Creating a Culture that Promotes Spiritual Care
Supportive Voice Vol. 11 No. 2 Summer 2006
by Carol Taylor, RN, PhD
Dr. Taylor is director, Center for Clinical Bioethics; senior research scholar, Kennedy Institute of Ethics; and assistant professor of nursing, Georgetown University. She has been a featured speaker at both of the Coalition’s National Congresses on end-of-life care. She can be reached at TaylorCR@georgetown.edu
We all know people in our work environments who walk into a tense situation and immediately calm everyone present. Invited to reflect on individuals who epitomize healing presence, we are probably all able to quickly visualize someone who has been a positive presence for us in a moment of exquisite vulnerability. But how many of us identify healing presence as a personal strength or claim it as a personal development objective? A ministry committed to continuing Jesus’ radical healing mission can’t take healing presence for granted—especially in today’s fastpaced, efficiency-driven, bottom-lineoriented health care culture.
In this short essay I want to develop three points. First, if healing, not mere cure, is our mission, Catholic health care must make spiritual care a priority. Everyone in our institutions must be evaluated in light of their ability to actively promote the mission of healing. The seriously ill and dying and their families deserve more than our best high-tech rescue effort. Second, while some people seem naturally blessed to be healers, and to do this effortlessly, all of us, with a little intentionality and effort, can successfully cultivate this art. For the type A personalities among us, it just takes more practice. Third, institutional leadership must sufficiently value spiritual care to resource it adequately and to monitor its success. Who is benchmarking best practices for spiritual care?
I’ll begin with a few definitions. First the difference between “healing” and “curing.” Curing is the alleviation of symptoms or the termination or suppression of a disease process through surgical, chemical, or mechanical intervention. Healing may be spontaneous, but more often it’s a gradual awakening to a deeper sense of self (and of the self in relation to others) in a way that effects profound change. Healing comes from within and is consistent with a person’s own readiness to grow and to change. A healing attitude is “a belief system that recognizes that all of life’s experiences, including injury, illness, and other setbacks, provides us with opportunities to learn and to grow toward that we are meant to be. Seen in this light, disease is not an enemy but a teacher and motivation. Disease is manifesting, in a physical way, the desire or need of the psyche to reestablish balance and integration through a change of direction in one’s lifestyle, behavior, or attitudes.”
A friend living with three cancers shared the following narrative that clearly demonstrates the type of growth that can result from healing even when the body cannot be cured.
. . . I want to tell you about one good trade. It has been the hardest one by far. It’s ongoing. I had to trade in my old definition of ME. I thought I WAS my abilities. My job. The amount of money I made. The highest degree I earned. The way I looked. The way I cooked. The presents I gave. I had to figure out that those things aren’t me. They are a part of my life, and losing them counts, but they are not ME. The girl God made is that stripped down substance/soul underneath all those things. I had to figure out how to be brave enough to let that me be enough. Be ME. Ungiftwrapped. That is a huge shift in thinking. A huge shift toward truth. Naked living. Vulnerable. Scary. But real. Really real. The first time I got so weak from chemo that I couldn’t feed myself, I thought I would come completely undone. My personal dignity was so tangled up with my ability to control my body and its functions. With my independence. My abilities. I cared so much about what the person holding the spoon thought of me. It is still hard for me to trade down, and I fight to keep as much control of my life as I can, but at least some of the time, I can remember what part is really me. I am still me when my friend is feeding me. Still me when I need help. Maybe more me. ...I am glad I have had the time to learn the things that dying has taught me. I’m closer to being an authentic person than I would have been without this. Right now I am not so much worried about taking my last breath. I’m more worried about having the emotional stamina to stay real all the way to the end. I pray for that. I want to die with my eyes wide open.
Healing presence is the condition of being consciously and compassionately in the present moment with another or with others, believing in and affirming their potential for wholeness, wherever they are in life. My colleague Tom Butler writes that when one is truly present to another there is:
•An alleviation of loneliness
•An affirmation of one’s authentic self and invitation to wholeness
•Potential for spiritual bonding
•A deeper sense of our common humanity
•A recognition and acknowledgement of the other as person
•An invitation to self-transcendence
•Possibility for greater self reflection & self-revelation
•Sharing on a deeper, spiritual level
Healing presence is the foundation for spiritual care which may be defined as care that enables individuals to meet the universal basic spiritual needs: (1) need for meaning and purpose, (2) need for love and relatedness, and (3) need for forgiveness.
Making Spiritual Care a Priority
The Ethical and Religious Directives for Catholic Health Care Services remind us that since our institutions are communities of healing and compassion, the care we offer must not be limited to the treatment of a disease or bodily ailment. Our care embraces the physical, psychological, social and spiritual dimensions of the human person.3
Spiritual care is simply not optional. And we cannot presume it is happening because we have pastoral care departments. While our chaplains are professionally prepared to offer spiritual care and can serve as excellent resources for other professional caregivers, spiritual care is everyone’s responsibility. The national consensus project for quality palliative care clearly mandates spiritual care.
