A Qualitative Analysis of a Healthcare Professional's Understanding and Approach to Management of Spiritual Distress in an Acute Care Setting

Abstract

Objective:

The goal of this study was to explore healthcare professionals' (HCPs') perception of their role in provision of spiritual care, in addition to attempting to identify a simple question(s) to help identify spiritual distress.

Background:

Spirituality is well recognized as important to whole-person care, particularly in those with terminal illnesses. Understanding the role of front-line providers in the identification and management of spiritual distress, however, remains challenging.

Methods:

Twenty-one HCPs (eight physicians, seven nurses, six social workers) underwent qualitative semi-structured interviews exploring an understanding of spirituality/spiritual distress. HCPs were drawn from inpatient and outpatient settings in a tertiary care facility, and all had experience with patients with terminal illnesses. Interviews were subsequently coded and analyzed for dominant themes.

Results:

Essentially all participants spoke of the high importance of spirituality and spiritual care, particularly for those facing end of life. However, the majority of HCPs had difficulty in formulating definitions/descriptions of spiritual care and spiritual distress, in marked contradistinction to the importance they ascribed to this aspect of holistic care. Almost universally provision of spiritual care was seen as critical, yet in the domain of chaplaincy/dedicated spiritual care providers. Reasons frequently cited for HCP's reluctance to provide such care themselves included time available, lack of training and expertise, and the sense that others could do a better job.

Discussion:

Despite spirituality being highlighted as important to care, few HCPs felt able to provide this, raising questions around how such care can be encouraged and developed in busy acute care settings.

Introduction

Spiritual care is an important part of holistic patient care,^1,2 and it is particularly relevant for patients in palliative care.^3,4 The current challenge lies in identifying which patients experience spiritual distress and would most benefit from spiritual care. Spiritual distress may have a negative outcome on health outcomes and contribute to overall suffering^4,5; however, it is challenging to accurately identify patients' spiritual concerns.⁶ Accurately detecting spiritual distress has been an ongoing area of research in palliative care,⁷ and a number of approaches have been described in the literature, including the use of various questionnaire tools^8–10 and semi-structured interviews.^11–13 Although such approaches have utility as assessment tools, they are more time consuming and labor intensive than what front-line healthcare professionals (HCPs) can realistically use in either busy clinics or acute care wards.

The overall purpose of this study was to identify simple question(s) for front-line HCPs to identify spiritual distress in patients with serious, significant illness and advanced disease. The work included two parts: a set of qualitative interviews with patients and a set with HCPs. This article reports on the findings from the HCP portion of the study.

Methods

Data collection

The study was conducted at Sunnybrook Health Sciences Centre (Toronto, Canada) with the Palliative Care Consult Team (PCCT), the outpatient Palliative Care Clinic, and the Palliative Care Unit. Study participants were approached between March 2014 and November 2014. Eligible HCPs included licensed physicians, nurses, or social workers who routinely cared for patients with advanced life-limiting illnesses. Social workers were invited during a routine team meeting, while a member of the research team individually approached physicians and nurses. For all groups, if interest was expressed, the research assistant further explained the study and obtained consent for participation.

Participants engaged in an in-depth semi-structured interview by one of two experienced interviewers. The interviewer used an interview guide (Appendix 1) to explore a participant's views on spirituality, spiritual distress, and spiritual care. All interviews were audiotaped and later transcribed verbatim. The hospital research ethics board approved the study, and all participants provided written informed consent.

Interview guide

The interview guide was developed by the research team to explore participants' perspectives on spiritual distress. Questions were chosen that would elicit participants' views of spirituality, experiences with spiritual distress, and spiritual care, and that would provide insight into approaches and questions used to address spiritual distress. The research team reviewed the guide after the first several interviews to ensure the content elicited and matched the goals of the study.

