Ebook Oxford textbook of spirituality in healthcare: Part 2

(BQ) Part 2 book “Oxford textbook of spirituality in healthcare” has contents: Psychiatry and mental health treatment, social work, care of elderly people, palliative care, care of the soul, next steps for spiritual assessment in healthcare, spiritual experience, practice, and community,… and other contents.

for example the pioneering work of Koenig et al.[1] The importance of nursesaddressing the spiritual dimension is also reflected in some of the healthcareguidance at world, European, and national levels These issues are discussed inmore detail in Ross.[2]

Historical perspective

Historically, in the West the sick were looked after in religious orders The bodyand spirit were cared for together, signifying the practice of truly holistic care atthat time, i.e care of the body, mind, and spirit, where the whole is more than thesum of the parts There then followed the ‘period of enlightenment’, with all thatbrought with it, including an escalation in medical research, and knowledge andprevalence of a medical model of treatment which focused on disease processesand cures, rather than the spirit This medical model still prevails today withinmany health care services across the world However, it could be said that, untilrecently, nursing has never lost sight of the holistic concept of care, which hasremained at the heart of the profession right through to the current day Thisunswerving focus on the whole person is a constant core and founding principle

shaping and influencing how nursing is defined, practised and taught as shown

in the next section Nursing is also in the process of developing its own evidencebase for spiritual care

Above we implied that nursing has maintained its focus on the holisticconcept of care However, in the United Kingdom (UK) at present, there isconcern that nursing may be in danger of losing sight of this focus moving awayfrom the founding principles on which it is based The need to refocus on thesecore values of nursing, such as care, compassion, dignity, respect is evident in anumber of reports where the quality and standard of nursing care are criticized.[3–8] In these reports nurses are accused of treating individuals without dignityand respect Claire Rayner (the late President of The Patients Association in theUK) wrote:

For far too long now, the Patients Association has been receiving calls on our Helpline from people wanting to talk about the dreadful, neglectful, demeaning, painful and sometimes downright cruel treatment their elderly relatives had experienced at the hands of NHS nurses.[4, p 3]

For nurses to be described in such derogatory terms is of great concern, since itimplies that the core principles, beliefs, and values that underpin nursing havebeen eroded, lost and misplaced within contemporary nursing practice Whilethese reports have been published within the UK the ramifications and lessons to

be learnt are of international relevance, since they bring into question thepublic's image of the nursing profession, and the need for nurses to re-establishthe fundamental principles of care and caring

This definition emphasizes the importance of nurses working collaborativelywith the individual to establish their needs The definition underlines andreinforces the importance of nursing adopting a holistic and patient centredapproach to care which is at the heart of the American Holistic NursesAssociation mission statement.[10]

Florence Nightingale considered that ‘the sick body … is something morethan a reservoir for storing medicines’.[11, p 36] This sentiment is still evident

in the Royal College of Nursing's (RCN) most recent definition of nursing,where nursing is defined in terms of its key functions These are concerned withpromoting, improving and maintaining health and healing, helping people tocope with health problems, and to achieve the best possible quality of life Thenurse's focus is on the whole person and their response to health, illness,disability which includes their spiritual response Spiritual support is identified

by the RCN as a key part of the nurse's role.[12] In addition the first of the 8 newprinciples of nursing practice is concerned with dignity, respect, individual needand compassion.[13]

Models should not be solely developed in the ‘ivory towers of academia’ and then be expected to work

in practice This top-down approach to theory development may overlook and fail to incorporate many issues that are being faced by nurses working on the front line This approach may have prevented the spiritual dimension from being incorporated within contemporary nursing theories and models.’

Martsolf & Mickley[20] undertook a detailed review of some modern nursetheorists’ ideas concerning spirituality Their review sheds light on two keyareas:

1 The contribution to nursing knowledge made by some of the contemporarynurse theorists

2 The position that spirituality has within those ideas; whether implicit orexplicit

It is beyond the scope of this chapter to provide a full critique of the place

spirituality holds within each model It is sufficient to say that, within nursingmodels and theories, the importance of the spiritual dimension for individualhealth and wellbeing is now recognized.

Codes of ethics and education guidelines

Spiritual care is central to nursing Codes of Ethics, both internationally andwithin the United Kingdom (UK) The International Council of Nurses (ICN)Code of Ethics for Nurses states:[21, p 2]

In providing care, the nurse promotes an environment in which the human rights, values, customs and spiritual beliefs of the individual, family and community are respected.

The Australian Nursing & Midwifery Council[22] accepts and builds upon theICN Code

In the UK, the Nursing and Midwifery Code of Professional Conduct statesthat: ‘You must treat people as individuals and respect their dignity.’[23]

Unlike the ICN code[21] the spiritual dimension is not explicit, but implicitwithin the NMC (2008) code (and its associated publications) through the use ofthe words ‘individual’ and ‘respect for dignity.’ Therefore, failure to include aspiritual dimension within nursing and recognizing the importance of this forsome individuals, may lead to a violation of an individual's fundamental humanrights The NMC further expects that at point of registration newly qualifiedgraduate nurses should be able to:

‘Carry out comprehensive, systematic nursing assessments that take account of relevant physical, social, cultural, psychological, spiritual, genetic and environmental factors …’.[24, p 18.]

The Essential Skills Clusters for pre-registration nursing programmesidentifies ‘skills that are essential’ in order to be ‘a proficient nurse.’ Includedunder the ‘Care, compassion and communication’ cluster is the expectation thatthe nurse will ‘demonstrate an understanding of how culture, religion, spiritualbeliefs … can impact upon illness and disability.’[24, p 108]

This is a similar expectation of the Quality Assurance Agency for HigherEducation which expects nurses to be educated to:

Undertake a comprehensive systematic assessment using the tools/frameworksappropriate to the patient/client taking into account relevant… spiritual needs Plan care delivery to meet identified needs

Demonstrate an understanding of issues related to spirituality.[25, pp p 10,

12]

Despite the above guidance, there is great variation in the amount and nature ofthe spirituality component within nurse education programmes Despite these

inconsistencies, there is evidence that spiritual care teaching is gaining moreattention as evidenced by the increasing numbers of papers debating the manyissues and dilemmas raised Currently, a great deal of work has[26–28] and isbeing done (a current doctoral level study is in progress) to establishcompetencies in spiritual care for nurses and midwives at point of registration.This is a much needed development.

Spiritual care: what is it and what does it look like?

If one looks at the evolution of spirituality and spiritual care in nursing thenthere is a noticeable shift in emphasis and direction Much of the earlypioneering work sought to elucidate and define the concept at a macro level.Macro in this instance, means applying generally and universally to the nursingprofession This early work was concerned with understanding the meaning andperception of spirituality, and the practice of spiritual care and much of it wasAmerican.[29–31] The emphasis now is not so much on elucidation of theconcept, but about practical relevance and application Nurses are now engagingwith the concept at a micro-level Micro- meaning they are trying to apply thegeneral principles of spirituality and spiritual care and developing knowledgeand understanding specific to their own sphere of practice be this mental health,orthopaedic or critical care nursing This micro approach has seen nursing focus

on spiritual assessment within the different branches of nursing

Spirituality

The spiritual dimension is deeply subjective and there is no authoritativedefinition of spirituality.[32] Swinton and Pattison[33, p 236] affirm that it isprobably more beneficial for nursing not to have a definitive definition whenthey write:

‘As a matter of fact, it is probably important that spirituality remains a contested and functional concept rather than becoming consolidated if it is usefully to denote the kinds of contextual absences that need to continue to be recognized and worked with.’

