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BY: FREDERIC C. CRAIGIE JR., PhD

Suggestions for Processes and Programs

Summary
Recent research has demonstrated a clear link between spirituality and health, but it remains a challenge for many organizations to weave spirituality into organizational life and make it an integral component of clinical care.

Three dimensions of spirituality work together in healthcare: spiritual well-being of patients and families, spiritual well-being of workers, and spiritual well-being of the organization. To cultivate these dimensions in the life of healthcare organizations, several strategies may be employed. First, the definition of "spirituality" must be clear. Consider spirituality at the core of providing healthcare, instead of parallel to or part of clinical approaches. Separate spirituality from chaplaincy, since nurturing spiritual values is the responsibility of everyone in the organization.

It is important to affirm what people already do spiritually, focus on what they have to offer instead of on deficiencies, and cultivate spirituality individual by individual. Organizational leaders must demonstrate spirituality in their personal and professional lives, and keep the organizational mission to the fore. When working to enhance organizational spirituality, create a vision within the organization of its spirituality and emphasize peer support and collaboration.

Programs to help organizations inculcate spirituality include retreats or renewal programs for employees, forums to explore employees' spirituality, inclusion of spiritual issues in training and orientation programs, educational and development programs for working groups, regular review of spiritual well-being, training selected employees as spiritual facilitators, and supporting research on spirituality, health, and healthcare.

A great deal of research and writing over the past two decades attests to the link between spirituality and health. The answer to the question "Does spirituality make a difference?" is clearly yes.¹ It remains a challenge, however, even in organizations with germane mission statements and chaplaincy programs, to weave spirituality finely into the fabric of clinical care and organizational life. How can we operationalize spirituality and make it an integral part of the work, and the workplace, of healthcare organizations? In other words, how can we think of spirituality not only as a clinical issue, but as a vital organizational component of good clinical care?

In the spring of 1996, I was visiting fellow at the Seton Cove, in Austin, TX, a small interdenominational spirituality center that has its origins in the Catholic traditions of contemplative spirituality and ministry to the poor in spirit. Seton Cove has a working relationship with the Daughters of Charity Health Care System and the system's Austin affiliate, the Seton Health Care Network. There I had an opportunity to wrestle with systemic questions about cultivating spirituality in healthcare organizations.

Dimensions of Spirituality in Healthcare Organizations
At the Seton Cove, I had several discussions with senior leaders of the Seton Health Care Network about the challenge of broadly incorporating spirituality into the life and work of their organization. They valued and respected the ministry of chaplains and had a clear commitment to making spirituality real in ways that went beyond clinical pastoral care and could be integrated more fully into patients' and staff members' lives and relationships.

I also had a number of opportunities to interact with other people from the healthcare, religious, and business communities. People from the corporate sector who served in senior leadership, human resources, organizational development, and wellness promotion roles were remarkably interested in and, in many cases, sophisticated about issues of spirituality and organizational life. I also became acquainted with the growing literature on spirituality and organizational life, including books from the corporate² and religious³ sectors that have something to say to those of us who work and practice in healthcare settings. In this work I discerned three dimensions of spirituality in healthcare organizations.

Spiritual Well-Being of Patients and Families
This dimension embraces the ways that providers support healthcare consumers' religious and spiritual values and honor their experiences and struggles. It also encompasses the ways in which we challenge people to cultivate meaning in their lives and develop their own gifts. In a healthcare context, this has to do with clinical skills and approaches.

Spiritual Well-Being of Workers
This dimension embraces the ways in which healthcare providers cultivate meaning, purpose, balance, and wholeness in their own lives. It includes their awareness of their own gifts and limitations.

Spiritual Well-Being of the Organization
This dimension relates to the ways in which the beliefs, values, and norms of the organizational culture support and promote spiritual well-being in individuals and teams, and the extent to which coworkers feel a spirit of community. Is there a clear organizational mission and a sense on the part of workers of participating in that mission in a significant way? Do workers feel safe and supported in taking risks (with appropriate accountability) and in experimenting with their talents? Does the leadership style promote and enrich spiritual well-being?

Each of these dimensions influences, and is influenced by, the other two. Spiritually sensitive clinical care of patients and families depends on the spiritual well-being of individual workers and groups in the organization. Such care requires more than a clinically skilled workforce; it requires a spiritually healthy workforce and a workplace culture that promotes wellness, creativity, and organizational commitment.

Processes of Incorporating Spirituality
How can these three dimensions of spirituality be incorporated and cultivated in the life of healthcare organizations? I have several recommendations.

Define Spirituality
The word "spirituality" obviously needs definition and explanation in secular organizations, but in religious organizations, because of the variety of religious experience and views in all but the most homogeneous groups, definition is needed as well. It is a challenge, in both secular and religious organizations, to define the word in ways that will be meaningful and also widely interpretable and acceptable.

