Health Progress Articles

Holistic health care is a buzzword these days, written into the mission, vision and values of health care systems throughout the country. There's a good reason for this: more and more research points to the positive impact of treating the whole person on patient outcomes, patient and family satisfaction, and staff morale.

Paradoxically, health care is increasingly specialized and productivity-driven, with little time for practitioners to truly know their patients. Interdisciplinary teams often function in a silo manner rather than working together to understand how each aspect of a person's life impacts their illness trajectory and healing pathways. Perhaps the least understood aspect of human life is its spiritual dimension.

What Is the Spiritual Dimension of Life?
I respond to a nursing referral for spiritual assessment. As I enter the patient's room, she sees my badge identifying me as a chaplain. Before I can introduce myself, she calls out: "I don't need what you're pedaling. I am not religious." Taking the risk of slightly irreverent humor, I immediately respond: "Well, this is your lucky day. I'm not a religious chaplain." My comment lands well, and I hear her chuckling: "All right, come in. You have three minutes to deliver your elevator speech."

I stand bedside and ask her these questions: "As you lie here, are you wondering what really matters in your life?" She nods her head affirmatively. I continue: "Do you find yourself considering the nature and state of your relationships with yourself, others and however you understand a higher power?" She nods affirmatively again. I notice her eyes welling up with tears. I ask, "Are surprising questions and concerns rising up unbeckoned?" At this point, she says, "Please pull up a chair, I need to talk about these things." I then listen to key elements of her life story.

Spirituality is that aspect of human life concerned with meaning, purpose and connection. It finds expression in our ultimate values, key relationships and core beliefs. Our values reflect what matters most to us. Our key relationships are primary sources of comfort, strength and love. Our core beliefs collectively form the lens through which we see, interpret and experience life events. When healthy, the spiritual dimension of life helps us to ground ourselves in hope, engage with coping resources, and find meaning and purpose in life's many circumstances, including illness and, ultimately, death. When unhealthy, it amplifies stress, lessens peace, creates or increases anxiety, and may even contribute to illness.

Spirituality and religion are often confused or conflated. Spirituality is a dimension of all human life. However, not all expressions of spirituality or means of nurturing it are religious in nature. Religion is an organized system of beliefs and practices that provide a framework for understanding the Sacred and our responsibilities to all of creation. Every religion embraces specific values, beliefs and practices to inform and guide followers' behaviors and relationships. As such, all religions are expressions of spirituality. However, the converse is not true, as not everyone practices a religion. All expressions of both religion and spirituality can be barriers or conduits to wellness.

The crisis of illness or injury inevitably impacts the spiritual dimension of our lives:

Spirituality and religion are often confused or conflated. Spirituality is a dimension of all human life. However, not all expressions of spirituality or means of nurturing it are religious in nature.

What matters most becomes clearer. Are we living in sync with our values, or neglecting who and what are important to us? This may elicit feelings of guilt, regret and/or prompt us to make changes in our priorities, choices and behaviors.

The health of our key connections becomes front and center. Do we have the support we need? Do we experience more community or isolation in life? What internal resources have we developed through self-care and spiritual practice? The quality of our relationships with self, others and a higher power figures prominently in our ability to be resilient.

Our ultimate beliefs show up in the questions we raise and in how we interpret and thus experience our illness. Do we wonder what we've done to deserve this illness? Do we blame others or God? Or do we see this experience as part and parcel of life, asking not why but what next? Like a computer operating system, our core beliefs may not be consciously apparent to us but are always at work in the background, strongly influencing our perspectives and understandings.

Why Spiritual Care Is Important in Health Care
I'm hired by a health care system to develop a chaplaincy presence at an outpatient practice. At the time, outpatient chaplaincy is in its infancy, and the clinic is unsure of my role, as am I. Space is at a premium and so I'm asked to "sit in the waiting room and talk to people." At first, I feel awkward; however, in time, people come to the clinic just to talk with me. As trust develops, I hear information that provides context to their health issues and, with permission, bring it to the attention of their practitioner.

I summarize each visit with a presenting issue and underlying spiritual dynamic. One particular case catches the eye of the medical director. The patient, well-known to the clinic for her chronic gastrointestinal issues, is referred to me as a "Hail Mary pass." She has had numerous tests to rule out life-threatening diseases and was ultimately diagnosed with irritable bowel syndrome. The patient continued to come to clinic in distress; medical staff felt they had exhausted care options, and a social worker had also been working with the patient. 