However, when one looks at the range of definitions of spirituality acrossdisciplines involving diverse groups of people with differing worldviews, thereseem to be common attributes, namely: hope and strength; trust; meaning andpurpose; forgiveness; belief and faith in self, others, and for some a belief inGod/deity/higher power; values; love and relationships; morality; creativity andself-expression

Given this broad concept of spirituality, what then does spiritual care looklike? And how can it be given?

of spirituality over many centuries and they have a wealth of knowledge andskills that shed valuable light enabling a deeper understanding of the concept.However, while nursing must and should draw upon the wealth of knowledgegenerated by such disciplines it must not be held ransom by them, in that theyare not the sole avenues of knowledge and understanding Nursing must continue

to plough its own furrows with regards to spirituality and its application tonursing, however being mindful of the important contribution other disciplinescan make to helping nursing understand and expedite this field of enquiry

A further criticism of the spirituality-in-nursing debate has been theperpetuation of concepts theory and definitions that have not been developedwithin the context of empirical study One example of this is the uncritical andalmost universal adoption of a definition of spirituality first presented by Murrayand Zentner.[34] This definition was used uncritically and unchallenged bynursing scholars and academics, especially within the UK A further concernraised has been the relationship of spirituality with other humanistic aspects ofthe individual, such as psychosocial care Clarke[35] proposes that nurses havealways addressed the spiritual concerns of individuals which wereaccommodated within the psychosocial domain Clarke35, p 1672] suggests thatthe reason for the inability to distinguish between the spiritual and psychologicaldomains is that the model of spiritual care developed by nursing is ‘… too large,too existential and too inclusive to be manageable in practice without beingindistinguishable from psychosocial care.’

For nursing research into spirituality to be more representative then it mustseek to be more heterogeneous.[36] This point is made because, if one reviewsthe many studies undertaken in this area, the samples are often homogenous,lacking religious, ethnic, and cultural diversity, primarily reflect a Judeo-Christian perspective and often only focus on key groups, such as nurses,chaplains, and patients There is a need for the nursing profession to be moreinclusive, ensuring that study samples reflect the diversity of people, cultures,and groups within contemporary societies

by Swinton and Pattison.[33] This article offers a positive way forward fornursing in understanding and applying the concepts of spirituality and spiritualcare within nursing practice The following quotation presents succinctly theoutcome of recent controversy and where a solution may be found outlining thedirection for future activity:

‘We suggest that instead of arguing about whether or not spirituality can exist in any realist, essential sense—a line of argument that has proven to be somewhat circular, controversial, and unhelpful—it is more useful to develop a thin, vague, and functional understanding of what this word and its cognates might connote and do in the world of health care.’ (p 227)

Spiritual care

For some people, the experience of illness, the uncertainties about diagnosis andthe possibility of disability or even death may trigger spiritual distress It hasbeen said by Granstrom that:

‘Many individuals do not seriously search for meaning and purpose of life, but live as if life will go on forever Often it is not until crisis, illness … or suffering occurs that the illusion (of security) is shattered … Therefore illness, suffering … and ultimately death by their very nature become spiritual encounters as well as physical and emotional experiences.’[38, p 26]

Karl Jaspers[39] calls such encounters ‘limit situations,’ i.e situations that wecannot change and cause us to think about what is really important in life.Questions like ‘Why is this happening to me?’, ‘Am I going to die?’, ‘What liesafter death?’ may be triggered, and cause existential, spiritual distress Nursesare often the first point of contact for people facing such challenges It isimportant, therefore, that they are equipped to be able to respond appropriately

in such circumstances

Spiritual care has been defined as:

‘That care which recognizes and responds to the needs of the human spirit when faced with trauma, ill health or sadness and can include the need for meaning, for self-worth, to express oneself, for faith support, perhaps for rites or prayer or sacrament, or simply for a sensitive listener Spiritual care begins with encouraging human contact in compassionate relationship, and moves in whatever direction need requires.’[40, p 6]

Giving spiritual care

The practice of spiritual care is about meeting people at the point of deepestneed Some pointers are given in Box 30.1 and have been adapted from the RCNPocket Guide which the authors helped to produce.[41]

Of course our own values and beliefs are very dear and personal to each one

of us This can cause conflict for nurses in their dealings with patients, clientsand families, particularly if the latter's life view differs from that of the nurse.When this happens we often hear about it in the media Some examples of recent

Using observation to identify clues that may be indicative of underlying spiritual need, e.g peoples’ disposition (sad/withdrawn), personal artefacts (photographs, religious/ meditational books and symbols)

It will usually involve some form of documentation within the nursing notes and care plan as part of the wider nursing process.

Knowing when to seek further help:

It is important to know your strengths, limitations and when to seek help (42) There is nothing wrong with referring to someone else, e.g colleague, mentor/preceptor, chaplaincy team (who are there for staff and patients of all faiths and none), counsellor, psychologist.

This media interest resulted in two of the biggest ever surveys of nurses by theNursing Times[42] (which attracted more comments and views than any otherstory to date) and the Royal College of Nursing[43] whose survey had the 2ndlargest response to a survey by its members These response rates underline theimportance nurses place on spiritual aspects of care and on the general interestnurses have in these concepts

The overwhelming message from both surveys was that nurses recognize theimportance of spiritual care, but want more guidance on spiritual care practice,particularly in relation to the conflict between their own personal beliefs/valuesand their professional practice Here, are some key findings from the RCNsurvey.[44] Of the 4054 members who responded:

83.4% agreed that spirituality and spiritual care are fundamental aspects ofnursing care

90% believed that providing spiritual care enhances the overall quality ofnursing care

Only 4.3% felt that it was not the nurses role to identify patients spiritualneeds

79.3% agreed nurses do not receive sufficient education and training inspirituality

79.8% felt that spirituality and spiritual care should be addressed withinprogrammes of education

78.8% felt the provision of guidance and support should come from the NMC.While 78.1% felt that the RCN also have a responsibility in this area

The RCN commissioned a Task and Finish group (which the authors were partof) to produce guidance for nurses tackling some of the key concerns raisedabove by participants in the survey about this important part of care Thisguidance is in the form of a ‘Pocket Guide’ and on-line resource.[45] A checklist

of things to think about before responding to patient/client spiritual need is given

in these resources

Nursing practice today should be based upon research evidence The evidencebase for spiritual care within nursing is fairly new, but has escalated in recentyears For instance a literature review conducted by LR in the late 1980s/early1990s showed that there was very little published research on spirituality bynurses at that time, with only one American published study.[46,47] Mostunpublished Masters work was also American in origin When this review wasrepeated in 2006, 45 original research papers were identified for the period1983–2005 Whilst much of this research was still American, the number ofcountries had expanded to include the UK, other European countries,Scandinavia, Australia and Japan The full review is published,[45] but in briefshowed that on the whole nurses consider spiritual care to be an important part

of their role, but they feel unprepared for it, feeling in need of further educationand training They also tend to focus on the more obvious religious part of carewhich in many ways is easier to deal with than the broader aspects of spiritualcare

Box 30.2 Some recent media headlines

‘Nurse suspended for prayer offer’[48]

‘Nurse sacked ‘for advising patient to go to church’ (News, 26 May 2009)[49]

‘Muslim nurses CAN cover up, but Christian colleagues can't wear crucifixes’ (Mail Online, 19 Oct 2010)[50]

‘British Medical Association to debate religion and prayer in the NHS’ (News 29 June 2009)[51].