Qualitative analysis

The verbatim transcripts were subjected to a qualitative descriptive analysis.¹⁴ For the purposes of generating content categories, six members of the research team all read through several transcripts and made margin notes about the content. Subsequent discussion among this group resulted in a list of topics or content categories for coding. All transcripts were then entered into NVivo9 (QSR International) software and subsequently coded by one individual using this agreed-on coding framework. Three authors (D.S., D.S., M.F.) then reviewed the coded content in each content category and identified key ideas or messages within each category. Subsequent discussion among these three investigators, comparing and contrasting their independent observations, resulted in the identification of themes within five major topic areas: “Definition of spirituality,” “Definition of spiritual distress,” “Definition of spiritual care,” “Perceived role in spiritual care,” and “Questions to use as spiritual screening questions.”

Results

Participants

In total, 21 HCPs participated in the study. Participants consisted of eight physicians, seven registered nurses, and six social workers. Nurses, physicians, and social workers worked in inpatient and outpatient settings in oncology, internal medicine, and palliative care. Participants had a minimum of one year's experience working with people with advanced end-of-life illness, but the majority had in excess of five years' experience. The majority of participants were female (one male social worker and three male physicians participated).

Topics

The thematic results are presented later for each of the five main topics: “Definition of spirituality,” “Definition of spiritual distress,” “Definition of spiritual care,” “Perceived role in spiritual care,” and “Questions to use as spiritual screening questions.” Themes presented are those arising within the analysis of the content categories, representing the ideas that participants raised within each major topic area. Relevant quotes will be added to illustrate the various themes.

Topic 1: Definition of spirituality

Prominent themes that emerged as participants described their ideas or thinking about spirituality included:

(1) A focus on formal religious belief systems versus a personal belief system separate from organized religion

(2) Spirituality was individual and unique to each person

(3) The key importance of meaning, purpose, and “making sense”

Although virtually all participants cited the importance of spirituality, the interviews were striking for HCP's frequent difficulty in articulating their thoughts about the concept. Some participants were well aware of, and commented on, how challenging they found the question whereas others seemed unaware of their difficulty (Table 1).

Table 1.

Definition of Spirituality

Theme	Example
Formal religious belief systems vs. a personal belief system separate from an organized religion	“To me (I believe) that there is a huge distinction between spirituality and religion. A religion is organized set of beliefs and spirituality is any sort of connection that we have (connection with or without religion) but in terms of—so I believe we are all spiritual beings.” (8) “Spirituality is identification with a certain religious or other belief system. I don't think it has to be certain (like, an organized religion per se) …” (10) “I think it's important to recognize that spirituality is not necessarily religious.” (11)
Spirituality was individual and unique to each person	“The definition of spirituality is very subjective to interpretation for different individuals.” (13) “The way I see spirituality is it's a belief in something … so sometimes it's difficult to define what spirituality means to each individual.” (18)
Key importance of meaning, purpose, and making sense	“I think spirituality helps them get a sense of meaning and connection with their loved one as well as with the overall universe in regards to the situations they are going through.” (7) “Spirituality is in part looking at trying to find an answer as to why this has happened.” (4) “I think of it as a way which we kind of cope and make sense of things.” (3)
Difficulty of articulating thoughts about spirituality	“And I find that it's a very nebulous concept. Um … you know, I think I have good labels, or I know what I mean when I use other words … um, I feel like I can have a very … um … er, compassionate interaction with patients and families. But the actual concept of spirituality is one … I personally find quite challenging …” (1) “I don't know if I've been talking in circles.” (7)

Parentheses represent patient identification numbers.

Topic 2: Definition of spiritual distress

Prominent themes that became evident as participants talked about their ideas related to spiritual distress included:

(1) Questioning and a search for meaning

(2) Negative emotions such as anger, fear, regrets, guilt, loneliness, and a sense of disconnection

(3) Difficulty in differentiating between the concepts of spiritual distress and spiritual pain

The notion of “suffering” rarely emerged. Furthermore, participants generally viewed spiritual pain as “more intense” than spiritual distress; however, most respondents had no clear concept of the terms being similar or different.

Perhaps most notable, HCPs had significant difficulty in providing examples of spiritual distress from their practice and even when described, stories shared contained a paucity of emotional detail. Physicians tended to have the most detailed descriptions, also noting that they had had long-term relationships with the patients they described (Table 2).

Table 2.

