Special Issue “International Conference of Spirituality in Healthcare. Creating Space for Spirituality in Healthcare,”—Trinity College Dublin 2017

Abstract

This is an editorial of a Special Issue pertaining to the “International Conference of Spirituality in Healthcare. Creating a Space for Spirituality in Healthcare” Trinity College Dublin 2017. This was the third International Spirituality in Healthcare Conference hosted by Trinity College Dublin, with future annual conferences planned. This conference has provided a space to facilitate clinicians, healthcare practitioners and academics to present and debate current issues with this domain. This editorial summarises some of the papers that have been published arising from that conference.

1. Spirituality in Healthcare

Spirituality is diverse, with recognition that there is no one definition generally, it is understood that all “human life has a dimension of spirituality” (Bella et al. 2016, p. 9). Religious aspects are often associated with spirituality, yet many secular aspects, such as seeking to find meaning, purpose, hope and a sense of being whole, as well as activities such as yoga, meditation, mindfulness and tai chi are integral components of spirituality. Spirituality is thus a complex but important topic, reflected in the increased volume and subtlety of research in the field (Lucchetti and Lucchetti 2014). The importance of spirituality in healthcare is emphasised by the many national health agencies and professional regulatory bodies and services that have included spirituality as core to the work that they undertake. Many nursing bodies, like the International Council of Nurses (ICN), have referred to the inclusion of spiritual care in their standards and ethics documents. For example, HIQA (2012) the US Joint Commission (2016) outline guidance on the provision of spiritual care. HIQA is an independent authority that exists to improve health and social care services for the people of Ireland. This increased interest in spiritual care can be attributed to broader changes in culture and religion in Western society. It is evident that there has been some shift away from established religion and religious practices, towards a more individualised spirituality, a personal search for meaning and yet an awareness of being connected with others (Puchalski et al. 2014). This has encouraged an exploration of the relevance of spirituality across many social fields, including healthcare (Cockell and McSherry 2012; Monod et al. 2011; Pike 2017; Williams and Sternthal 2007) but also in business and the workplace (Crossman 2010; Karakas 2010; Pawar 2009; Phipps 2012). The papers contained in this volume were presented at the fourth International Spirituality in Healthcare Conference in Trinity College Dublin on 22 June 2017, and reflect this growing interest, while also demonstrating the diversity of application of spiritual care concepts in areas such as intellectual disability, eating disorders, cancer, addiction services and staff well-being.

2. Religion and Spirituality in Patient Care

Interest in the importance and impact of spirituality across the lifespan has grown internationally. This is certainly reflected in this special edition with varied contributions, for example, by Balthip et al. (2017) exploring how spirituality and dignity play a role in the lives of Thai adolescents living with HIV; Human Immunodeficiency Virus (HIV) is a virus that attacks the human immune system and weakens its ability to fight infection and disease. Keenan and Kirwan (2018) capture nurses’ understanding of the spirituality of older people living with dementia in a continuing care setting. Balthip et al. (2017) reinforce that adolescents have the potential to make a significant contribution to the social and economic capital of any nation, but to achieve this they require health and education. Sadly, Balthip et al. (2017) present the harsh reality that this is not the case for adolescents living with HIV, who may not reach their full potential and may die prematurely because of the “social and physiological restrictions of the condition” (Balthip et al. 2017, p. 1). This research is both timely and significant in demonstrating the positive role that spirituality and dignity play in the lives of adolescents living with HIV. Balthip et al. (2017) interviewed twenty-two adolescents living with HIV and, using thematic analysis, found that spirituality and dignity were manifest in the lives of their interviewees. Interestingly, the main category identified was living life responsibly. Living responsibly meant the adolescents not only possess a clear understanding of the disease, but also focus on living their lives with hope and purpose. This pioneering research provides practical strategies for all those offering support to adolescents living with HIV and indeed, perhaps with any chronic or life-limiting condition.

There is a growing awareness of the unique issues associated with caring for people living with dementia and a growing body of evidence that promotes person-centred and family-centred approaches to compassionate care. However, the precise role that spirituality may play in the lives of individuals living with and caring for dementia, and how they can be supported spiritually by healthcare professionals, present new opportunities for research. Keenan and Kirwan (2018) rise to this challenge by presenting the findings from the first study in Ireland exploring these issues with registered nurses. Using a qualitative descriptive design and purposive sampling, they conducted eight semi-structured interviews with registered nurses caring for older people living with dementia in a rural Irish community hospital. Using thematic content analysis, they identified the broad theme of ‘Understanding spirituality’ and associated subthemes, namely the participating nurses’ own understanding of spirituality and their understanding of spirituality and older people living with dementia. Keenan and Kirwan (2018) confirm the importance of utilising person-centred approaches to care and highlight the positive impact of spiritual care on the overall quality of life of older people. They recognise and reinforce the need for more guidance and educational standards around spirituality so that nurses will feel better prepared to address this aspect with the individual living with dementia.

