CHAPTER 6
Skills Required to Provide Spiritual Care
Introduction
This chapter will review the different skills health care professionals require in order to assess, plan, implement and evaluate spiritual care. At this stage in the book, you are probably recognizing that the concept of spirituality is subjective, diverse and unique to each individual. The subjective nature of the spiritual dimension means that health care professionals require a broad range of skills for them to overcome many of the barriers that can prevent the provision of spiritual care. By utilizing these skills and developing their own self-awareness, health care professionals will be in a stronger position to act as advocates for their patients, clients or service users who present with spiritual need(s). The chapter demonstrates the need for multidisciplinary and inter-disciplinary collaboration in the provision of spiritual care. It is argued that no single professional group has a monopoly with respect to the spiritual dimension.
In Box 6.1, the quotation from Burnard highlights the subtle nature of spiritual care. It reveals that spiritual care is not easy, and at times is uncomfortable, indeed a challenge. The quotation implies that there are right and wrong methods to be utilized in this aspect of care. Fundamentally, the quotation indicates that the area of spiritual care is a two-way process that can enrich the lives of both the patient and the nurse or health care professional – a term I have called professional enrichment (McSherry 2004). However, if spiritual care is to be effective and the dispirited person and the health care professional are to benefit from the interactions and encounter, then there are certain skills or guiding principles to be followed.
Box 6.1 Food for thought
This, then is the challenge in nursing (health care) the spiritually distressed person: to listen, to accept, to explore and finally, to offer no ready answers. This is clearly a difficult task but a rewarding one. In the end, persons who discover their own meaning and their own reason for believing in what they do will usually be the more satisfied. The nurse’s task is not to get in the way of that process taking place. But equally and almost paradoxically, it is the nurse’s task to become involved with the dispirited person. The balance between standing back and becoming immersed is a difficult one to achieve. It is also, a very human and important one. (Burnard 1987, p.381)
Identifying the skills
In order to proceed with this chapter, there is a need to identify the skills that may be required by health care professionals to support and facilitate spiritual care. Read the following Case study 6.1 and spend several minutes reflecting upon the skills you would require in order to meet the patient’s spiritual needs.
You may have identified several skills that are necessary to support Vincent and meet his spiritual needs. You will have recognized the need for good interpersonal skills in helping you to address Vincent’s immediate concerns. The questions that Vincent expresses are existential, questioning his reason for living, indicating that you may require some insight into what constitutes spirituality. A comprehensive list of skills required to enable Vincent to achieve total well-being is given in Box 6.2. It must be stressed that these skills are not used in isolation. The biggest danger of identifying lists is that we assume each skill is separate from the next, not connected or used in conjunction with the others. If you observe skilled practitioners, you will see that they draw upon their knowledge and use all their skills in an integrated manner. The skills and knowledge become an integral part of the person. These skills are drawn upon to resolve an issue or concern. The same principle applies when supporting individuals with spiritual needs. The provision of spiritual care must become a natural part of the practitioner’s experience or else the care will be fragmented and unnatural – rather like using a checklist when a vehicle has been booked in for an MOT test. McCavery (1985, p.139) alerts us to this fact: ‘However, spiritual activity can never be restricted to mere religious practice, nor can spiritual needs be fulfilled successfully in a scientific, planned way.’
Case study 6.1 Questioning meaning and purpose
Vincent is 38 years of age and works as a business executive with an international company. He has been married for 10 years and has three young children, all under six. He is a little overweight and smokes around 10 cigarettes per day. His wife has been encouraging him to slow down but with little success. Life operates around Vincent’s need to meet deadlines and production targets. Early one morning, he is woken by a tightness around his chest and a pain radiating down his left arm and up into his jaw. His wife phones for an ambulance and Vincent is rushed into hospital diagnosed as a myocardial infarction. You are the nurse responsible for Vincent’s care. The day after admission, in conversation he says to you, ‘My life will never be the same’ and ‘What will I do about work and who will support my family?’
Perhaps while examining the skills listed, you may feel that many health care professionals already possess such skills, which are developed to a high standard and used frequently in their clinical practice.