Definition of Spiritual Distress

Theme	Example
Questioning and a search for meaning	“… So when it comes to spiritual distress, I think it's that—that, there's something missing that—in that individual's experience. Like usually when you say spiritual distress it could be that you are searching for meaning. You are searching for truth.” (21) “… So when I think about it with respect to healthcare and disease, to me, spiritual distress would be that you question why something is happening to the point that your faith in a higher power goes down.” (9)
Negative emotions such as anger, fear, regrets, guilt, loneliness, and a sense of disconnection	“I can see people you know, sort of having some mental anguish about, you know, maybe things they regret doing or haven't done (you know, with respect to their belief systems).” (12) “So I think the whole concept of distress is often a disconnect between expectations and reality and what to do with those two kinds of confounding issues.” (10) “Fear of death, loneliness, social isolation, guilt. All those factors come into play.” (13) “So angry with the whole world; angry with the nurses, angry with the doctors, angry with the whole situation” (16)
Difficulty in differentiating between the phrases spiritual distress and spiritual pain	“Spiritual pain? I'm not exactly sure. Like, I'd have to think about—I can understand spiritual distress. Like, I can kind of conceptualize it but I can't conceptualize spiritual pain.” (9) “I honestly don't know how I would—to me, I can understand spiritual distress. I don't really know that I would have a different term or—when you know what spiritual distress is, I could easily think of examples of that but spiritual pain I must admit I think is harder. I don't know. I wouldn't really be able to define that.” (12)
Difficulty in providing examples of spiritual distress from their practice	“You know I remember some cases where a woman did confide to the team that she felt that God had let her down. Or, her … her spiritual community … um … had not stepped up to address her spiritual distress. You know, the “why me?” questions, things like that.” (1)

Parentheses represent patient identification numbers.

Topic 3: Definition of spiritual care

Prominent themes that emerged as participants described their notions of spiritual care included:

(1) Whole-person care

(2) Finding peace

(3) Dealing with illness

(4) Focusing on relationships/connectedness

(5) Exploring beliefs

(6) Role of the spiritual care team

Participants cited the importance of “coming to terms” and exploring beliefs as central to spiritual care. Importantly, spiritual care was generally not associated with specific faiths, but rather with addressing the individual spiritual needs separate from religious needs. Many participants were unable to provide a definition for spiritual care and simply described calling “someone else” when the need arose (Table 3).

Table 3.

Definition of Spiritual Care

Theme	Example
Whole-person care	“I think it is part of you caring for the person as a person. So I'm not coming in and caring for you as the appendectomy. I'm caring for you as the whole person.” (19)
Finding peace	“As you take care of people's bodies, you should be able to take care of their minds and their emotions and help them have peace with whatever is going on at the time that they are experiencing it.” (9)
Dealing with illness	“So spiritual care to me is assisting patients with coming to terms with their diagnosis (their health, their illness) and that we do that from a physical perspective, from an understanding perspective, from a social perspective and also (I guess) from an emotional perspective.” (13)
Focus on relationships/connectedness	“If they would ask for a person in particular to call a family member, to call a friend, to call anybody. To—you know, whatever it is (I would help them). I would help to meet their spiritual need.” (20) “Spiritual care is about how we connect with others …”
Exploring beliefs	“So spiritual care to me (in a nutshell for me) is helping people to explore their—probably in many cases pre-existing spiritual beliefs and how they fit into their new reality and coming to terms with that and how they can be utilized to strengthen (make them more resilient).” (7)
Role of another healthcare provider	“So, you know, we certainly are there to support them but we really can't introduce the question or ask what we can do for them spiritually.” (15) “spiritual care is probably something that is (I see as being) outside of the medical model of care” (11) “I guess what comes to mind is the Chaplains in the hospital.” (14)

Parentheses represent patient identification numbers.