Another study that was presented that examined the impact of spirituality across the lifespan was Borges et al.’s (2017) quantitative study. Religious expression of spirituality was the central concept in Borges et al.’s (2017) exploration of coping with breast cancer treatment. They demonstrated that spiritual, religious coping is important and helpful for Brazilian women. Using an adaptation of Pargament et al.’s (2000) scale to measure the positive and negative potential of religion in emotional coping, they found that positive religious coping was more evident amongst those who participated in religious activity than those who did not. Interestingly, positive religious coping was significantly correlated to those undergoing chemotherapy, but not other treatment measures. These findings indicate that there is a need for health professionals to be prepared to facilitate spiritual and religious care, particularly for the religiously observant. Potentially negative aspects of religion on emotional coping were less evident amongst the more religiously observant cancer patients. Those who did not belong to any religion, perhaps unsurprisingly, had more negative views on God and religious institutions. There was, however, no significant correlation between the views of the less religious and any aspect of cancer treatment. The relationship between positive spiritual coping and chemotherapies would seem to warrant further exploration. This application of spirituality to healthcare practice illuminates the potential contribution of supporting patients’ spiritual needs in terms of the positive potential impact on coping. Other studies presented explored possible benefits of spirituality to mental health.

3. Spirituality and Mental Health

Cleary and Donohue (2018) interviewed five people who had worked in addiction for ten or more years. Their findings suggest that using spirituality as part of the recovery process supports addiction workers to better manage issues emerging for the person with addiction. Spiritual awareness also enhanced the workers’ personal and professional lives. For spirituality as part of the recovery process to be successful, Cleary and Donohue (2018, p. 4) argue that there needs to be “an openness and awareness around spirituality” of the client, whether or not those working with addiction have spiritual beliefs themselves. Cleary and Donohue identify the distinction between spirituality and religion and present a body of evidence in support of the benefits of spirituality for people with addiction. The participants, who were a mix of people in recovery and those who were not, saw value in spirituality as part of the recovery process for the person with addiction. Clearly, this belief may have attracted worker participants with a particular interest in the subject of spirituality, nonetheless, Cleary and Donohue recommend that workers receive more guidance and education to support people with addiction in meeting their spiritual needs. This need for education and training in relation to understanding spiritual care and spiritual care provision and support among health professionals is a pervasive theme in the literature on this topic and was also highlighted at the 2017 conference.

4. Training and Practice of Health Care Professionals

Many creative and innovative ways of enhancing the spiritual education of health professionals were presented. Each has the potential to increase the quality of life of patients. Research has highlighted the need for further education and training to improve nurses’ knowledge and confidence, which are sometimes lacking (Petley 2017), but also in relation to the assessment of spiritual needs and to the timely delivery of interventions that are appropriate to the individual’s needs (Austin et al. 2017; Martins et al. 2017). Education, however, like research, needs funding.

Wigley’s (2017) grounded theory study explores how pre-registration and undergraduate nursing students develop personal understandings, awareness, meaning, and experience of spiritual aspects and needs within the clinical practice environment. An examination of these associations is timely, as evidence suggests that students are underprepared to engage fully with spiritual care provision of patients (Lewinson et al. 2015; Egan et al. 2017; Austin et al. 2017; Ross et al. 2018). Wigley (2017) explored students’ spiritual awareness and their needs, interpreted through three Basic Social Processes: ‘struggling’, ‘safeguarding’ and ‘seeking’. Wigley (2017) identifies specific challenges that students confront in practice; namely, the inability to define and articulate what spirituality is. This is coupled with fear and uncertainty for those who hold a particular belief system, while disguising their own spirituality. Paradoxically, a student’s spirituality and prayer serve as protective factors to buffer the student’s spiritual development and to prevent spiritual distress when facing a patient’s suffering and dealing with conflicting and/or negative situations. The paper highlights the importance of students’ personal spirituality and needs. Their strategies for coping with spiritual loss through storytelling were identified as a significant resource for maintaining hope and preventing compassion fatigue in the face of anxiety and stress. Wigley (2017, p. 272) further proposes “restorative supervision” and a “pastoral care model of support as means of educators” increasing students’ levels of awareness and endorsing students’ spiritual needs and those of patients, families, and co-workers. Spirituality was conceptualized as being fundamental to students’ nursing practice and needs to be addressed and integrated into nurse education programmes.