Palliative care is operationalized through effective management of pain and other distressing symptoms, while incorporating psychosocial and spiritual care according to patient/family needs, values, beliefs and culture(s). Palliative care affirms life by supporting the patient’s and family’s goals for the future, including their hopes for cure or life-prolongation, as well as their hopes for peace and dignity throughout the course of illness, the dying process, and death.
The clinical practice guidelines articulated in 2004 include Domain 5: Spiritual, Religious and Existential Aspects of Care. Among the criteria for this domain is the following: Regular, ongoing exploration of spiritual and existential concerns occurs and is documented (including but not limited to life review, assessment of hopes and fears, meaning, purpose, beliefs about afterlife, guilt, forgivenesss, and life completion tasks). Whenever possible a standardized instrument should be used.4
Earlier, Promoting Excellence in End-of- Life Care, a national program of The Robert Wood Johnson Foundation, highlighted spiritual care. Identifying seven domains, quality indicators and related interventions for end-of-life care in the intensive care unit they included domain six which addresses spiritual support for patients and families.5
Domain 1 - Patient and Family Centered Decision Making
Domain 2 - Communication within the Team & Patients/Families
Domain 3 - Continuity of Care
Domain 4 - Emotional & Practical Support for Patients/Families
Domain 5 - Symptom Management & Comfort Care
Domain 6 - Spiritual Support for Patients/Families
Domain 7 - Emotional & Organizational Support for ICU Clinicians
Cultivating the Art of Healing Presence
The healer who wishes to offer spiritual care begins by assessing how well he or she is meeting his/her own spiritual needs. Assessment criteria include:
Holds spiritual beliefs that meet needs for meaning and purpose, love and relatedness, and forgiveness Derives from these beliefs strength for everyday living, especially when confronting pain, suffering, and death in his or her professional practice
Sets aside regular periods to nurture his or her spiritual self
Demonstrates in interactions with others peace, inner strength, warmth, joy, caring, and creativity
Respects the spiritual beliefs and practices of others even when they are different from the healer’s own Increases knowledge of how the spiritual beliefs of others influence their lifestyles, responses to illness, health care choices, and treatment options
Demonstrates sensitivity to the spiritual needs of patients and their family caregivers
Develops successful strategies to assist patients and their caregivers experiencing spiritual distress
Miller and Cutshall remind us that healing presence can take many forms. You cannot do healing presence-you become healing presence, expressing it gently yet firmly in various ways: Listening, holding, talking, being silent, being still, being in your body, coming home to yourself, being receptive. You can deepen your healing presence by slowing down, by doing only one thing at a time, by reminding yourself regularly to come back to the present moment. You can encourage healing presence by being appreciative, forgiving, humble kind.6 Those interested in cultivating this art might want to consult their book, The art of being a healing presence. A guide for those in caring relationships.
Another helpful work is Fredriksson’s analysis of presence, touch and listening.7
Creating a Culture that Promotes Spiritual Care
Finally, the institutional culture must support spiritual care if it is to flourish. An institutional culture that values spiritual care:
•Clearly articulates in its mission a commitment to identifying and meeting spiritual needs
•Includes identifying and meeting spiritual needs in the job descriptions and core competencies for all clinicians
•Uses identifying and meeting spiritual needs as a core element in performance reviews.
•Holds employees responsible for self-care: physical, intellectual, spiritual, emotional and social
•Is characterized by respectful and loving relationships among all parties
•Holds leadership accountable for creating a culture that promotes spiritual care; responsibilities of governance and management are identified
•Dedicates space for quiet reflection
•Dedicates adequate financial resources to spiritual care
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NOTES 1. McGlone, M.E. (1990). Healing the spirit. Holistic Nursing Practice, 4(4), 77-84.
2. Personal communication.
3. United States Conference of Catholic Bishops. (2001). Ethical and Religious Directives for Catholic Health Care Services, 4th ed. Washington, DC: Author.
4. National Consensus Project for Quality Palliative Care (2004). Clinical practice guidelines for quality palliative care. http://www.nationalconsensusproject.org
5. Promoting Excellence in End-of-Life Care is a national program of The Robert Wood Johnson Foundation dedicated to long-term changes in health care institutions to substantially improve care for dying persons and their families. Visit PromotingExcellence.org for more resources. These domains, quality indicators, and interventions or behaviors were generated in a modified Delphi approach as described in the following article: Clarke EB, Curtis JR, Luce JM, Levy M, Nelson J, Solomon MZ, for The Robert Wood Johnson Foundation Critical Care End-of-Life Peer Workgroup Members. (2003). Quality indicators for end-of-life care in the intensive care unit. Critical Care Medicine, 31(9), 2255-2262.
6. Miller, E.J. & Cutshall, S.C. 2001. The art of being a healing presence. A guide for those in caring relationships. Willogreen Publishing.
7. Fredriksson, L. (1999). Modes of relating in a caring conversation: A research synthesis on presence, touch, and listening. Journal of Advanced Nursing, 30(5), 1167-1176.