Topic 4: Perceived role in spiritual care

Common themes among participants in describing their perspectives on their own roles in spiritual care included:

(1) Listening carefully

(2) Being present with the patient

(3) Referral to chaplaincy or spiritual care team

(4) Lack of time to provide spiritual care

Some responses reflected an active role of front-line healthcare providers in spiritual care. However, the most common response was to “hand off” to the spiritual care team, a tendency that seemed to vary with comfort level, perceived skill set, time, and resources. Participants who expressed a willingness to address spirituality with patients were predictably more comfortable with the topic, often citing their own personal sense of being spiritual or religious. In contrast, participants who did not see spiritual care as their job were generally less comfortable with the topic area and regarded it as a specialty practice belonging to others who had had specific training. Lack of time and education were repeatedly raised as barriers to providing front-line spiritual care (Table 4).

Table 4.

Perceived Role in Spiritual Care

Theme	Example
Listening carefully	“So it's really about advocating–listening.” (17) “There is a lot of listening that comes with the talk about spirituality.” “I don't try to tell them anything different. I just listen and I be with them.” (20)
Being present with the patient	“I open the discussion and ask them, you know, what would help you at this moment?” (21) “We may not feel like we have the expertise to do it, but providing a presence … walking into that room every day, saying ‘what is going on’, I am going to be here … .you know that is of huge benefit to patients and families.” (1)
Referral to chaplaincy or spiritual care team	“I guess I just don't see that as a job I could do as well as probably other people. Be it other well trained palliative care physicians or, you know, people from Chaplaincy or spiritual care providers.” (12) “Connect them with a Chaplain.” (14) “If someone is teary, whether they got bad news or they are thinking about the situation (and maybe need some spiritual help), I would say to them, ‘Do you need to talk to the Chaplain?’” (20)
Comfortable with spiritual concepts	“I would attend to any kind of spiritual need whether it be spiritual distress or just simple wanting to have something accomplished spiritually. Like, if I'm able to help a patient in any way with their spirituality, of course, I would be very open to it.” (20) “Talking about spirituality with our patients. … personally very comfortable. It is part of what we do-opening to explore it.” (10)
Less comfortable with spiritual concepts	“Asking people about religion feels fake to me. … .it just isn't my bag at all.” (14) “There's places where I get stuck with it for sure. And there are places where I feel uncomfortable.” (3) “I guess I'm somebody who says ‘This part I can't do. I'm going to let somebody else do it.’” (15) “So I think after awhile, it was, OK, we know that, you know, I acknowledge that this is your plan. Let's talk about how your symptoms are … you know, I kind of acknowledged that this existed, but then we just focused on the medical.” (2)
Time constraints on provision of spiritual care	“Just the current reality is we are stretched for time.” (13) “Unfortunately I don't have the time or the training to do it properly or adequately I suspect. For example, I saw, I don't know 36 patients yesterday.” (11) “When they come in for clinic they are here for 10–15 minutes max. How do you be effective in recognizing it and providing some intervention or referral in a short period of time with everything else going on around.” (17) “And I know listening and acknowledging are intervention in themselves, but you're not going to open up that conversation in a short period of time.” (17) “You want to provide support. You want to address these concerns and issues. You need to be there helping but you can't be in there 24/7. You do have other people and budgetary constraints. Like, not to sound mean, but budgetary constraints are budgetary constraints.” (19)

Parentheses represent patient identification numbers.

Topic 5: Questions to use as spiritual screening questions

The major themes that emerged when participants were asked about how to easily identify or screen for spiritual distress included:

(1) No idea what single question/questions could be used to detect spiritual distress

(2) Asking about belief systems

(3) Asking about how the patient was coping

Most respondents felt there was no single way to identify spiritual distress, though they almost universally indicated a wish that there was a straightforward way to do so. Some raised the concern that patients could react negatively, along the lines of “I must be dying if they are talking about the chaplain.” Once again, there was marked variation in the comfort level answering this question, ranging from simply “no idea” to descriptions of what that individual's practice is, before landing on the sense of there being no ideal approach (Table 5).

Table 5.