To assume that no health care professionals are able to deal with patients’ or service users’ spiritual needs is presumptuous and judgemental, bearing in mind the concerns raised by Walter (2002) that not all practitioners may want to be involved or could be involved in the delivery of spiritual care. One cannot generalize and say that health care professionals are not able to meet their patients’ or service users’ spiritual needs. Such a generalization would be misleading, contradicting current research findings (Harrison 1993; McSherry 1997; Narayanasamy 1993; Waugh 1992). An excerpt from McSherry’s thesis (1997, p.127) supports this point, indicating that nurses are recognizing patients presenting with a spiritual need(s):
However, there is no room for complacency because only a small percentage of qualified nurses felt they were able to meet their patients’ spiritual need(s) successfully. In several research studies (McSherry 1997, 2004; Narayanasamy 1993; Waugh 1992), nurses and other health care professionals have asked for more education regarding addressing the spiritual dimension of care. This recognition of their own limitations indicates that health care professionals still feel uncertain about how to address this aspect of care. This uncertainty may arise because they feel that they do not have sufficient insight or skills to address the spiritual dimension.
Box 6.2 Skills required to provide spiritual care
Good interpersonal and communication skills
Development of trust
Sensitivity
Self-awareness – clarification of personal values
Provision of support to the patient/service users and colleagues
Education and training
Openness and honesty
Multidisciplinary collaboration
Recognition of your own limitations
Hierarchy of support
McSherry (2004, p.286–288) identified a hierarchy of support that health care professionals may use to support individuals to meet any spiritual need(s), whether these have been assessed formally or just expressed by the individual. There seemed to be identifiable within the nurses’, patients’ and the health care professionals’ transcripts a ‘hierarchy of support’. This hierarchy ranged from providing ‘general support’, to supporting individuals with ‘specific or complex’ needs (Figure 6.1). The hierarchy is clearly illustrated in the following transcript:
Participant (P): ‘I actually think that you can help them to achieve their spirituality by sitting (presence) with them, actually and that’s okay, if that’s what they want? Em, I don’t think, it takes any more than that! I think, if you want to listen to them em… [short pause] or if they want to talk (express) about their spirituality, then that’s okay, em, but like anything else I might want to talk about it and I might think crumbs, I don’t know anything about this, but it’s not, about, necessarily about, what they are saying, but it’s about your response to it, and the contact or the quality of the contact you have with them… [short pause] does that make sense?’ (P 4 Nurse II)
At the base of the pyramid would be the term ‘expressing’, where individuals feel supported to disclose their worries and concerns, or feel confident to request particular resources. This would move on to the next area of support, that staff are ‘receptive and listen’ to expressed need. At the middle of the pyramid would be ‘presence and facilitation’. Staff are able to provide time and give of themselves to assist patients with requests for help. This may involve the nurse or allied health professional liaising with religious/spiritual leaders or even specialist counsellors, practitioners. Towards the top of the pyramid come religious needs and specialist interventions such as counselling.
Figure 6.1: Hierarchy of support
The nurses and the health care professionals recognized that there may be certain religious rituals, practices, and emotional, psychological problems that may warrant specialist and continued intervention to help patients to meet specific religious, spiritual needs. The pyramid reveals that spiritual support may be dependent upon several components which, if not present, may inhibit the provision of spiritual care. For example, without the first, ‘expressing’, the others could not occur.
This hierarchy of support operates at two levels: first, this may be the order in which individual patients test the water for spiritual care. Second, it can be applied to all the allied health professionals in that it describes the types of interventions, the order and sequencing of skills that may need to be used if any form of ‘care’ including spiritual care is to be provided effectively. This hierarchy can be superimposed on all types of care since spiritual care should be integrated and not fragmented.
Communication/interpersonal skills
It could be argued that communication and interpersonal skills are fundamental to all aspects of health care. This is certainly a central theme in Essence of Care: Patient-focused Benchmarks for Clinical Governance (DH 2003), a document aimed at raising standards within health care practice. Without the use of good interpersonal skills and communication, important information may not be conveyed adequately between patient or service user and other health care professionals. Given the deeply sensitive and personal nature of spirituality, there is a greater need for communication to be effective in removing barriers and alleviating fears. It would appear that effective communication is a prerequisite to the formation of any kind of relationship (McCavery 1985). Without the use of good communication, we can never expect to know, understand or become aware of individuals’ innermost fears, motives or spiritual concerns.