Integrating personal belief and professional responsibility

The nurse's own personal spirituality seems to have a bearing on how spiritualcare is delivered This can be illustrated by referring to two cases that gainedconsiderable media attention in the UK: one involved the suspension of a nursewho offered to pray for a patient The nurse had been caring for a woman in thecommunity and as she left asked if the lady would like her to pray for her Thewomen said ‘no’ Subsequently, the lady complained to the Trust and the nursewas suspended pending an investigation Her suspension was on the grounds thatshe had not followed her code of professional practice specifically around theuse of professional status; promoting causes that are not related to health Thenurse was later reinstated, after public outcry that political correctness has beentaken to extremes with her suspension.[for more details see 48]

The other case concerned a nurse who refused to remove a crucifix which she

of appeal The tribunal claimed that the wearing of a crucifix is not a mandatoryrequirement of the Christian faith.[50]

These cases bring into question the relationship that exists between the nurse'sown personal beliefs and professional practice It is clear that there is aprofessional duty for all nurses to practice in accordance with their professionalcodes of ethics which guide conduct Ultimately, these situations highlight theimportance of nurses developing self-awareness of their own spirituality and notusing their privileged position to peruse their own goals or purposes One of thebiggest challenges nurses face is the integration of personal belief andprofessional practice Spiritual care is not about imposing your own beliefs andvalues on another or using your position of trust to convert or proselytize.Therefore, nurses must always be guided by the person for whom they arecaring; spiritual care like any other nursing intervention requires consent, andthis must always be obtained prior to performing any task or intervention.Furthermore, the nurse must always act in accordance with their professional andemployers code of practice Crucially, the nurse must have the prerequisiteknowledge, skills, and support to carry out any task competently and safely[41]

Assumptions and expectations

Nursing cannot make assumptions about what spirituality may mean for diversegroups of patient A significant finding from McSherry's,[19] investigation wasthat some of the patients interviewed had very little expectation regarding theprovision of spiritual care Furthermore, the investigation stressed theimportance of nursing not making assumptions that patients and the generalpublic, share the same understanding of spirituality as that constructed withinnursing However, this is not to say that just because some nurses and patients donot share the same understanding that the spiritual dimension is unimportant or,indeed, obsolete On the contrary, for some patients, the spiritual part of their life

is important to them, particularly when faced with illness and all theuncertainties that come with that, providing them with strength, hope, meaning,and wellbeing For those with a faith, being able to continue to practice that faith

is important For those with no faith issues surrounding meaning, hope, love andbelonging, forgiveness, peace, direction, and guidance can become important.Many patients, however, feel they are given little help with these sorts ofconcerns and that hospital staff are too busy dealing with the physical part ofcare to be concerned with the metaphysical However, there is evidence that

Practice

McSherry[54, p 66] provides a useful framework for considering four majorchallenges that require deliberation by the nursing profession if the practicalapplication of spirituality is to be fully realized The four broad challenges are:

Conceptual: consideration must be given to the diverse ways people define,

perceive and understand the nature of spirituality Assumptions andgeneralizations cannot be made by nurses with regards to this personaldimension of human existence If concepts and theories of spirituality andspiritual care are to be developed that have meaning and relevance to practicethen flexibility will be required so that the needs of diverse groups andindividuals can be accommodated

Organizational: all institutions and organizations that are involved in the

provision of nursing care, in whatever context, community, hospital,residential facility, must acknowledge the importance of people, places, andprocesses when seeking to offer or provide any form of spiritual care Unlessthese organizations acknowledge the importance of this dimension for thehealth and wellbeing of those receiving and providing care, then the provision

of spiritual care will be ad hoc, uncoordinated, and fragmented.

Practical: this is a broad term that spans any of the practical implications for

the delivery of spiritual care This may include attention to areas such asspiritual assessment, the resources to support nurses in the delivery ofspiritual care and the educational preparedness of nurses to be involved in thespiritual dimension of people's lives The nursing profession has madeexcellent progress in some of these areas The emerging literature reveals thatnursing scholars and practitioners are engaged in a broad range of debatesand activities that will develop nursing practice in this area such as thedevelopment of educational competences and the construction of spiritualassessment tools for use in specific clinical settings More importantly there

is a real desire to ensure that these developments are informed by the voice ofpatients and those who require nursing care

Ethical: the nursing profession must start to engage in a more meaningful way

and consider the ethical issues and potential dilemmas raised and encounteredwhen supporting people with the spiritual aspects of human existence Thespiritual dimension of people's lives is influenced by a number of factors,personal, social, cultural, political Therefore, the spiritual dimension by its

very nature is ‘ethically laden’ Until recently little attention has been paid tothe ethical issues inherent when supporting patients with spiritual aspects oftheir lives For example is it correct to routinely assess all patients forspiritual needs only to find that there are inadequate resources to support boththe individual and staff involved in this activity A further consideration may

be educational preparedness that is do nurses have the requisite knowledgeand understanding to support patients with these deeply personal aspects ofhuman existence?

A way forward for nursing is to review and evaluate the evidence basedeveloped to date mapping this activity against the four challenges outlined Thisexercise would provide a benchmark for where the nursing profession has comeand more importantly the direction it needs to go in the future It would be fair tosay that the nursing profession has pioneered understanding and developments inspiritual care Recent debates highlight that the nursing profession is not closedand rigid, but flexible and willing to engage in dialogue and further debate inorder to advance this important dimension of holistic care

Conclusion

This chapter has offered a brief synopsis of the nursing profession's involvement

in the spiritual dimension of care It is by no means a definitive account of all thepioneering research and scholarly activity that has been undertaken by nursesinternationally, over several decades and indeed since its historical inception andevolution in the twentieth and twenty-first centuries The chapter has highlightedthat the spiritual dimension of care is perceived by the nursing profession to be alegitimate and fundamental aspect of nursing practice The spiritual dimension isrecognized as one of the core founding principles of nursing that is enshrined inmany codes of ethics and practice The research evidence demonstrates thatspirituality and spiritual care are considered by nurses to be intricately linked tothe quality of nursing care and in maintaining the general health and wellbeing

of patients

The chapter affirms that the nursing profession's liaison with the spiritualdimension is not some attempt at professionalization, or some fleeting interest,but a sustained and sincere attempt to ensure that the spiritual aspects of holisticcare are understood, realized and integrated within nursing practice This willensure that spiritual care is available for all individuals who require support withthis dimension of their lives

References

1 Koenig, H.G., McCullough, M.E., Larson, D.B (2001) Handbook of Religion and Health Oxford:

5 The Patients Association (2010) Listen to Patients Speak Up for Change Available at:

http://www.patients-association.com/Portals/0/Public/Files/Research%20Publications/Listen%20to%20patients,%20Speak%20up%20for%20change.pdf (Accessed 17-1-2012).

6 The Mid Staffordshire NHS Foundation Trust Inquiry (2010) The Independent Inquiry into Care

Provided by Mid Staffordshire NHS Foundation Trust January 2005—March 2009, Volume I.

Australian Nursing and Midwifery Council, Royal College of Nursing, Australia and the Australian Nursing Federation.

37 Swinton, J (2006) Identity and resistance: Why spiritual care needs ‘enemies’ J Clin Nurs 15(7): 918–

28.