Questions to Use as Spiritual Screening Questions

Theme	Example
No idea	“I wouldn't know how to approach this.” (15) “I'm not sure I would know the question to ask—specifically spiritual distress.” (1) “I could do a … I could ask about suffering, I could ask about distress in the general sense, but spiritual distress? I am not sure I have the right words to even get at that information.” (1) “It's really—it's hard for me to think of anything better than, ‘would you like to speak with a Chaplain?’” (14)
Asking about belief system	“Do you have a belief system/value system? Do you feel it is helping you right now?” (10) “How has this affected your relationship with your higher power or God?” (9)
Asking about coping	“How are you coping? What helps you cope in difficult times? What are you struggling with most right now? What are you most frightened of?” (2) “Simply ‘How are doing?’ can open up a floodgate sometimes for people.” (6)
Concern about asking a question	“I'm not—Like, I'm just not sure if you're asking everybody if they have spiritual distress. I mean, I don't want to freak people out too, right?” (12)

Parentheses represent patient identification numbers.

Discussion

Spiritual care has been well accepted as an important component in patient care, particularly for those with advanced illness for whom end of life may be nearing.^2,12,15–17 Identification of spiritual suffering or distress, however, can be challenging, particularly for front-line HCPs⁶ where long/complex questionnaires may not be practical or feasible.¹³ This study was undertaken to deepen an understanding of front-line HCP's perspectives on, and comfort with, spiritual care along with a goal of identifying a simple question or questions that could be used as a screening approach, akin to that used for the screening of symptom and emotional distress.

The findings of this qualitative exploration were striking in two fundamental ways. First, the great level of difficulty that many HCPs had in discussing this topic area compared with the high level of importance that the participants placed on spirituality and spiritual distress was not anticipated. There were difficulties in describing the concepts of spirituality, spiritual distress, and spiritual care and challenges in formulating definitions or providing examples from their practices. The difficulties as reported in these findings mirror those of other authors.^18,19 However, what struck us was that the struggle to articulate definitions and define their role in spiritual care was incongruous with the importance that HCPs placed on spirituality in providing comprehensive care.

Possible reasons included the sense that, no matter how important it is, “someone else will handle this” (specifically chaplaincy) as well as the perceived lack of formal training in spiritual care. For those identifying themselves as comfortable with spirituality, most commonly this was related to personal religious knowledge or to having had a mentor in the past modeling spiritual care. Very few could cite formal training within their respective programs of study. Further, even those describing a sense of comfort with spirituality expressed hesitations about directly addressing this with patients, commenting on worries of crossing boundaries, or creating fear (they may think the end is near if the topic is raised). Given these barriers, combined with an ongoing sense of “there is never enough time,” HCPs may easily avoid exploration of spiritual issues, furthering their discomfort and difficulty in articulating its components.

Second, we were struck by the almost immediate response of “referring to the chaplaincy team” when a patient or family member spoke of anything reflecting faith, beliefs, or religion, or if any signs of spiritual distress were detected. There was relatively little description about what the front-line practitioner would do as basic spiritual care or clarity regarding their role within this sphere of care. This is in contrast with the findings of Edwards et al.,¹⁸ where HCPs were found to view spiritual assessment and care most commonly as a nursing role, though involving all members of a team. Edwards et al.¹⁸ noted that chaplains were “sometimes called upon, especially when other healthcare givers felt uncomfortable” (p. 763).

Our institution has a strong chaplaincy presence that may have influenced our respondents, though the relief with which the availability of chaplaincy was described remained quite striking, reflecting a general sense of discomfort in handling spiritual distress. Many participants cited a lack of confidence in their skill set to handle spiritual distress, going as far as to feel it would be a disservice for them to provide spiritual care when “experts” were available. However, in a climate of budgetary cutbacks, chaplaincy may become an increasingly limited resource, leaving open the question of how to provide for those in need.

An essential step in the provision of spiritual care is the need, first, to recognize the presence of spiritual distress. The difficulty participants had in describing lived examples of spiritual distress in their patients raises the question of how such distress is identified and assessed. A key component of our study was to ask HCPs to identify means of detecting spiritual distress within the setting of a busy acute care hospital. The vast majority of respondents had difficulty in articulating a response and those who could most commonly linked the question to a formal belief system.

