By Richard Egan
You can’t tell anyone what to think or how to behave, not really. You can only ask good questions, offer interesting answers, and create environments where people can explore these things for themselves. The challenge is, in our largely post-Christian age[i] (in Aotearoa New Zealand (NZ) / Australia), there are fewer and less formal (let alone informal) opportunities to explore existential/religious/spiritual questions.
Yet we know when faced with ageing, a serious or terminal illness, these questions almost inevitably arise1: questions about who we are, what we’ve done, who we’re leaving behind, and what’s next?
This article is a reflection on teaching about spiritual care, from my own experience and peer-review literature.
When I was an English teacher, I used every opportunity possible – from Shakespeare to Margaret Atwood – to explore the big questions in life. Then as a mental health promotor, the best work I did included workshops about spirituality with an aged care organisation and a mental health provider, led by those with experience. What was striking about these workshops was that I always learnt more than I taught. The older people involved drew on a lifetime of experience and wisdom, and loved the opportunity to explore meaning and purpose. And those who had or were experiencing mental distress often talked about spirituality as part of the pathway to recovery.
I imagine many of you reading this agree that spiritual care is important in healthcare and aged care. It’s fair to say that spirituality in the healthcare literature is no longer emergent; rather, with a range of journals, books and conferences, it has emerged. Many of our models, frameworks and principles now include spirituality. Therefore the spiritual care mandate is clear.
Sadly this has not filtered up to the funders, senior managers and others in power – but there are signs of change. In Australia, both Spiritual Care Australia and Meaningful Ageing Australia are leading the way in developing evidence, resources, competencies and more. Here in Aotearoa New Zealand, our health system is being restructured to include a parallel Māori Health Authority, which has the potential to affirm the place of wairua (spirituality) across the system.
With a conducive research and policy environment, spiritual care education is crucial to help inform practice. Since 2018, I have been teaching spirituality in healthcare to nursing students, and since 2019, we introduced a ‘spirituality in clinical care’ lecture for medical students. I was surprised nursing education did not explore spiritual care more, given spiritual care has always been part of nursing2, albeit often implicitly by ‘’being with’’, what Pulchalski calls “compassionate presence”3 with their patients.
But more exciting, from my point of view, was when I was asked to teach one session for second-year medical students and then later an additional one in the third year. While only a couple hours of teaching, this innovation reflects a sea change. You might even suggest that here at the southernmost medical school on the planet, we are reflecting a global movement away from bio-reductionism towards a more holistic bio-psycho-social-spiritual approach4.
Why? Because of the growth of evidence and models that highlight spiritual care. And we are being reminded of the importance of spirituality by Māori and other indigenous peoples5.
Here is what I cover in my teaching on spiritual care: students’ understanding of spirituality, a framework to understand spirituality6, approaches to spiritual care, referral pathways and ethical issues. This is partly based on the Association of American Medical Colleges guidelines regarding spiritual issues7,8. In 2021, I shifted the emphasis slightly to include more about students’ own spirituality in light of the growing evidence around healthcare professional burnout and moral and spiritual distress9,10. As well as asking them what spirituality means for them, I also ask the students where they developed their ideas about spirituality and how they address their own spiritual wellbeing.
We move from their general understanding, to thinking critically about their spiritual history, to considering their spiritual self-care strategies. I talk about the evidence and introduce some basic strategies to ask their patients about their spiritual wellbeing. I also introduce evidence-based assessments, such as Pulchaski’s FICA tool11, and Anandarajah and Hight’s HOPE tool12. The medical students use the latter tool in face-to-face interactions with aged care residents.
There are literally dozens of published assessment tools. My current favourite is the ConnecTo spiritual screening tool. The beauty of the ConnecTo tool is that it gives us a point of entry to connect with the aged care resident through conversation, undertake an initial assessment of spiritual wellbeing, and set up a basis for an ongoing relationship.
Further, ConnecTo is useful as a spiritual self-assessment tool – it asks us to think about our connection to nature, creativity, self, others, and something bigger (which could be religion). Each of us has a different balance across these connections as well as a different focus on what matters most, what sustains us, and what is meaningful.
Spiritual care is essential. This is affirmed by research, our principled approach, the zeitgeist and indigenous wisdom. We are teaching this to our healthcare professionals and this will slowly impact our healthcare and aged care sectors – which will ultimately improve the quality of life, and death, for hospital patients and aged care residents.
[i] “Post-christian” is a term used by Lloyd Geering (see Geering L. The World to Come: from Christian past to Global future. Wellington: Bridget Williams Books; 1999.). It appears the secularisation thesis was not right; in fact over 80% of the world are still religious. The term “post-secular” is now being used. It’s a fairly opaque term, but my reading is that religion and spirituality are (still) important.
Richard Egan is a director of the Cancer Society Research Collaboration and co-director of the Social and Behavioural Research Unit, and an Associate Professor in the Department of Preventive & Social Medicine, Dunedin School of Medicine, University of Otago, New Zealand.
He is also an Honorary Research Consultant for Meaningful Ageing Australia, a Global Network for Spirituality & Health member, and he works with Hospice NZ on spirituality matters. Sarah (wife), Benji (son, aged thirteen) and Milo (dog) remind Richard about ‘what matters most’.
- Egan, R., MacLeod, R., Jaye, C., McGee, R., Baxter, J., Herbison, P., Wood, S. “Spiritual beliefs, practices, and needs at the end of life: Results from a New Zealand national hospice study”. Palliative & Supportive Care. 2016; FirstView:1-8.
- McSherry, W. The meaning of spirituality and spiritual care within nursing and health care practice. London: Quay Books; 2007.
- Puchalski, C.M., Vitillo, R., Hull, S.K., Reller, N. “Improving the spiritual dimension of whole person care: reaching national and international consensus”. Journal of Palliative Medicine. 2014; 17(6):642-56.
- Chuengsatiansup, K. “Spirituality and health: an initial proposal to incorporate spiritual health in health impact assessment”. Environmental Impact Assessment Review. 2003; 23(1):3-15.
- Valentine, H., Tassell-Mataamua, N., Flett, R. “Whakairia ki runga: The many dimensions of wairua”. New Zealand Journal of Psychology (Online). 2017; 46(3):64-71.
- Egan, R., Blank, M-L. “A framework for understanding spirituality and healthy ageing: perspectives from Aotearoa New Zealand”. Journal of Religion, Spirituality & Aging. 2021; 33(2):112-26.
- Puchalski, C.M. Spiritual Care: Practical Tools. A Time for Listening and Caring: Spirituality and the Care of the Chronically Ill and Dying. New York: Oxford University Press; 2006. p. 229 – 52.
- Sajja, A., Puchalski, C. “Training physicians as healers”. AMA journal of ethics. 2018; 20(7):E655-63.
- Woods, M., Rodgers, V., Towers, A., Grow, SL. “Researching moral distress among New Zealand nurses: A national survey”. Nursing Ethics. 2014.
- Sulmasy, D. The Healthcare Professional as Person: The Spirituality of Providing Care at the End of Life. A Time for Listening and Caring: Spirituality and the Care of the Chronically Ill and Dying. New York: Oxford University Press; 2006. p. 101 – 14.
- Borneman, T., Ferrell, B., Puchalski, C.M. “Evaluation of the FICA Tool for Spiritual Assessment”. Journal of Pain and Symptom Management. 2010; 40(2):163-73.