When pressed for a succinct definition, I also describe spirituality in terms of "what life is about," what is deeply important and sacred to people. I also like C. Everett Koop's definition: "The vital center of a person . . . that which is held sacred."⁴ For a longer description, I refer to five dimensions⁵: ceremonies and sacraments, prayer and devotional practices, community, meaning and purpose, and relationship with Spirit.

When defining spirituality in organizational settings, there are four points to remember:

• The understanding of spirituality must be inclusive. It must recognize and honor the perspectives of people who experience spirituality in terms of traditions of particular religious faiths and practices, as well as the perspectives of people who do not. Couching discussions in terms of spirituality, rather than religion, is acceptable to many audiences, since many persons view religion as a deeply personal matter not appropriate for public discussion.
• The understanding of spirituality must be distinctive. Countless models of individual and organizational development point to the importance of principles and values such as honesty, open communication, and respect. Such values are certainly relevant, but there is a richness in spirituality that goes beyond emotional or psychological domains. The concepts of wholeness (unity, coherence, and balance in individual and organizational life), groundedness (in values which flow from that which is held sacred), and connectedness (to God and to meaningful communities of people) are useful in helping people see the distinctive elements of spirituality.
• It is important to attempt to develop a reasonable common language of spirituality, but not to be too particular or restrictive about what spirituality and spiritual well-being mean. People need to define these concepts in a meaningful way for themselves. Be open to the richness of different definitions and perspectives.
• Defining spirituality may be less important than experiencing it. A Health Progress column by Sr. Carla Mae Streeter, OP, describes spirituality in very experiential terms:

  We catch a glimpse of what spirituality is when we remember when someone was really there for us. Spirituality is experienced most as the tone of someone's presence when we are in his or her company. Spirituality is being "all there" when every part of the human is functioning as God has made it. When we know someone with this spirituality, we sense that person's real presence to people and events, a way of being that points to the holy, the mystery beyond our human limits.⁶

As we promote dialogue about spirituality in organizations, therefore, it is important to be open both to people's understanding of spirituality and to people's experiences in which their understanding is grounded.

Separate Spirituality and Complementary Medicine
Do not equate spirituality with biomedical or complementary clinical approaches. Spirituality does indeed subsume certain techniques of healing (prayer, sacraments, and devotional practices, for example) that can be included among complementary medicine approaches, but spirituality is not reducible to techniques. It has more to do with valuing and being than with doing. Ultimately, the metaphor of spirituality being at the core of providing healthcare is more accurate than considering spirituality on a parallel path with clinical approaches.

Distinguish Spirituality and Chaplaincy
Do not define spirituality in healthcare organizations in terms of chaplaincy. Although pastoral caregivers provide unique and vital services, creating an environment that nurtures people and honors spiritual values is the responsibility of everyone in the organization, not just of chaplains. Laypeople can often be particularly effective in advocating on behalf of spirituality in clinical, personal, and organizational arenas.

Affirm What People Already Do
Incorporating spirituality in organizations clearly involves some "top down" approaches such as presenting models, stimulating dialogue, and offering vision. However, "ground up" approaches, drawing on workers' experience and resources and engaging them as cocreators of a spiritually sensitive organization, deserve equal, if not greater, billing. Therefore acknowledge what people already do, framing the discussion as cultivating that which is already present rather than introducing something new. Use language of development ("cultivating," "affirming," "supporting") rather than language of introduction ("teaching," "educating").

Focus on the Half-Full Glass
Focus on the giftedness and creativity of people in their experience of spirituality, rather than on needs or deficiencies. Every employee has something to teach about spirituality.

Take It One Person at a Time
Group programs have a role to play in promoting spirituality. Ultimately, however, the unique personal meanings and associations of spirituality will only be addressed in dialogue with individuals.

Model Spirituality by Leaders' Example
Commitment to spirituality — personally, in leadership styles, and in developing organizational culture — needs to be modeled by leaders. Are leaders at various levels in the organizations enthused by their work? Do they take joy in it? Do they incorporate values in dialogue and decision-making in a visible way?

Ground Spirituality in Mission
Most healthcare organizations, both religious and secular, have statements of mission, philosophy, and values, which help to define their core of spirituality. Frequent reference to these statements can help to focus attention on organizations' spiritual goals.

Measure and Evaluate
Gather data as you go. Data may include:

• Measures of spirituality and well-being. Some variables related to spirituality, well-being, and work can be evaluated with standardized measures.⁷ Other variables, such as workers' recognition and development of their talents, will require some development of measures.
• Parameters that are routinely important to the organization (patient satisfaction, courtesy, sensitivity). Look at the association of spirituality development with these measures.
• Narrative data. Look for stories — and for the life meanings they convey — about how people have had their experience of spirituality enlivened in their personal and organizational lives.

Create a Vision about the Incorporation of Spirituality in the Organization
With greater organizational attention to spirituality, what will it be like to come to work? What leadership styles will occur? What will relationships among colleagues be like? What norms and values will be apparent in the organizational culture? To what extent are these visions being realized now?