Wigley (2017) found that student nurses struggle to support patients’ spirituality in clinical areas, and yet they held strongly to the belief that patients’ spiritual needs were important to address. Both Petley (2017) and Wigley (2017) point out that the sense of hope that spirituality can bring is an important concept for patients, even in tragic circumstances, and it can help to give meaning to events and overall coping. Wigley (2017) highlighted that nursing students need support in understanding both spirituality and spiritual care delivery in healthcare.

There are, however, inconsistencies in competencies, standards, and assessments methods in students’ assessments that warrant attention (Martins et al. 2017). Significant gaps exist in educational provision to nurses, and this is one of several areas that needs to be addressed and supported by research investment internationally in order to enable healthcare professions to fully address patients’ and families’ spiritual needs. This is particularly important in contemporary societies that are increasingly diverse, multi-ethnic, and secular. Reassuringly, some progress has been made in this regard. The international development of core competencies for undergraduate nurses and midwives’ provision of spiritual care is being led by one of the authors [WMcS] through the successful acquisition of Erasmus Plus EU Programme for education funding. The project—Enhancing Nurses and Midwives’ Competence in Providing Spiritual Care through Innovation, Education and Compassionate Care (EPICC)—will be crucial to the development of a more cohesive and consistent empirical foundation for European nurses and midwives’ spiritual care education (see http://www.epicc-project.eu/).

Moving beyond education to the application of spiritual interventions in workplace practice settings, Marshall et al. (2018) highlighted the benefits of the mind–body practice of tai chi to promote well-being, attention, focus, and resilience in stressful healthcare occupations.

Cohen (2018), in his paper, briefly charts the professionalisation of chaplains in the US towards the latter half of the 20th century. He presents a critique of institutional failure to acknowledge spiritual services, though not necessarily liturgical services, as a fundamental ‘patient right’. He considers that “Faith (what we believe) and religion (the (public) expression of those beliefs, which may or may not involve ritual), are the cultural and ethnic filters to our spirituality” (Cohen 2018, p. 2). Cohen, spurred on by an exploration of research on pastoral care and chaplaincy, posed the following question: what is the evidence base to enable chaplaincy to flourish as a discipline in contemporary healthcare, and to embrace more fully its faithfulness to patient-centred spiritual care? Cohen takes the view that chaplains’ concern to be autonomous or self-determining in how they organise their care, and the search for an evidence base to support their role are, together, features of increasing professionalisation of chaplaincy.

Keating’s (2017) study is set against the context of increasing secularisation and describes 70 children’s experiences of meditation (ages 7–11 years) in four Irish primary schools (three denominational and one non-denominational). The paper describes the fruits of mediation for children and explores how children and young people might be allowed to be themselves without becoming prisoners of their own thoughts. The notion of spiritual literacy and how to give voice to the spiritual life of a child is explored and described in this paper. Keating’s study created a space to explore primary school children’s perception, practice, and experience of meditation, with an understanding of ‘the transcendent’ and its impact on spirituality. Innovative visual research methods of photo elicitation and an original tangible approach referred to as ‘Selection Box’ was designed specifically to assist the expression and reflection of the children’s experience of spiritual aspects of meditation practice. Four key themes were revealed: meditation helps you to be yourself; it helps you to feel the goodness inside; it brings you closer to God; and it makes you a kinder person (Keating 2017). Keating discusses children’s perceptions of the nature of meditation as a heart-filled energising practice. He concludes that meditation promotes children’s innate spirituality through fostering strong associations that connect a child’s true sense of self with the Divine. Keating also identifies the need for a critical space within healthcare, for professionals to consider meditation and spiritual care provision for children, young people, and families who experience illness.

5. Integration of Religion and Spirituality into Clinical Context

Lycett (2018) and Grant (2018) both have applied elements of spirituality to eating disorders and disordered eating. Lycett (2018) outlines a proposal for a randomized control trial to test the efficacy of a church-based weight-loss program (“Taste and See”) that was designed to help participants develop a healthy relationship with food. The overall aim of the programme is to break the cycle of dieting and weight gain by improving mental and spiritual well-being, rather than continuously reducing weight. The study aims to compare changes in variables such as emotional eating and psychological, spiritual, and physical well-being between participants undertaking the “Taste and See” programme and participants randomised to a delayed start-waiting list control group. A longitudinal approach will be used with data taken at the start and at 6 months and 2 years post-intervention. If the “Taste and See” program is shown to be effective, a holistic standpoint, which includes spiritual care, may be suitable in managing obesity, as with other healthcare issues.