As I talk with her, I notice something intriguing. She identifies several core values and then describes a significant lifestyle choice that is in direct conflict with these values. I gently point this out to her, which takes her by surprise. As we discuss the situation in greater detail, she realizes she has an important decision to make: either she changes her behaviors to align with her values, or she reassesses her values and sheds those that no longer "fit" with her life. She spends several weeks in prayerful reflection, makes her choice and comes to terms with what this will require of her.

Within a matter of months, her gastrointestinal distress is gone! Afterward, the medical director asks me to present a monthly case study to medical staff and highlight the impact of a spiritual issue on a patient's presenting health concern.

While spiritual issues don't usually play such a dramatic role in a person's medical condition, there are many reasons why identifying and addressing them is important for health and healing. Health crises can shake us to the core, both challenging our entire belief system and uncovering any cracks or gaps in our spiritual foundations. Illness or injury can cause spiritual distress, described as "a state of suffering related to the impaired ability to experience meaning in life through connections with self, others, the world or a superior being."¹

Reasons for integrating spiritual care into a patient's overall treatment include the following:

• Spiritual distress may cause us to feel helpless and hopeless, especially if we believe it's God's will that we are sick. This may directly impact our willingness to engage in treatment. Further complications can arise if we feel God has caused the illness or accident, leading to emotional turmoil and isolation from the very resources we may need for recovery.
• The experience of physical pain can be enhanced by spiritual distress. This directly impacts one's quality of life. In 2018, the Joint Commission dedicated two issues of its periodical, The Source, to spiritual distress. Its findings included: "Unmet spiritual needs have been associated with greater emotional distress, more pain and poorer quality of life."²

I'm called to see a patient being monitored hourly for pain management. I listen attentively as she shares her life context, spiritual journey and concerns. As she shares her burdens and I respond in ways that help her navigate them while honoring her faith, I see subtle changes in how she holds her body and in her facial expressions. When her nurse comes in and asks her pain level on a scale of 1 to 10, she answers, "About a 4." The nurse is surprised, reminding the patient that just an hour earlier her pain level was a solid 10. She looks up, giggles and says: "Well, the chaplain is almost as good as a pain pill."

Additional reasons for integrating spiritual care into a patient's overall treatment include:

• When faced with life-threatening, unexpected or chronic illness, we inevitably confront underlying spiritual beliefs. This kind of spiritual distress often presents as an existential crisis, and patients may need skilled help to get unstuck from tunnel vision or find different frameworks for understanding and making peace with their circumstances.
• Life-altering health events disrupt many aspects of life: finances, relationships, work, our sense of self and the spiritual need to find meaning and purpose in life. How now shall we live? It is critical that we find new ways to contribute meaningfully in life.
• Illness or injury often brings us face-to-face with our mortality. I find that patients frequently want to talk about death and dying when confronted with serious illness or as they approach surgery.
• In addition to issues or concerns, many of us also have spiritual resources to draw from, which can help us face whatever may come with courage and hope. Identifying internal and external spiritual resources can contribute to resilience.
• Integrating spiritual and cultural values and practices into a patient's treatment plan can improve communication and collaboration with the treatment team and encourage active participation in the healing process.

Steps Toward Integrating Spiritual Care Into Treatment
I am in Arizona sitting in a circle with members of a clan of the Navajo Nation, reflecting on the past year. The grandfather, whom I've been supporting as a hospice chaplain, is approaching the end of his life. I am approaching the close of my time here.

I am struck in this moment by the beauty of barrenness, the stark desert in sharp contrast with the brilliant sunset hues. Life on the reservation isn't easy, and yet this is a people known for the phrase and fuller prayer "In Beauty May I Walk." The prayer is about balance and harmony in life. It is rooted in the understanding that, like strands intertwined in the blankets they weave, all aspects of life are interconnected. A spiritual perspective is woven into their understanding of illness and wellness, with the basic theme of bringing all dimensions of life into balance.

As I've reflected on what I experienced among the Diné (Navajo people), I see parallels in Eastern medicine and wonder how our Western practice of medicine has become so compartmentalized, with spirituality, at best, a stepcousin and, at worst, an afterthought fraught with stereotypical understandings. Here are a few thoughts on practical steps toward a fuller integration of spiritual perspectives and care into medical treatment.

Appropriate provision of spiritual care: While all members of a health care team can contribute to spiritual care by honoring what matters most to their patients, professional, board-certified chaplains have the education, training, skill sets and competency standards to provide clinically informed spiritual care to people of any or no religion. They are medically and religiously "bilingual," allowing them to serve as a bridge between both worlds.

Life-altering health events disrupt many aspects of life: finances, relationships, work, our sense of self and the spiritual need to find meaning and purpose in life. How now shall we live? It is critical that we find new ways to contribute meaningfully in life.