When addressing an individual’s spiritual needs, the health care professional must use all forms of communication and interpersonal skills to identify and evaluate the problem. It is not the intention of this section to explore all aspects of communication, but rather to identify methods that are important when attending to patients’ spiritual concerns. Three important aspects of communication that seem pertinent to the issue of spiritual care are attentive listening, non-verbal communication and the use of presence (Box 6.3).
Attentive listening
A brief definition of attentive listening is provided. However, there is more to attentive listening than merely paying attention. We can give all the indications to a patient and service user that we are listening when in reality we hear little about what they have expressed. Burnard (1988a, p.371) warns us of this hidden danger:
The first practical step in helping others with spiritual problems, then, is listening to them. This may seem so obvious as to not need stating. However we often spend considerable time with others rehearsing our replies to what they are saying, rather than truly listening to them.
Attentive listening
This means listening to and not necessarily saying anything as the patient discloses his or her spiritual need. It is about paying attention to words, tone of voice and non-verbal language. Attentive listening is not a shallow activity but one that allows you to engage with the patient at a deeper level.
Non-verbal communication
The area of non-verbal communication is crucial in generating a therapeutic relationship between health care professional and patient. Health care professionals must have an insight into the non-verbal gestures, expressions and body language that they display. They must be able to observe the non-verbal cues exhibited by their patients and service users.
Presence, or making time
By far the greatest consolation an individual can have when experiencing a spiritual concern is knowing that someone is there for him or her in this time of need. Presence means being with the individual in a physical, psychological and spiritual sense.
It would appear that attentive listening is about focusing upon what the patient or service user has to say and clearing our head of any judgements, ideas or opinions that we have concerning the problem, thereby giving our undivided attention. In situations that are intense and stressful, there is a tendency for us to fill the silence. However, silence can be a powerful tool in that it allows individuals to think, reflect and process points that may have been raised. When facilitating workshops on spiritual care, it is always tempting to fill natural silences with speech, especially if the content of what was being discussed prior to the silence was emotionally challenging. Morrison (1992) tells us that possibly the best form of communication is silence.
Narayanasamy (1997) provides a list of attributes of a good listener. These are summarized here:
•Giving your complete attention to the patient or service user. Suspending your own thoughts and opinions on the subject – clearing your own head.
•Using reflection and paraphrasing to indicate you are giving full attention, and listening hard.
•Responding warmly to the patient or service user. Using open gestures and speech to encourage the individual to talk, indicating acceptance of his or her spiritual need.
It must be stressed that attentive listening is difficult. This particular skill is not developed overnight but through much experience and practice. The use of prolonged attentive listening can be demanding, resulting in the health care professional feeling exhausted. This is because such interventions require the nurse to enter into a relationship that draws upon his or her own spiritual reserves. Therefore, attentive listening is not easy because it is time-consuming and demanding. However, the benefits of simply listening to and allowing patients to express their inner concerns, fears and spiritual needs can in itself be therapeutic. As part of listening, the nurse may also be observing for other non-verbal cues that indicate the patient has a spiritual need.
Activity 6.1
Consider the points that have been raised in this section regarding attentive listening. Write down what attributes are to be found in a good listener. Can you think of any ways in which we can improve our listening skills?
Non-verbal communication
The importance of observation was stressed in the section addressing assessment (Chapter 4). An important part of assessment is being alert to factors or cues that may be suggestive of a patient having spiritual need(s). McSherry (1996) recalls how a patient’s non-verbal behaviours indicated a deep spiritual need as summarised in Case study 6.2.
Case study 6.2 The importance of non-verbal communication
A patient was withdrawn, used limited communication and detached herself from any form of interaction with other patients. It emerged after several days that the patient had experienced a great loss and needed time to grieve and reconcile, adjusting to the loss. This resulted in her displaying the non-verbal cues that the nurses interpreted as odd. The nurses reacted to the cues in a judgemental manner, viewing the patient’s behaviour as antagonistic. The patient was immediately labelled unpopular (Stockwell 1984). (Adapted from McSherry, 1996).
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