The%20Challenges%20of%20Teaching%20Spirituality%20in%20Palliative%20Care

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The Challenges of Teaching Spirituality in
Palliative Care
Centre for
Practice and Service Improvement

• Dr Wilf McSherry
• Professor in Dignity of Care for Older People

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Aim

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

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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

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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

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Challenges
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The Educational Considerations
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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)

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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.

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What is Spirituality?
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Patients Perceptions

• I have not a clue. I really dont know what it
  means. To me it is just about religion. I dont
  know how you describe it quite honestly. Thats
  why when you rung up I thought to myself, I dont
  know what I am going to say to you because I
  dont know what it means
• Patient Acute Trust
• Never has interested me even illness its never
  interested me has religion. It has done nothing
  for me.
• Patient Palliative Care

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Patients Perceptions

• Well thats 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

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Nurses Perceptions

• I think its 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. Its the sparkle.
  Yeah its just Je ne sais quoi! I dont know?
• Nurse Palliative Care

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Health Care Professionals Perceptions

• My current understanding is that its
  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

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A Taxonomy of Spirituality
DESCRIPTORS DESCRIPTORS DESCRIPTORS DESCRIPTORS DESCRIPTORS DESCRIPTORS DESCRIPTORS DESCRIPTORS
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 lifes 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 LEFT...........................................RIGHT LEFT...........................................RIGHT LEFT...........................................RIGHT LEFT...........................................RIGHT LEFT...........................................RIGHT LEFT...........................................RIGHT 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. 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. 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. 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. 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. 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. 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. 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.
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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.

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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?

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Why the interest in Spirituality?

• National Legislation/Guidance
• Codes of Ethics and Professional Conduct
• Educational preparedness
• Changing society

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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

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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

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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

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Nursing and Midwifery Council (NMC)
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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

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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 p1012)

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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

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Spiritual Religious Care Competencies
forSpecialist Palliative Care (MCCC, 2003)
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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.
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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?

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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?

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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

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NT Survey
Yes No
1. Have you ever been unable to respond to a patients 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
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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
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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
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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

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Understanding of spirituality changed due to
undertaking nurse education

• 57 (n 62) of respondents agreed
• 11 (n 12) strongly agreed
• Top three themes
• Understanding of the concept of spirituality
• Distinction between spirituality and religion
• Providing spiritual care

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Understanding of spirituality changed due to
experiences in clinical practice

• 43 (n 46) agreed
• 7 (n 7) strongly agreed
• Top three themes
• Through experiencing/ meeting a diverse range of
  people
• Encountering Death/ Disease/ Illness
• Learning how to incorporate into practice

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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).

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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?

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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.

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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

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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