38 Hitchens, E.W (1988) Stages of faith and values development and their implications for dealing with spiritual care in the student nurse-patient relationship, Unpublished EdD thesis Seattle: University of

50 BBC news (2009) Row over nurse wearing crucifix Available at: http://news.bbc.co.uk/1/hi/england/devon/8265321.stm (accessed 7 November 2011).

51 Nursing Times (2009) ‘British Medical Association to debate religion and prayer in the NHS’ Available at: http://www.nursingtimes.net/whats-new-in-nursing/management/bma-to-debate-religion-

52 Murray, S.A., Kendall, M., Boyd, K., Worth, A., Benton, T.F (2004) Exploring the spiritual needs of people dying of lung cancer or heart failure: a prospective qualitative interview study of patients and

55 McSherry, W (2010) Spiritual Assessment: definition, categorization and features In: W McSherry, L.

Ross (eds) Spiritual Assessment in Health Care Practice Keswick: M&K Publishing.

This chapter focuses on the development and outworking of faith communitynursing within Christian faith communities This faith has embraced the FCNrole and this group are most frequently represented in the published literatureinternationally There is limited information as to how faith-based healthcare andparticularly the FCN role is enacted in groups from other faiths, but information

is becoming available as nurses from other faiths (such as Islam and Judaism)share spiritual and religious aspects that impact healthcare delivery in thepublished literature.[5–7] Many religions have a philosophical worldview thatenables them to positively influence values formation and human behaviour

which promotes health and wellbeing.[8] Many Christian denominations areembracing the FCN health ministry as a vital and contemporary ministry thatenables a tangible outworking of their mission.[9–11] Health ministry providescompassionate care activities related to health needs, as well as health promotionand disease/injury prevention and healing activities that are conducted as a part

of the church's overall calling.[12]

The amount of faith-based healthcare varies within and between countries.Policy and perspectives differ as to the amount and type of services religiousgroups can offer People continue to debate the role that organized religionshould play in the delivery of healthcare; however, there are 1.3 billion peoplelacking healthcare worldwide, so the World Health Organization (WHO) statesthere will continue to be room for faith- based organizations to make acontribution alongside, and in tandem with, government and private sectors.[13]

In the developing world faith-based organizations already provide a significantpercentage of health care.[14] For example, in Sub-Saharan Africa, faith-basedgroups provide up to 70% of the region's HIV/AIDS health services, and up to40% of other health care.[13,15] As the cost of healthcare escalates and thepopulations of the developed world continue to age, the health systems of manywestern countries are under strain as the cost burden of current healthcare isdifficult to maintain The governments of many countries are looking forinnovative and sustainable ways to care for people within the community Somegaps have become apparent which are readily addressed by faith-based healthministries such as aged care, community mental health, primary healthcare,community health.[10,14,16–18] Large denominational health ministry networksexist in most western countries and these can be brought together to effectivelymeet the needs of many people in culturally competent, accessible, affordable,and socially acceptable ways.[11,19]

Background to faith community nursing

Faith community nursing is a renewal of the Deaconess role, which is wherecontemporary nursing has its historical roots.[20] Nursing in western countriestoday is commonly based on the Nightingale model that developed in Christianchurches in Europe, particularly the Deaconess Institute at Kaiserswerth,Germany Lutheran pastor, Theodor Fliedner, commenced a hospital to trainyoung women to care for the sick and needy using a Deaconess model.[21]Florence Nightingale chose to obtain her nursing education at Kaiserswerth,graduating in 1851.[22] The ‘Nightingale model’ she implemented at StThomas's hospital in London was characterized by a focus on sanitation,

hygiene, client education, and benevolent support of the client, as well as thepersonal, moral, and spiritual discipline of the nurse who was trained in theologyand nursing skills.[22] Nightingale nursing viewed nursing work as a vocationalcall, where, in return for a simple salary, nurses were housed, fed, trained, caredfor, and provided with spiritual oversight.[23] Graduates trained in this modeltravelled to countries across the globe, therefore this model became the templatefor much western healthcare after the mid-1800s.[21]

The past century has seen an increased emphasis on biomedical, centred approaches to healthcare with improved body care, which is the practicedomain of medicine, nursing and the allied health professions The care of themind has become the practice domain of psychiatrists, pyschologists, andcounsellors, and the care of the human spirit has been relegated topastors/priests/ chaplains/imams/rabbis, etc., and faith community-basedvolunteers However, the 1970s called into question the scientific reductionistview of the ‘body as machine,’ claiming it was a narrow perspective that did notattend to the needs of the whole person Arguments for a more holisticperspective of the person focused more attention on disease prevention, healthpromotion, and illness management

disease-American churches responded to the holistic health movement in the1970s/1980s by trialling holistic models of health service delivery by faithcommunities.[24] Rev Granger Westberg, a Lutheran pastor, was involved intrialling holistic health centres that used a team approach to service delivery byclergy, doctors, nurses, and social workers, but Westberg noted that nurses werethe vital link between all aspects of the health system and the faith community.[25] Consequently, he launched the first ‘parish nurse’ programme aiming formore economically viable models to provide holistic programmes within thefaith community.[26] From these trials came the revitalization of nurses workingwith/in churches known as ‘parish nursing’[27] and later as ‘faith communitynursing’ because this name encompassed a broader ecumenical and interfaithmovement.[4] The FCN role has many names that are adapted to fit the localculture and the language of the faith community and the country in which therole is enacted [e.g parish nursing (Catholic and some protestant denominations)congregational nursing (Jewish), church nursing and pastoral nursing (someprotestant denominations), crescent nursing (Muslim)] Today there areapproximately 12,000 FCNs in the United States[28] and networks havecommenced in Australia, the Bahamas, Canada, United Kingdom, Fiji, Korea,Madagascar, Malaysia, New Zealand, Palestine, Scotland, Singapore, SouthAfrica, Swaziland, Wales, and Zimbabwe.[29]

Health ministry is the deliberate organization and resourcing of appropriatelyqualified and gifted people to facilitate the pastoral health, healing, and care ofpeople within the church, and the community it serves The contemporarymovement of health ministry includes specific worship rituals and liturgy, such

as healing services, anointing of the sick, prayer, and sacraments.[30] However,there is more to health ministry and it includes education for healthy living, goodstewardship of the person, as well as communal health and wellbeing.[12] Itincludes activities that promote social justice, and reduce and prevent violence,oppression and poverty.[8] Activities that provide advocacy, support, directassistance, and healthcare for those who are sick or in need are central to healthministry, as are actions that prevent injury and disease, promote healing andhealth, and improve the social determinants impacting an individual's orcommunity's health and wellbeing.[31–33]

The faith community and the healthcare continuum

Christian churches have long seen the need to provide care to the sick inresponse to the gospel directives of Jesus Christ to follow his example andbecome actively concerned about the physical, mental and spiritual health ofpeople Consequently, faith communities have provided acute care hospitals,secondary health services and community health services In fact, in Australiathe largest district nursing services were all commenced in the 1800s byChristians compelled to enact their ethos and send out trained women andreligious nuns to work amongst the sick, poor and needy within the community.[34] Faith communities recognize the importance of a social perspective ofhealth and seek to provide food, clothing, medicines and care to those most inneed within the community, aiming to prevent hospitalization and promotewellbeing.[22]

Christian denominations today continue to play an important part in healthcareprovision within most western countries However, healthcare is becomingsecularized and concurrently faith communities have lost their capacity tomeaningfully connect with people in their time of need, which is an importantpart of their mission and mandate When sickness occurs people often havequestions about life, hope, meaning, purpose, suffering and transcendence, butaside from appointed healthcare chaplains/spiritual care workers, most personnelworking in modern healthcare organizations have little time, or perhapsinclination, (and at times they have no permission) to discuss such importantissues with the sick person.[35]

The Christian faith community is largely absent from the primary healthcareaspect of the healthcare continuum except for the FCN and health ministryprograms (see Figure 31.1) Faith communities are key service providers insecondary and tertiary healthcare, but have little input into primary healthcare(PHC) PHC is gaining importance as countries search for sustainable ways todevelop their communities and improve the health of their population.