Emphasize Peer Support and Collaboration
Look for ways to cultivate spirituality in relationships among peers and colleagues, for example, through nursing reports, in-service education programs, or committee projects.

Include Everybody in the Organization
Ultimately the goal is to include all staff in dialogue about spirituality, including nonclinical, nonprofessional staff.

Keep Talking
By talking frequently with a variety of people in the organization, reinforce the vision of spirituality.

Programs for Incorporating Spirituality
Process issues are as important as programmatic recommendations. Following, however, are some examples of possible programs relevant to cultivating spirituality in healthcare organizations:

• Support of individual spiritual reflection and direction for employees. As with other activities, this might take place off-site at a setting for retreat and renewal or on-site for employees who cannot travel off-campus.
• Forums exploring employees' perceptions, experiences, and stories about spirituality and their work.
• Inclusion of spirituality issues in training and orientation of new employees.
• Educational and development programs for mixed groups of staff. A series of programs at the Seton Cove, for example, engaged people from the business and healthcare communities in dialogue about spirituality and meaningful work, spirituality and leadership, and spirituality and organizational culture. Programs can be offered to heterogeneous groups throughout the organization, or to groups at similar organizational levels, such as nurse managers or department heads.

Some such programs, like those at the Seton Cove, will be home-grown. The process of developing local programs may have the benefit of challenging program leaders to wrestle with the hard questions, "What is important here?" and "What are we trying to accomplish?" Program leaders also may draw on resources such as the Catholic Health Association's teaching program, "On Holy Ground,"⁸ a tool for facilitators working with groups of healthcare leaders who wish to deepen core spiritual competencies.

• Development and support programs for intact work groups. As an example, the Seton Cove sponsored a second series of programs for nurses, physicians, social workers, and other staff from several network oncology sites.
• Checkpoints. Consider ways to check in with employees about their perceptions of spirituality in their careers and in the organization. At a major Austin corporation, for instance, supervisors regularly review employees' perceptions of spiritual well-being in their work and careers.
• Sessions of dialogue that engage physicians.
• Training people within the organization to serve as facilitators in their own units.
• Research on spirituality and health and healthcare. At this point, there is a special need for narrative or qualitative research. Providing patients and employees with the opportunity to tell their stories would further define the meaningful ways in which spirituality contributes to people's lives.

The author gratefully acknowledges the hospitality, support, and spirited collaboration of his Austin colleagues, particularly Sr. Mary Rose McPhee, DC; Jan Berger; Leslie Hay; Catherine Wilson; and Travis Froehlich.

For more information, contact Frederic Craigie at 207-626-1894.

NOTES

1. J. S. Levin and P. L. Schiller, "Is There a Religious Factor in Health?" Journal of Religion and Health, vol. 26, no. 1, 1987, pp. 9-36; J. Gartner, D. B. Larson, and G. D. Allen," Religious Commitment and Mental Health: A Review of the Empirical Literature," Journal of Psychology and Theology, vol. 19, no. 1, 1991, pp. 6-25; F. C. Craigie, D. B. Larson, and I. Y. Liu, "References to Religion in the Journal of Family Practice: Dimensions and Valence of Spirituality," The Journal of Family Practice, vol. 30, 1990, pp. 477-480; P. C. Hill and E. M. Butler, "The Role of Religion in Promoting Physical Health," Journal of Psychology and Christianity, vol. 14, no. 2, 1995, pp. 141-155.
2. T. Chappell, The Soul of Business, Bantam Books, New York City, 1993; J. A. Conger, et al., Spirit at Work: Discovering the Spirituality in Leadership, Jossey-Bass, San Francisco, 1994; L. B. Jones, Jesus, CEO: Using Ancient Wisdom for Visionary Leadership, Hyperion, New York City, 1995.
3. M. Fox, The Reinvention of Work: A New Vision of Livelihood for Our Time, Harper, San Francisco, 1994.
4. C. E. Koop, "Spirituality and Health," Keynote Address, Eighth Annual Thomas Nevola, MD, Symposium on Spirituality and Health Care, Kennebec Valley Medical Center, Augusta, ME, June, 1994.
5. Craigie, et al.
6. C. M. Streeter, "What Is Spirituality?" Health Progress, vol. 77, no. 3, 1996, p. 17.
7. C. W. Ellison, "Spiritual Well-Being: Conceptualization and Measurement," Journal of Psychology and Theology, vol. 11, no. 4, 1983, pp. 330-340; K. Herth, "Development and Refinement of an Instrument to Measure Hope," Journal of Scholarly Inquiry in Nursing, vol. 5, 1991, pp. 39-51.
8. Catholic Health Association, On Holy Ground: A Facilitator's Guide, St. Louis, 1996.

Dr. Craigie is psychologist/faculty, Maine-Dartmouth Family Practice Residency, Augusta, ME, and associate professor of Clinical Community and Family Medicine, Dartmouth Medical School, Hanover, NH.