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As a Catholic health ministry, we are called to the sacred work of caring for those who are acutely sick, seriously injured or facing a significant life transition. These realities challenge, shape and potentially transform the spirituality of those receiving and providing care. To respond to this need, we take our mission seriously and equip associates for the responsibility of caring for the whole person. Our understanding of human dignity and the value of whole-person care goes beyond the current focus on spiritual distress screening in many health care settings because such a screening does not necessarily equal wholeness and health.

Seeking to better assess and respond to the spiritual needs of our patients at CHRISTUS Trinity Mother Frances Hospital in Tyler, Texas, we developed and are piloting an assessment that was inspired by another health system's screening tool that uses the values of love, joy and peace.¹ These values are rooted in, but not exclusive to, our faith, which makes the assessment integral to our associates, patients and their families.

LEANING INTO OUR CULTURE
At CHRISTUS Trinity Mother Frances Hospital, our emphasis on whole-person care is rooted in our mission to extend the healing ministry of Jesus Christ. Holistic care is fundamental to who we are as a Catholic-sponsored hospital. We recognize that to fully live out our mission, we must be intentional in providing this care to our patients and community, and we need to collectively embrace and nurture our holistic care culture. We have many caring and empathic individuals across disciplines tending to physical, emotional and spiritual needs. But we know that, as a ministry, we need our efforts also to be a distinguishing feature of our identity.

For whole-person care to be culturally ingrained, everyone needs to champion it, not just mission integration and pastoral care. With more than 2 million patient encounters per year in our hospitals and clinics, asking a specific group (such as chaplains) to meet these needs is impossible. More importantly, for care to be truly holistic — meaning for it to encompass the physical, psychological, social and spiritual dimensions of life — we need a multidisciplinary approach rather than segmenting aspects of care into single departments. When this care comes from all disciplines, it conveys our shared value and respect for humanity.

While researching and exploring whole-person care, we found an interdisciplinary assessment tool using love, joy and peace. AdventHealth Tampa introduced us to this assessment tool, which they received from a Catholic hospital. The first question asks, "Do you have religious beliefs or cultural practices that influence your medical decisions?" One of our nurse educators, Teresa Jamez, helped us examine and revise the wording to include those who might not identify as either religious or spiritual. At its core, this question conveys that, as a Catholic health care ministry, we value the beliefs and practices that are important to our care recipients.

The second question assesses relational health and asks, "Do you have someone who loves and cares for you?" The joy question, "Do you have a source of joy in your life?" assesses for sources of meaning and purpose. We have found that this question requires some translation for both colleagues and patients because joy is often used synonymously with happiness, though it has much richer theological and spiritual implications. The final question, "Do you have a sense of peace today?" is designed to assess emotional health.

The love, joy and peace approach is appealing for several reasons. First, it focuses on assessing and promoting spiritual wholeness, rather than screening for distress like other approaches in health care. Second, it is congruent with our values and faith, while being inclusive, cross-cultural and multifaith. Third, it uses common language, understood by both employees and care recipients. By looking for wholeness, we believe that the care team can honor our care recipients' spiritual and cultural values, foster the positive connections between spirituality and health, and explore alternative meanings of healing when physical healing is no longer a likely reality.

A wholeness approach is open to understanding our care recipients' definitions of spiritual wholeness. This does not mean that we accept their assessments of their spiritual health and do not provide interventions. We still address instances of spiritual illness and distress, but we want more than just the mere absence or void of spiritual distress or struggle. We intervene, for those who are open to it, with the goal of promoting spiritual wholeness.

EQUIPPING ASSOCIATES FOR WHOLE-PERSON CARE
Our whole-person care approach adopts a spiritual care generalist and specialist model. As spiritual care specialists, our chaplains are responsible for equipping staff and providers to offer basic spiritual care in addition to providing specialized spiritual care to patients and their families with acute needs. The generalist/specialist model has deep theological roots. As pastoral/spiritual care leaders, we understand our calling to include the responsibility to "equip the holy ones for the work of ministry, for building up the body of Christ … ." (Ephesians 4:12) We believe that all employees and providers are able and capable of this work. We are people created in the imago Dei, providing care to persons that are a sacred and complex unity of body, mind and spirit.