The PHC movement was endorsed by the World Health Organization[36] in

1978 as a solution to the escalating cost of high tech healthcare, which wasviewed as unsustainable and a contributing factor in increasing inequity betweenthe developed and developing world.[37,38] PHC seeks to reorganize healthcare

by developing strategies to promote sustainable health services using aphilosophical framework that includes analysis, planning, action, and awarenessthat health requires inter-sectoral collaboration, community engagement, andsound political governance if it is to be available, affordable, acceptable,accessible, and sustainable to all.[39,40] In recent times, PHC has recognizedthat wellbeing depends on a range of social, cultural, political, economic, andenvironmental factors that need to be configured effectively if they are topromote health.[37,41] This has become known as ‘the new public health’ whichfocuses planning on ten social determinants of health,[37,42] which includeone's earliest life experiences, social status, presence of stress, level of socialinclusion, level of work, level and type of employment, level of social support,presence of addiction, presence and availability of food and water, andavailability and accessibility of transport.[43] Faith communities can contributepositively to these determinants in the activities they conduct in their localcommunity and as global entities

Nurses as leaders of health ministry teams

The office most often associated with health ministry historically is that ofdeacon/deaconess and the religious orders However, today health ministryincludes lay people with specific gifts in pastoral health and care who workalongside qualified and educated health professionals as a team In the FCNmodel (Figure 31.2) the health ministry team is often led by a registered nurse.Some reasons FCN leadership was recommended by Westberg[44, p 2] include,

‘The nurse has the sensitivity—the peripheral vision … to see beyond thepatient's problems and verbal statements She can hear things left unsaid Andshe is the best listener.’ Westberg asserted nurses have scientific expertise,special gifts in caring, and excellent people skills, which are essentialrequirements for effective health ministry He noted nurses command respectfrom the community and are trusted by people enabling them to open up to anurse For example, every year in Australia, an annual ‘Image of Professions’survey is undertaken by a reputable national polling group, nurses haveconsistently topped that poll for 16 consecutive years, as the most ethical andhonest professional group, surpassing both the medical profession and ministers

of religion.[45] Westberg[27] notes that nurses use their ‘peripheral vision’ toidentify people who they know need to be visited quickly leading him torecommend nurses as the profession of choice to lead a faith community-basedhealth ministry Nurses today are well educated in primary healthcare andcommunity health, and have a broad knowledge that crosses multiple disciplineboundaries, making them ideal ‘navigators’ of an increasingly complex healthsystem, and an excellent resource people to promote health within the faithcommunity

The overarching goal of all FCN functions is transformation that leads tohealing and restoration in all the dimensions of the person (body, mind, spirit,socio-cultural).[1] This includes transforming the individual's and the

in ways that enable them to respond positively to life and improve their being This transformative process is a dynamic, life-long journey, which enablespeople to grow closer to Jesus Christ and to find their healing and wholeness inHim

well-How this model works to facilitate transformation and promote health andhealing is best understood by examining the dimensions of the person (keeping

in mind that in reality there is no distinction between these dimensions) Humansare inseparable wholes, but the prevailing western perspective of the person incontemporary healthcare continues to reduce the person to component parts Thereductionist worldview of most medical care focuses attention on parts of thebody and still smaller parts that give rise to sub-specialties within medicalspecialties

In the FCN model there are four dimensions to the person For simplicitythese are termed physical (body), mental (mind), socio-cultural (relational), andspiritual (spirit) Each of these dimensions is governed by unifying principle/s.For healing to occur people need to undertake certain activities to reconstitute ornurture health within each dimension FCN care is directed toward unifyingactivities aiming for outcomes that change thoughts, behaviours, and actions andlead to healing, restoration, and health

The physical dimension is governed by the principle of homeostasis.Reconstituting activities revolve around adaptation, aiming to restore or maintainequilibrium, wellness, and promote healthy growth Nursing care is focused onprevention of diseases, curative regimes, and/or management of thecondition/disease, and the promotion of healthy growth and development

The mental dimension is governed by the principle of creative balancing.Reconstituting activities involve enlightenment and creative activities aiming tobring contented thinking, inner harmony, stable identity, creativity and mentalgrowth Nursing care is focused on emotional and intellectual support,stimulation, and/or rest

Figure 31.2 Faith Community Nursing Model.[4] (NB revised 2010 for this edition.)

The socio-cultural dimension is governed by the principle of connection Thereconstituting activities pivot around unifying activities that seek to facilitateidentity and values formation, connection, and community growth Nursing care

is focused on promoting developmental health and strengthening interpersonalrelationships

The spiritual dimension is governed by the principle of restoration, healingand salvation Reconstituting activities encompass transformative activities thatseek to provide spiritual growth, healing, wholeness and shalom (Table 31.1).Nursing care is focused on nurturing relationships within self, with others, withthe environment, and with God

Box 31.1 Health ministry model using faith community nurses

The model represents health ministry as a life giving tree that yields fruit all year that brings forth healing transformation, health and life for individuals and the community The tree is grounded and rooted in love for God and from God, love for other people and from other people, and love for one's self and from one's self.

The tree trunk represents the major model concepts that give the model cohesion The model's applicability and utility depend on how these concepts interrelate, because when they work together they sustain the life-giving capacity of the health ministry.

The Person is understood as a whole unity of body, mind and spirit; made in the image of God and sanctified by God to live in relationship Those relationships include a relationship with God, the natural environment and with other people.

The Faith Community is a gathering of people who share a common religious belief, and commune together for the purpose of worshipping God, fellowship, witness, teaching, encouragement, service and healing The faith community is built in and on love.

The FCN is called by God to focus her/his unique gifts, talents and professional nursing knowledge to

the goal of promoting health, transformation, and healing, and the compassionate care of people The religious faith of the FCN motivates her/him to a life of service, stewardship, and whole person care that intentionally integrates the FCN's faith with their professional nursing practice.

The Environment is understood as the circumstances and conditions (e.g natural, physical, cultural) in which a person or community live, relate, grow and develop All of life is an endowment from God and humans have been made stewards of the environment, which brings both accountabilities and responsibilities.

socio-How these four concepts relate and interrelate impacts healing capacity and health Health is nurtured in life-affirming relationships within one's self (body, mind, spirit, socio-cultural), between the self and others, between the self and the environment, and between the self and God Health enables people to fulfil many purposes in life, but it is not the be all and end all of living Relationships that promote harmonious interconnectedness facilitate transformation, growth, healing and health Health can be promoted by responsible stewardship of one's body, one's relationships and one's environment It is promoted and dependent upon social justice and the capacity to provide compassionate care to others in their time of need.