This difficulty of suggesting a question or questions as a screening device could reflect both the complexity of the topic and the general lack of comfort around spirituality. Many cited the recurring theme of spirituality being very personal and, hence, not amenable to a single question that would be appropriate across different religions (including absence of), different cultural backgrounds, and different life experiences. In addition, some noted that addressing spirituality should be seen as “a conversation” more than as a screening question and wondered about the need for an established relationship with a patient before such a conversation could occur. Steinhauser et al.²⁰ reported on a single screening question “Are you at peace,” noting that it functioned to open an exploration of spiritual concerns. Doing this, though, would require a level of comfort with pursuing the discussion that our respondents did not describe, citing the barriers of time, lack of training, and a general lack of comfort despite its recognized importance.

Implications and Conclusions

In considering solutions to these challenges and potential implications for practice, questions arise in three areas: role definitions, education and training, and healthcare service settings.

The first area to consider is the role of healthcare practitioners in spiritual care. Can we define the role and describe the relevant activities? One would expect the actual role to differ not only from discipline to discipline but also between those in the front-line positions and those who are experts in spiritual care. The relevant and expected behaviors ought to be based on the identified roles. It could be argued that the action of recognizing spiritual distress and making a referral demands a certain level of knowledge and skill, whereas responding to the spiritual distress to lower its impact even at a basic level demands a deeper level of knowledge and skill; however, the level required is not that of the expert.

Perhaps the basic response should be focused on making certain that there is a brief person-centered conversation that truly acknowledges the patient's distress, validates their concern, and begins to explore potential solutions. The burden of distress for an individual may be reduced by the front-line provider during a short person-focused dialog, similar to the patient outcomes observed with enhanced communication skills training of HCPs and brief (one session) therapy interventions in psychosocial oncology.^21,22 The more complex response, requiring a more prolonged interaction and a deep level of skill, should be placed in the hands of experts in spiritual care. Tiered models of intervention, based on the degree and depth of the patient's emotional distress, have been developed in psychosocial oncology^23,24 and recommended for spiritual care.²⁵ The challenge lies in operationalizing these models.

The second area where questions arise concerns the preparation of healthcare practitioners regarding spiritual care. Assuming that education and skill training will lead to an increased comfort, confidence, and capacity to engage in spiritual care, and that role expectations are clearly defined, the principal question is how can the agreed-on roles and actions be taught effectively to the healthcare practitioner already in practice? In addition, can these expected actions be taught effectively to students? The question has two fundamental components—first, can the relevant skills be taught? and, second, how best to teach them within the context of current practice settings?

Skills such as active/deep listening, compassion, and provision of comfort may, indeed, be the ones mastered through repeated experience, as opposed to traditional modes of education. However, communication skills training initiatives have shown that the skills of holding empathetic, person-focused conversations can, indeed, be mastered by healthcare practitioners.²⁶ Such learning happens most effectively for practicing professionals through highly interactive, case-based sessions, which build on existing knowledge and skills. The actual practice of the required skills (e.g., role playing), feedback on performance, and mentoring for transfer of skills into clinical practice are key components for mastery.^27,28

Perhaps the more challenging aspect given today's healthcare settings with fiscal restraints and escalating patient caseloads is adapting educational programs and strategies, as well as finding opportunities to engage practitioners in the most relevant type of learning. Education of students in this arena may require different approaches given that they may not have the basis in clinical practice or experience with patients on which to draw.

The third area where questions arise is the actual practice environment. Can we truly expect the front-line practitioner to routinely provide spiritual care given the nature of the current healthcare environment? The number and acuity of patients, the fiscal constraints, and the complexity of treatment in both inpatient and outpatient settings are all increasing and raise concerns about the models of care that are in use and the responsibilities of the various members of the inter-professional team. Clearly, discussions are needed about what is realistic to expect of front-line staff regarding spiritual care, what is feasible to implement, and what the capacity is to achieve the desired patient outcomes. Leaders in clinical settings are in key positions to facilitate these types of conversations. This aligns with calls for health system change,^29,30 and the creativity and innovation needed to develop models of care that will facilitate whole-person care and allow the full range of patient needs to be met, including spirituality.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

Appendix 1. Spiritual Care

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