Grant’s (2018) paper deliberates the practical application of Christian spirituality as a tool for aiding recovery from an eating disorder. The evidence in support of various psychotherapeutic and mind–body practices is outlined. The journey from self-destruction requires engagement with a reconstruction of the self in a process, which may involve loss of hope, relapse, and despair. Grant discusses the potential of engaging with spiritual concepts and attributes hope and trust, acceptance and surrender, and courage and resolve in order to underpin current evidence-based recovery interventions for eating disorders. Psychotherapeutic interventions, including cognitive behavioural therapy, seek to challenge and reframe negative mind-sets related to body image, weight, and eating patterns. Mindfulness-based practices, including meditation and prayer, are identified by Grant (2018) to reduce psychological and emotional distress and to harness self-compassion. Other mind–body techniques including yoga, tai chi, and massage, and creative practices, such as art therapy, have been used to bring balanced recovery from eating disorders.

Grant argues that addressing individual spiritual needs and applying spiritual principles can help engage with these various therapeutic interventions. Hope for recovery and trust in oneself and therapy can be framed as part of a spiritual journey. Acceptance and surrender, again spiritually framed as mindful self-compassion, may be sustaining during treatment and possible relapse. Spiritual, indeed explicitly Christian, interpretations of courage and resolve are presented by Grant as part of a journey to freedom and recovery from eating disorders.

Both Lycett (2018) and Grant (2018) have contributed to the evidence supporting the use of spirituality concepts in eating disorder recovery. As with any other topic, varied and robust research methods are required to build evidence in the field.

6. Methodological Issues

Martins et al.’s (2017) paper provides an overview of research methods used to explore the field of spiritually in nursing care. Encompassing three decades of work on the topic, the review highlights emergent patterns and trends. The first identified paper was published in 1986 and since this time there has been a steadily increasing number of publications. However, overall, the numbers remain small by comparison to clinical topics in nursing and healthcare (Martins et al. 2017). Martins et al. (2017) identifies that there is a preponderance of small-scale qualitative studies, but reassures that this is a normative process in the early development of scientific knowledge in any area of study. Papers on spirituality in healthcare appear in a range of international nursing journals, with the Journal of Clinical Nursing, Oncology Nursing Forum, and the Journal of Advanced Nursing being leaders in the field (Martins et al. 2017). Spirituality research informs key nursing concerns, such as coping and acceptance during illness (Martins et al. 2017), and so needs to have greater support in the international health research agenda and funding bodies.

Weathers (2018) notes that most studies of spirituality and health have been conducted in Western settings (Moberg 2002; Koening et al. 2012). She presents a literature review of studies of spirituality and health originating in Middle Eastern countries, noting the majority come from Iran. Spirituality from a Muslim–Arabic perspective was the main focus of the qualitative and quantitative papers coming from a variety of health settings, highlighting similarities and differences from Western research studies. The variety of research methods used, and a relative lack of intervention-based studies, is consistent with Western settings. Weathers ascribes the common lack of intervention studies to ambiguity in the definition of spirituality. Weathers, however, reports a distinctly Islamic religious perspective within reviewed studies, without the secularism or attempt to make explicit a distinction between religion and spirituality, which seems more evident in Western discourse. Religiosity and Islamic religious observance seemed particularly pervasive in studies of nurses’ perspectives on spirituality.

7. Conclusions

These papers demonstrate the variety of healthcare practitioners who find spirituality to be at least applicable, if not central and essential, to a holistic approach to health. Equally diverse are the health conditions and settings where the spiritual nature of human experience is being explored and empirically tested. Martins et al. (2017) convincingly reassure us that the preponderance of small-scale qualitative studies is an early phase in the scientific development of any area of study. More recent emergence of large-scale studies on spirituality in health is testament to the growing maturity of this field within the nursing profession. Although outside of the scope of their paper, the lack of funding opportunities internationally was considered likely to be contributing to the plethora of small-scale research projects. It is evident that human spiritual experience is deeply embedded in human understanding of health. This series demonstrates that spirituality in healthcare research has become, and continues to be, a vibrant and exciting field of human endeavour.