Disease and illness are the person's reaction to internal and/or external stressors which can act in/on any human dimension, but the impact is experienced by the whole person The act of living requires responses to change, stressors, and perceived stressors that may originate within or external to the

person Stressors can vary from tangible microbes to environmental pollutants, substance misuse, or mystical spiritual issues All individuals must adapt to stressors, remove them, ameliorate their effect, or build up inner resources to prevent stressor impact Certain life changes are in the person's control, such

as some relational and lifestyle stressors, but other stressors are outside the person's control, such as developmental changes, war and natural disasters The whole person must respond by finding new ways

to live and be in the world The FCN can assist the person/community to respond to their changing conditions by developing new and alternate patterns of living.

The functions of the faith community nurse

The branches of the tree represent the key functions of the FCN that enable thehealth ministry to meet its goals These functions include:

Educator and facilitator

The FCN uses various methods to educate individuals and facilitate small groups

in the community regarding such issues as lifestyle factors, relationships, faithand health enhancement activities, illness/injury/disease prevention or riskreduction, disease management for those with chronic conditions, environmentalawareness, social justice issues, and other health and wellbeing issues that arepertinent to the specific community of people that the FCN serves

Care manager

The FCN may assist clients with existing illnesses, complex conditions, and/ordisabilities to manage their condition, aiming to prevent exacerbation of illnessand/or limit complications The FCN's holistic approach to care managementconsiders the client (body, mind, spirit, relational), their family, the client's

environment and the faith community, when developing care management with

the client and their family

Health promoter

The FCN seeks to promote health by facilitating the transformative growth thatenables a person/community to respond positively to life's changes, empoweringthem to act in ways that improve their well-being Much FCN work focuses oncreating and fostering positive relationships as the foundation for the personalgrowth and transformation that nurtures health This can be enacted via specificprogrammes and activities targeted at lifestyle choices, e.g physical fitnessprogrammes, immunization, mental health awareness, suicide preventionactivities, sexual health programmes, courses that develop interpersonal skillsetc

Table 31.1 The process of healing and transformation in the human dimensions

Dimension Unifying

principle

Personal reconstituting activities

FCNs focus Anticipate

client outcomes

Physical Principle of

homeostasis

Adaptation activities

Care focused on: prevention of condition, disease cure and/or management of condition, disease promotion of healthy growth development

Equilibrium Wellness Body growth

Mental Principle of

creative

balancing

Enlightenment and creative activities

Care focused on emotional and intellectual support, stimulation and rest

Contentment Inner harmony Creativity Mind growth Socio-

cultural

Principle of

connection

Unifying activities

Care focused on developmental health and strengthening interpersonal relationships

Value formation Connection Community growth Spiritual Principle of

restoration

and healing

Transformative activities

Care focused on relationships within self, with others, with the environment, and God Communicating God's love in word and deed.

Shalom Spiritual growth Wholeness

Counsellor and advocate

Personal and small group counselling is an important aspect of the role Thefocus of such counselling is brief, aiming to help people with issues impactingtheir health, listening and advising as required, supporting and recommendingreferral when needed, in addition to home visits and monitoring progress Thefocus of this function is to empower people to make an informed choice within asupportive milieu, which can include offering knowledge of viable options toassist the individual in the decision making process

FCNs may be called upon to publicly support, uphold, advocate, or defend aparticular position/person This may involve interpreting a point of view orhelping someone to ‘see’ another perspective Advocacy often occurs on behalf

of the client with the broader health system, but it is always undertaken with theclient's permission Advocacy can include mediation to bring about agreementand/or reconciliation between people It also includes prayer with and for theclient and their family

Resource and referral

The FCN liaises between the individual and the faith community, and theindividual and other health and community services The FCN is able tonegotiate access and assist entry into health services and local communitysupport networks of which the person may be unaware This resource and

referral activity occurs within the faith community and beyond, aiming to bettermanage and coordinate care for the individual, the family/group and thecommunity.

Managing practice

The FCN role is an advanced practice registered nurse role that is supported byother health ministry team members As a regulated profession, nurses mustmanage their practice in ways that can demonstrate the use of moral reasoningand ethical decision making The nurse must be able to document andauthenticate her/his practice, and demonstrate that she/he is practicingaccountably and legally by adhering to professional standards of practice and thelaws governing healthcare To that end accountability and governance processesmust be in place before the FCN commences and the FCN should report againstthese and be held accountable for the stated standard of practice Further to this,all faith communities must have in place adequate public liability andprofessional indemnity insurance for the FCN and their health ministry team tocover all their salaried and voluntary activities

Managing volunteers

Health ministry is a corporate ministry of the church therefore it is useful to have

a team of people working from their knowledge, life experience, gifts, andstrengths This will help to assure the viability of the ministry for the long-termand provide corporate support to the FCN The FCN may need to coordinate,educate, equip, and support lay volunteers and health ministry workers to ensurethe health ministry is practising to its full capacity in an accountable manner

Self-care and personal growth

The FCN role can become overwhelming as the ministry grows When peopleknow there is a trustworthy, helpful and compassionate ministry to meet theirneeds they start using it and referring others to it Many FCNs have said thatthey have felt burdened, overwhelmed, and at risk of burn-out within a few years

of commencement.[46] This is particularly true for those in volunteer FCN rolesand those who do not have the support of a team Therefore, it is important that,

as part of the FCN function, the nurse practices good stewardship of her/hispersonal boundaries, health, growth, and development.[47] To that end, thehealth ministry team needs to enable the FCN to factor activities such asprofessional development, retreats, mentoring, spiritual direction, professionalassociation memberships, conferences, journals/books, study opportunities, etc.[48]

In most western countries there is no organization other than the faithcommunity, which regularly and voluntarily congregates people of all ages andfacilitates the development of long-term relationships across the life span.[35] Itbrings people of diverse backgrounds and ages together into meaningfulrelationships, where they have the freedom to share and have a share, to give andparticipate People may think that relationships need to be perfect to bebeneficial, but life lived in a community enables us to learn from each other'svictories and mistakes.[49] Relationships can grow in the midst of trial andtesting The key to growth lies in the connection and common grounding thatenable people to transcend difference and move on This makes the faithcommunity a fertile ground for the development of social connectedness andconsequently social capital, which is known to benefit community health.Putnam[50, p 327] notes that ‘social connectedness matters to our lives in themost profound way’, yet we know participation and affiliation to long-termgroups is declining throughout the western world, but group affiliation andvolunteering is still present within religious contexts

The challenge for many of today's faith communities in western countries isthe need to rediscover the health giving value of communing with each other andGod, learning how to be a community, rather than a weekly gathering place.Health ministry enables the provision of people to listen, accompany and care, sothat everyone experiences a sense of connection to the faith community.[51]Health ministry mobilizes the resources of the congregation to supplement andcompliment those already available in the community from the health and socialwelfare systems.[52] The entire faith community has the opportunity to supportthe health ministry, by using their gifts, talents, professional expertise andnetworks of contacts, thus building the social capacity of that community.[53]

We are living in a time of unprecedented challenge to healthcare asgovernments around the world face spiralling healthcare costs perpetuated byadvancing health technologies, pharmaceuticals, and treatments that come at aprice There is a huge demographic shift and altered disease patterns in mostwestern countries with ageing populations and the growing burden of chronicdisease.[38] Many countries are experiencing shortages in their healthworkforce, which is unevenly distributed across countries, leaving rural, remote,Indigenous and developing communities underserved, and concerned about thequality and safety of their health services.[19] There is a growing recognitionthat many current healthcare systems around the world are unsustainable.[38] Inthis challenging context faith communities have an opportunity to provide a

viable ministry that promotes health, healing and wellbeing, prevents disease andillness, develops personal and social capacity, and provides many of thepreconditions for good community health.[33] The questions is, are faithcommunities ready and willing to re-embrace this ministry and respond to thesecontemporary challenges by recommencing health and healing ministries thatcan serve their community?