The intense interpersonal components of Clinical Pastoral Education, the cornerstone of chaplaincy training, promote professional boundaries so that chaplains "First, do no harm." Board-certified chaplains should be the backbone of a health care organization's delivery of spiritual care.

Many health care systems, however, continue to use volunteers as primary spiritual care providers, which is problematic on many levels. While there is a role for volunteers within the spiritual care team, including community clergy, this should not include direct patient care, except for sacramental ministry. Volunteers are not members of the health care team, rarely understand the intricacies of HIPAA privacy rules, lack adequate training and may directly or indirectly engage in proselytizing. Chaplains refrain from imposing their own values and beliefs on those they serve.

Patients are vulnerable persons and "captive audiences" who may be harmed by well-meaning volunteers who impose their own beliefs, provide uninformed counsel and offer insensitive or offensive prayers. Investing in professional chaplains is foundational for integrating spiritual perspectives and care into medical treatment.

The importance of education: Professional chaplains bear the primary responsibility for educating staff on spiritual issues, resources and their role on treatment teams. While a growing number of medical and nursing schools offer coursework on spirituality, many do not, leaving medical staff with their private understandings, including biases. Chaplains must create opportunities for informal and formal education.

Informally, there is no substitute for consistent rounding. Chaplains should check in with a patient's nurse before and after visits. They should meet and greet administrators, department heads, nursing managers, social workers and unit coordinators, with regular check-ins. Furthermore, they should introduce themselves to hospitalists and seek them out when they have shareable information pertinent to a patient's context. Intentional visibility creates opportunities. Always.

Chaplains can also create formal educational opportunities through audacious advocacy. They can offer to do presentations at staff meetings, lunch-and-learns and case conferences for staff development. They can work with education staff to embed a standard module on the spiritual dimension of health into the organization's annual mandatory education program. They can identify key referral resources (providers, nurses, social workers, palliative care) and modify a core presentation to each discipline's role, always identifying ways in which their service can assist them in patient care. If their organization is connected to a nursing or medical school, they can offer to teach a class. Appropriate education increases patient care referrals. Always.

Demonstrate value: Hiring professional chaplains and educating medical staff serve little purpose if chaplains fail to demonstrate the value their role brings to patient care. They can do this through multiple ways:

• Documentation or charting is a primary way to communicate patient care interactions. Many spiritual care departments rely on checklists with "kitchen sink" drop-down menus in electronic medical records, which communicate little and are rarely read. Instead, chaplains can learn and use the same charting format as other members of the treatment team and become skilled at concisely and incisively capturing the visit.
• Effective chaplain consults often take time, which can be problematic in environments where productivity is measured by the number of visits. Instead, chaplains can identify and use key patient outcome indicators to measure productivity.
• Chaplains can capture and collect vignettes of consults that offer teaching opportunities and can also illustrate patient outcomes. They can excel at the use of narrative and engage patients to share foundational stories.
• Chaplains can find ways for their work to be noticed by medical staff and leverage this to present at ethics meetings and case conferences. For example, I was invited to present at monthly provider case conferences by simply identifying presenting issues and underlying spiritual dynamics in my documentation.
• The practice of obtaining referrals by asking patients if they wish to see a chaplain is ineffective. It doesn't identify patients who may be at risk for spiritual distress. Additionally, it presents a barrier for those with negative views of the word "chaplain." I highly recommend the spiritual struggle protocol screening developed by George Fitchett and James Risk.³ It is an effective and simple algorithm to be administered by nonchaplain health care staff and can be modified as needed.

Consistent and persistent demonstration of spiritual care's value promotes its fuller integration into treatment. Always.

Holistic care means treatment of the whole person, including the spiritual dimension of life. Spiritual care is good medicine. Healing has a rippling effect on each dimension of life. May we who are called to health care ministry in its various capacities commit to the work of reclaiming the spiritual dimension of health and healing.

REV. MICHELE J. GUEST LOWERY is an ordained minister in the United Church of Christ and a board-certified chaplain with the Association of Professional Chaplains.

NOTES

1. NANDA International, Nursing Diagnoses: Definitions and Classifications 2015 — 2017, 10th Edition (Wiley-Blackwell, 2014).
2. "Hospital Chaplains Contribute to Patient Satisfaction and Well-Being," The Source 16, no. 1 (January 2018): https://store.jcrinc.com/assets/1/14/ts_16_2018_01.pdf.
3. George Fitchett and James Risk, "Screening for Spiritual Struggle," Journal of Pastoral Care & Counseling 63, no. 1-2 (Spring/Summer 2009): 1-12.

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