One of our first tasks in equipping associates to provide basic spiritual care was to move from a screening to an assessment. Although a screening could help identify the need for specialized spiritual care and generate appropriate chaplain referrals, it fails to equip our staff to offer whole- person care. In January 2022, the hospital hired a staff chaplain and asked her to spend a quarter of her time implementing the assessment. We began our first trainings for nurses on the love, joy and peace assessment in the summer of 2022. By implementing this new tool, along with guides for interventions, we believe we can create a culture known for whole-person care.

The move to an assessment stemmed from conversations with nurse leaders and educators, with whom we engaged early in this process. They connected the questions and assessments with their sense of vocation and why they entered the nursing profession. They are called not just to medicine but to a deeper meaning and higher purpose, which is the essence of holistic care.

Nursing leaders and educators insisted that this assessment would not work if it became another screening that nurses asked patients while looking at a computer screen and clicking boxes. Although the questions are phrased in ways that make it possible for patients to respond with yes/no answers, we stress in our training that these questions are selected not only because they are easy to remember and understand, but because they are designed to be a conversation tool, which can elicit stories, emotions and values from our patients and their families.

With the help of our nursing leaders and educators, we have had opportunities for whole- person care orientations, trainings and pilots in our inpatient, ambulatory urgent care centers and outpatient settings. Using a model of planning, action, observation and reflection, we have learned from each training and pilot, receiving and incorporating feedback and observations from our nurses.

As part of that education, we developed suggested basic spiritual care interventions associates may use to meet deficits related to love, joy and peace, and guidance on appropriate referrals for specialized spiritual care by a chaplain. As expected, one of the concerns we often hear is that nurses are already tasked with so many responsibilities and are resistant to anything that might demand more of their time. Our education model stresses that intentional interventions, even brief ones during a moment of crisis, can have a lasting and meaningful impact on patients and families.²

We are currently running two successful pilots and are working toward inpatient rollout by training three additional floors this summer. Our pilot on a pulmonology floor received positive engagement from our nurses and has seen an 11% increase in patient experience scores related to emotional and spiritual needs being addressed. The second pilot, in our oncology outpatient clinic, involved a chaplain working closely with a licensed clinical social worker. They used the love, joy and peace assessment and interventions to provide spiritual care. This work is helping us imagine what this care can look like in the outpatient setting.

While training and equipping our staff, we also focused on training and reeducating chaplains. At times, this has been difficult as we examine old habits and learn new skills. It has required us to rethink how we assess and intervene to promote wholeness, rather than merely treat symptoms. To fully embrace whole-person care, our chaplains need to use the same assessment we are training others to use, just at a deeper level. It required us, as chaplains and mission integration staff, to make a philosophical shift in the way we assess and chart to focus on wholeness and health, to respond to more acute (often difficult) needs that require specialized spiritual care, and to plan for ongoing formal and informal education for our employees.

PROMOTING SPIRITUAL HEALTH AND WHOLENESS
As the assessment promotes human dignity, we have seen a positive impact on our patients and their families. One of our chaplains received a referral for specialized spiritual care for a patient whom the team described as noncompliant with rehab and treatment. This patient was reluctant to engage with the medical team, and they were concerned that the patient's noncompliance might be indicative of a desire to die. During her visit, the chaplain received minimal engagement from the patient and thought that the visit was not going anywhere. She asked if the patient would be willing to answer a few assessment questions. The patient consented and as the chaplain directly asked the questions, the patient began offering lengthy responses.

Through this, the chaplain learned that the patient had a supportive and loving community at a particular rehab facility. He also declined treatments and rehab because he was in physical, rather than emotional, pain. With this assessment, the team treated his physical pain and motivated him to begin participating in treatment so that he could return to the rehab facility.