11 Lindner, E.W Welty, M.A., National Council of the Churches of Christ in the USA (2007).

Congregational Health Ministry Survey Report (New York: National Council of the Churches of

Christ in the USA, and the Office of Research and Planning, Roberts Wood Johnson Foundation)

12 WHO (2007) Towards Primary Health Care: Renewing Partnerships with Faith-Based Communities

http://www.chagghana.org/chag/assets/files/FBO%20Meeting%20report%20_2_.pdf (accessed 10 October 2010).

13 Chand, S., Patterson, J (2007) Faith-based Models for Improving Maternal and Newborn Health.

Available at: http://pdf.usaid.gov/pdf_docs/PNADK571.pdf (accessed 10 October 2010).

Saharan Africa Available at: www.who.int/hiv/mediacentre/news66/en (accessed 10 October 2010).

14 WHO (2007) Faith-based Organizations Play a Major Role in HIV/AIDS Care and Treatment in Sub-15 Francis, S., Liverpool, J (2009) A review of faith-based HIV prevention programs J Religion Hlth

27 International Parish Nurse Resource Center (2009) Parish Nursing Fact Sheet Available at:

http://www.parishnurses.org/DocumentLibrary/Parish%20Nursing%20Fact%20Sheet.pdf (accessed 1 October 2010).

28 Solari-Twadell, P.A., McDermott, M.A (1999) Parish Nursing: Promoting Whole Person Health Within Faith Communities Thousand Oaks: Sage Publications.

38 Keleher, H (2009) Public health and primary health care In: H Keleher & C MacDougall (eds)

Understanding Health: a Determinants Approach, 2nd edn, pp 17–41 South Melbourne: Oxford

News Today Available at: http://www.medicalnewstoday.com/articles/193220.php (accessed 1 November 2010).

45 Thomas, S (2002) Spiritual formation for parish nurses In: L VandeCreek, S Mooney (eds) Parish Nurses, Health Care Chaplains, and Community Clergy: Navigating the Maze of Professional Relationships Birmingham: Haworth Press.

be afforded patients’ religious and spiritual resources for supporting hope,buffering stress, providing communities of support, and possibly activatingpsychosomatic processes that promote health.[3–7] They point to a need formental health professionals to regard patients’ spiritualities and religious lives asclinical resources.

Yet concerns about potential deleterious effects of religion and spirituality alsohave been raised Harmful effects from religious coping are noted periodically inthe lives of ill patients, whether by exacerbating guilt or despair, contributing torefusal of needed psychiatric treatment, or, in rare cases, justifying self-neglect,suicide, or violence towards others.[8,9] Moreover, psychopathology can beexpressed in religious experiences, thoughts and behaviours, and emotions.[8–11] Religious involvement also sometimes activates mood, psychotic, oranxiety symptoms that are misdiagnosed as serious mental illnesses.[4,8,12] Thechallenge then is how to harness the therapeutic potential of religion andspirituality, but while countering any adverse effects upon mental health Theseconcerns point to several questions that need answers:

1 How can a mental health professional draw upon a patient's spirituality andreligious life as a therapeutic resource, notwithstanding the secular context ofhealthcare and an absence of shared religious faith between clinician andpatient?

2 How can effects of spirituality and religious life that promote mental health bedistinguished from deleterious ones?

3 How can unusual or idiosyncratic, but normal, expressions of religiousexperience be distinguished from psychopathology?

Meeting a patient's religious identity respectfully: a cultural

handshake

Treating a patient's spirituality and religious life as a therapeutic resource mustbegin with a clinical conversation that learns about his or her religiousexperience, and its relevance for illness and health Initiating such aconversation, however, may require more than sincerity and good intentions due

to commonly-held fears by patients that their religious lives may be stigmatized

by clinicians Mutual distrust and stigmatizing judgments kept distance betweenreligion and the professional disciplines of psychiatry and psychologythroughout most of the twentieth century Sigmund Freud's attitude towardsreligion long-held sway in keeping religion at an intellectual distance from themental health disciplines Due to this long history of stigmatization, a clinicianoften must express an active interest in a patient's religious life Specificinvitation may be required in order for a patient to reveal comfortably his or herreligious life during psychiatric treatment or psychotherapy.[13]

Erving Goffman described how all forms of stigma—race, ethnicity, gender,physical disability, as well as religion—tend to evoke in targeted persons aheightened vigilance for potentially disdainful or humiliating responses fromothers.[14] A mental health clinician seeking to learn about a patient's religious

or spiritual must anticipate that the patient may:[7,8,13]

Feel vulnerable or exposed when questions about religious faith or spiritualityare asked

Watch vigilantly for subtle signs of acceptance or rejection

Edit responses to questions in order to avoid risk of ridicule

When unsure, interpret by default that silence or ambiguous communicationsindicate disdain, contempt, scorn, or belittlement

In order for open dialogue to begin, safety and respect must be conveyed bycourtesy and etiquette coupled with sincere expression of interest The FICAinterviewing tool has become widely used by primary care clinicians interested

in incorporating spirituality into patient care.[15,16]

F—Faith and belief (Do you consider yourself to be spiritual or religious? Do

you have spiritual beliefs that help you cope with stress?)

I—Importance (What importance does your faith or belief have in your life?)

to be a religious or spiritual person? Are there any important beliefs or religious practices that you would want us to know about?’ Mr Winston told how their church was the centre of their family life, a setting where they attended Sunday School and worship services on Sundays, and formed enduring personal friendships A son now coached a sports team in the church league ‘A lot of people will be praying for

me while I'm here,’ Mr Winston commented ‘Sometimes they will come here to be with me I hope you are comfortable with that.’ The psychiatrist's questions opened a conversation in which Mr Winston could make clear how important it was that his religious identity be acknowledged and respected.

The FICA questions or similar ones, invite a patient to reveal his or her socialidentity as a religious or spiritual person The patient states how this identityought to be regarded during treatment The clinician conveys acknowledgementand respect Such an interchange is a ‘cultural handshake’ that helps build acollaborative and egalitarian therapeutic alliance.[8] It can be regarded as aroutine component of humanistic care Further, it facilitates collaboration withchaplains or clergy as a natural juncture for asking: ‘Would you like for thechaplain to stop by your room?’ In the clinician–patient relationship, it also helpsput aside any felt aversion towards expressions of religious language, dress,beliefs, or practices that are off-putting for the clinician.[13] Contrary tocommon assumptions, discovering differences in beliefs and worldview oftenadvances mutual respect to a greater extent than does emphasizingcommonalities, provided that inquiry is conducted out of authentic interest anddiscovered differences are treated with respect.[17]

Meeting a patient's personal spirituality: an existential inquiry

Personal spirituality is religion for the person Personal spirituality is shaped bythe lived experiences of an individual person as a moral agent relating to otherpeople and the Divine, more so than by compliance with prescribed beliefs andpractices of a religious group Utilizing a patient's spirituality in psychotherapy

or psychiatric care thus extends beyond simple acknowledgment and respect for

a patient's social identity as a religious person It actively incorporates elements

of a patient's personal religious experience in treatment Opening treatment to apatient's personal spirituality means learning from the patient how his or herspirituality has made a difference in coping with life's adversities Existential

Existential questions inquire how a person responds to the struggles andsorrows of everyday existence.[8,18,19] They focus upon lived experience,rather than social identity Existential questions usually are experienced asnormalizing, rather than pathologizing, since they ask about dismal andthreatening circumstances through which all people, including the clinician,eventually journey:

What has sustained you through hard times? From where do you drawstrength?

