, your religious, spiritual and cultural needs at all times.”

Department of Health (DOH) (2001 pg 29) Your Guide to the NHS. DOH: London

The NHS Constitution (2009 p6)

“Respect, consent and confidentiality:

You have the right to be treated with dignity and respect, in accordance with your human rights”

Nursing and Midwifery Council (NMC)

Competences

Pg 13 – “Undertake and document a comprehensive, systematic and accurate nursing assessment of the physical, psychological, social and spiritual needs of patients, clients and communities.”

NMC (2004) Requirements for pre-registration nursing programmes NMC, London

Core Competences

2. Assessment and Care Planning

d. Ensure that all assessments are holistic, including:

Religion and/or spiritual well-being, where appropriate

5. Overarching values and knowledge

b. Person-centred practice that recognises the circumstances, concerns, goal, beliefs and cultures of the individual, their family and friends, and acknowledges the significance of spiritual, emotional and religious support and the diversities in these regards that there might be between family or social group members

DH (2009 p10–12)

How?

There are several fundamental points that must be considered in the teaching of spirituality:• Modular• Spiral• Fragmented v Holistic• Academic v reflective• Assessment v Developmental• Taught v Exposure in practice• Experience of Lecturer• Support• E-learning v face to face

Spiritual & Religious Care Competencies forSpecialist Palliative Care (MCCC, 2003)

Broad Groups for EoLC Workforce Development

GROUP DEFINITION MINIMUM SKILL AND KNOWLEDGE LEVEL

GROUP A: specialist palliative care staff, work entirely focused on people at the end of their lives.

Highest levels, through specialist training. To include all of common core competences.

GROUP B: staff who frequently deal with end of life care as part of their role.

Need to be enabled to develop or apply and competences. May require additional specialist training.

GROUP C: staff working within other services who are involved with end of life care infrequently.

Good basic grounding in the principles and competences; alongside knowledge of where to seek expert advice or refer on to.

When & Where?

• Stand alone module at mid point in course?

• Continuously throughout educational programme and in nursing - branch specific?

• Should it be classroom based or addressed in practice? Or should we develop E-learning/distance learning packages?

• Group size - cohort v small groups?

Who?• Should it be left to the chaplain or local religious

leaders? Is it a role to develop spiritual care specialist nurses?

• Have educators a role to play in teaching the subject?

• Preparation of lecturers - developing own spiritual awareness

• Should it be left to educators in practice to teach through example?

Caroline Petrie suspended for asking to pray for a Patient

Raises questions about:

•The role education plays in preparing nurses to be fit for practice and purpose

•Highlights the importance of self-awareness between ones personal beliefs and professional responsibilities

•Taking the initiative from the patient

NT Survey

%Yes %No

1. Have you ever been unable to respond to a patient’s request from another culture due to inadequate guidance?

27 73

2. Would it ever be appropriate for a nurse to pray with or for a patient?

91 9

3. Should nursing practice automatically include a spiritual element?

72 28

4. Has a patient ever asked you to pray for them? 43 57

%Yes %No

5. Is there sufficient guidance for nurses on praying for patients?

13 87

6. Is there sufficient guidance for nurses on dealing with religion at work in general?

24 76

7. Is nursing adequately prepared to deal with the religious needs of different cultures?

26 74

8. Should Caroline Petrie have been suspended for offering to pray for a patient?

9 91

Secularisation and Nurse Education

A scheme in which new hospital patients have their "religious and spiritual care needs" assessed has been condemned by the National Secular Society.

Southampton University Hospitals NHS Trust said people would be asked whether they had "any faith needs that can be supported during their stay". But the National Secular Society, which defends the rights of non-believers, said the move "misused NHS resources".

“How on earth have we reached the stage that you can't even go to hospital for treatment without having religion foisted on you like this?”

Terry SandersonNational Secular Society President

What nursing students thought?

• A 76.7% (176/135) response rate was obtained

• Demographic profile of the cohorts is as follows: the students were aged between 18 and 49 years with the majority of students falling into the 18 – 20 (37.3% n50) age groups

• A total of 16 males and 119 females completed questionnaires

Understanding of spirituality changed due to undertaking nurse education

57% (n = 62) of respondents agreed

11% (n = 12) strongly agreed

Top three themes

1. Understanding of the concept of spirituality

2. Distinction between spirituality and religion

3. Providing spiritual care

Understanding of spirituality changed due to experiences in clinical practice

43% (n = 46) agreed 7% (n = 7) strongly agreed

Top three themes1. Through experiencing/ meeting a diverse range of

people2. Encountering Death/ Disease/ Illness3. Learning how to incorporate into practice

What students said

“Experiences such as having to confront suffering and death has also made me question and analyse my own spirituality so I may adapt to the different environment I work in.”

“Helping a patient to wash – reassuring patients who express anxiety or fear – unsure! All the human elements of the work we carry out has some aspect of spirituality to it (i.e. being kind to others etc).”

My Ongoing Concerns

• We need to review the language of spirituality• Are we not fragmenting care?• Run the risk of complicating care delivery• Restricting spontaneity and intuition• Over intellectualising a hidden aspect of care• Spiritual care should be integral and not divisive • Is spiritual care mandatory or additional?• Differentiating psychosocial or spiritual care• Standardisation – Competences, performance; audit and

outcome measures• Are we not succumbing to a bureaucratic agenda?

The Gaps• Training programmes in supportive and palliative care for senior

health care professionals should include study of the theory and practice of spiritual care. (NICE 2004, p102)

• Identify and develop additional related competences, e.g. Spirituality and well-being, (DH, 2009 p 28)

• Research is needed (NICE, 2004, p 102):

to promote understanding of how spiritual needs and sources of support of different patient groups evolve over time and how spiritual concerns are best assessed and measured.

to determine best ways of providing spiritual support for different patient groups in different settings and at different stages of disease.

A Way Forward

• Review our own practice and thinking

• Reflect upon implications for current programmes and future curricula and programme development

• Collaboration - with other institutions who may already have integrated the concept or developed resources

• Need to be innovative and not risk averse

Conclusion

• We need to give consideration to the What, Why, How When, Where and Who

• We need to stop and evaluate research findings addressing the spiritual dimension and identify why it is still such a taboo subject and not being taught

• Future success will be dependent upon multi-disciplinary involvement and institutional collaboration in the devising of programmes to share best practice