We find that sometimes feeling love, joy and peace in the moment through the skillful interventions of our team is enough to promote wholeness and health. For example, our outpatient chaplain used the assessment to offer connection, love and care to a patient who was experiencing a sense of loss and loneliness due to losing her ability to talk. Through written conversation, the chaplain learned that the patient, due to events in her past, struggled with communicating feelings to her family and now, with the loss of her voice, was verbally unable to do so.

Through the chaplain's willingness to listen through reading, the patient shared things that she had never shared before. She expressed that she felt love and trust throughout the encounter. Through this assessment, the chaplain developed a care plan, in collaboration with the multidisciplinary team, to help the patient build on this experience and explore alternative modes of communication to promote healing and address her distress.

Whole-person care is not something that we use to generate a particular outcome or what the medical team believes is the best result. It is about helping people thrive and move toward an understanding of wholeness.

For example, one physician recently offered an intervention related to meaning and purpose while discussing goals of care with a patient's wife. After multiple team members had discussed with her these goals and the patient's poor prognosis, the physician took time to explore with the patient's wife what the patient valued as meaningful and purposeful in his life when evaluating his continued treatment. Afterward, the wife expressed how moved she was by her experience with the physician's concern and care for her and the patient. Although the wife supported the continuation of aggressive treatment for her husband, there was a noticeable shift in language and goals.

This change had a lasting impact as the patient moved to the next facility, where his wife built on the physician's interventions to help other family members consider goals of care. According to the wife, concern and support for their family were something that her husband would find meaningful and purposeful.

By promoting peace for patients, our care approach also promotes compassion satisfaction — defined as the pleasure one derives from doing one's work well — among our staff.³ In our inpatient pilot, one of our nurses was treating a patient with a substance use disorder. She felt that only offering physical treatment, which in this case would be treating symptoms, was insufficient. Through ongoing assessment from the medical team, she learned that the patient's substance misuse started with a family death and the patient's sense of guilt over failing to provide life- saving interventions to prevent that death.

By listening to his story, the nurse helped him explore his feelings of guilt, provided medical education and shared her own experience as a health care worker. This helped the patient work through his guilt. Following her intervention, there was a noticeable change in health and improved outcomes. Though only a beginning, this conversation helped the patient to be at a place where he could rehab and continue to heal. The nurse said she knew she provided care that was a step toward healing and spiritual wholeness.

THE ROAD AHEAD
Striving for spiritual wholeness is always a work in progress. It is intentionally slow. We are working toward lasting change. As we introduce our assessment to more units and settings, we will continue to plan, act, observe and reflect. Changes will occur as we learn together and recruit more disciplines.

Although chaplains, as spiritual care specialists, have been providing leadership for this process so far, we look forward to working with holistic care leaders and trainers from multiple disciplines. As we have been working within our own ministry, we have also had conversations with other ministries about this work and have enjoyed learning from each other. Together, we hope and pray that we will be known for living out our mission and authentically and intentionally providing whole-person care for our communities.

At CHRISTUS Trinity Mother Frances Hospital in Tyler, Texas, SARAH A. NEELEY is a chaplain. STEPHEN MURRAY is director of pastoral care and an ACPE-certified educator. ANDY NAVARRO is vice president of mission integration.

NOTES

1. AdventHealth Tampa graciously shared their love, joy and peace screening and promotional materials with us to modify, adapt and build our assessment upon.
2. Betty Ferrell, director and professor with the division of nursing research and education at City of Hope, talks about the impact one minute can make in the following webinar: "'Because it Matters': Multidisciplinary Efforts in Spiritual Care Training (SCT)," YouTube, June 2023, https://www.youtube.com/watch?v=MddZ-HGTo5Y.
3. Beth Hudnall Stamm, The Concise ProQOL Manual, 2nd Edition (Pocatello, Idaho: ProQOL.org, 2010).