As Mr Miller told his story, it became evident that his impending retirement was not his first encounter with adversity His father had bullied his son His mother had a long series of psychiatric hospitalizations for depression Mr Miller succinctly summarized his childhood as ‘alone, lost, and helpless,’ a recollection now echoed in the waves of anxiety that brought him again back to psychiatric treatment His marriage had ended in divorce Over the years, his intellect and work ethic brought him success in his profession, but no close friends with whom he could confide ‘Most of my life has been a struggle,’ he said He struggled with loneliness.

Against this bleak sketch of his life, I asked: ‘What kept you from giving up? When life is so hard and you are so alone—as a child and now as an adult—what has kept you from giving up?’ Mr Miller responded with a story that he initially had not mentioned In the Presbyterian Church of his youth, he found a community that noticed and responded to him ‘I saw in them another way of living I didn't see

in my family,’ he commented He recollected vividly a day when one of the adult church leaders put his arm around him As a teenager, he immersed himself in church youth activities and for a time toyed with the idea of becoming a minister Throughout his adult life, he always maintained some level of participation in a local church There seemed to have been no consistent pattern of doctrinal belief among the churches he had attended, whether theologically liberal or conservative fundamentalist ‘My church is

the only social place I have,’ he reflected The relationships he had with other church members and his priest, albeit limited in scope, nevertheless kept alive some sense that life can be worthwhile.

Despite his dread of it, Mr Miller successfully managed the transition to retirement Critical to this success was his locating a larger church with a well-developed programme of weekly small groups that met in members’ homes, together with an array of community ministries in which Mr Miller could volunteer Although he embraced daily personal prayer, specific theological beliefs and ecclesiastical practices of either his childhood church or his current one, this played little role in his religious experience The essence of his personal spirituality was his finding communion with others in open and compassionate relationships, despite his social awkwardness Out of this communion, hope and purpose

in living emerged.

Personal spirituality often stands as a major strategy for coping with adversity If a person has a meaningful religious life, the conversation usually turns there after an existential question has been posed The types of questions posed to Mr Miller: ‘What kept you from giving up? What kept alive a sense that life could be good?’ were not intrinsically religious questions, yet immediately brought forth a rich account of his religious life As anthropologist Arthur Kleinman (p 14) has noted, ‘Failure and catastrophe empower religion; religion, in turn, empowers people faced with adversity to overcome self- doubt and fear of failing, and to act in the world.’[20] Existential questions provide a safe and reliable path for learning about personal spirituality Facing illness and hardship, they provide narrative accounts for how spirituality can strengthen the patient as a person.

When a patient has already made explicit the importance of his or her religiouslife, existential questions can be asked that elicit details for how specificreligious beliefs, practices, or community support resilience:[8,18,19]

What does God know about your experience that other people don'tunderstand?

To guide the crafting of interview questions, existential postures ofvulnerability and resilience can be displayed as in 32.1.[8,18] Existentialpostures in the left column of Table 32.1 collectively make up the features ofdemoralization as a human condition Demoralization refers to the ‘variousdegrees of helplessness, hopelessness, confusion, and subjective incompetence’that people feel when sensing that they are failing their own or other's

expectations for coping with life's challenges.[22, p 14] Rather than coping,they struggle to survive It is apt that ‘dispirited’ is a synonym fordemoralization, which feels so much like the disappearance of one's spirit Formany, religion and spirituality serve an important role in supporting hope andcountering demoralization.[19]

As a patient tells how personal spirituality has mattered, it is important to hearits manifold expressions—as metaphors, stories, beliefs, prayers, spiritualpractices, community, or ethical commitments.[7] Which of these are mostsalient differs among persons and among religious traditions Mr Miller'srecollection of his Presbyterian Church was a narrative of religious experienceexpressed as community For others, prayer or doctrinal beliefs or spiritualpractices might have been more central Listening for the specific forms throughwhich a particular patient's spirituality is expressed opens conversations thatsupport resilience by clarifying meaning, purpose, and connection

Distinguishing health-promoting from deleterious effects of

religious coping

Religious faith for many patients provides the bulwark upon which they surviveand prevail against hardships, uncertainties, and sorrows of illness Yet religiousbeliefs, practices, or communities sometimes diminish, rather than strengthen,coping; or intensify, rather than attenuate, suffering

Some examples of dichotomous effects that religion can bear upon mental

Excessive emotional stimulation during the fervour of worship or ritualobservances activates psychosis in patients with chronic schizophrenia orbipolar disorder

Religiously-induced shame and guilt contributes to emotional suppression thatactivates an internalizing psychiatric illness, such as conversion disorder,anxiety disorder, or depression

Perceived stress and coping

Protective: Religious beliefs, practices, and community promote coherency,

hope, purpose, gratitude, commitment, and community, thereby strengtheningmorale

‘whole person to whole person’ relatedness, whether that relatedness isexpressed with other persons, with a personal deity, or reflexively with oneself

Such relatedness has been explicated by existentialist philosophers in terms of

‘I-Thou’[25] or ‘face-to-face’ relations.[17] Personal spirituality is characterized

by social processes of dialogue, empathy, compassion, and expression ofprimary (i.e authentic, unguarded, non-instrumental) emotional responses Bycontrast, life in religious groups is organized by sociobiological processes ofsocial identity, group role, hierarchical status, in-group/out-group distinctions,reciprocal altruism, and related group-based behaviours In order to strengthenthe group, social processes of religious groups typically prioritize the monitoringand regulation of personal emotions, hence constraining, rather than encouragingindividual spontaneity Religious groups often rely upon social emotions such asshame, guilt, and honour to maintain social roles and group cohesion Primaryemotions are often suppressed, with secondary (reactive) emotions, edited forsocial acceptability, displayed instead For example, joy may be publiclyexpressed even though anguish may be felt privately While these distinctionsbetween personal spirituality and religious group life have been noted insociological studies of populations,[26] advances in social neuroscience haveclarified how much their differences also reflect different brain circuitry thateach utilizes to process social information.[8]

Both religious groups and personal spirituality impact physical and mentalhealth, but in different ways and by different mechanisms For mental health,they each have their strengths and vulnerabilities In a meta-analysis of eleven

studies, Powell et al.[27] found committed church attendance to produce a 25%reduction in mortality compared with non-attenders, even after confoundingfactors and medical risk factors were accounted for These salutatory effectsupon health seem to arise from a general protection that tightly-knit socialgroups confer on human beings, rather than the depth of personal religiousexperience That is, a similar level of commitment and participation in an ElksClub, a sewing circle, or a hunting club might improve health as much as churchattendance By contrast, there is little empirical evidence that personalspirituality reduces mortality risks.[23,27] Personal spirituality, however, doesprovide powerful protection for mental health by promoting individual creativityand a robust sense of a personal self Its generation of hope, purpose, andcommunion with others strengthens resilience against suffering Optimally,group religion and personal spirituality complement each other in their support

of mental health The monastic life, for example, provides monks with both ahighly-organized social group, as well as facilitation of personal spirituality

As a general rule, religion that does harm, damages lives, and exacerbatessuffering, is religion in which religious group life with its roles, beliefs, andpractices has hypertrophied and personal spirituality has dissipated