Appendix B: Resources for Health Care Providers

(Recommended Beginning Reads are Noted With an Asterisk*)

Health Care Provider Wellness

Ecological Chaplaincy Pilot – Faculty of Environment – Simon Fraser University (sfu.ca)

Evaluating the Feasibility and Impact of a Well-being Retreat for Physicians and Advanced Practice Providers (louisville.edu)

Books

*Dornan, W. (2016). Restoring the Healer: Spiritual Care for Health Care Professionals. Templeton Press.

Wheatley, M. (2024). Restoring Sanity: Practices to Awaken Generosity, Creativity & Kindness in Ourselves and Our Organizations. Berrett-Kohler Publishers. 

Tending to the Spiritual Dimension of Holistic Health Care

(Available through your institutional library if not open access publications)

Quick Reference Guide:

Heering, H., & Gunder, S. (2021). CINAHL nursing guide:  Spiritual needs of hospitalized patients. 

Journal Articles:

*A Spiritual Care Toolkit: An evidence-based solution to meet spiritual needs.  

Interfaith Spiritual Care: A Systematic Review 

Frontiers | Defining Spirituality in Healthcare: A Systematic Review and Conceptual Framework

Psychology and Spirituality: Reviewing Developments in History, Method and Practice – PMC

What do clients want? Assessing spiritual needs in counseling: A literature review.

Religion, Spirituality, and Health: The Research and Clinical Implications – PMC (nih.gov)

Books:

Jeffers, S., Nelson, M., Barnet, V., & Brannigan, M. (Eds.) (2020). The Essential Guide to Religious Traditions and Spirituality for Health Care Providers. CRC Press.

Koenig, H. (2013). Spirituality in Patient care: Why, How, When, and What (3rd ed.) Templeton Press.

Philpot, J. (2024). Health for All: A Doctor’s Prescription for a Healthier Canada. Signal. (Note “Pt. 2: Spiritual’)

Timmons, F., & Caldiera, S. (Eds). (2019). Spirituality in Healthcare: Perspectives for Innovative Practice. Springer

*Wright, L., & Bell, J. (2021).  Illness Beliefs: The Heart of Healing in Families & Individuals. (3rd Ed.). Authors.

*See also 2020 Canadian Research Study (Scott Barss & Urban) at the end of this appendix.

Anti-Oppression, Reconciliation, and Decolonization

*Calling In and Calling Out Guide (harvard.edu)

Calls to Action Accountability: A 2023 Status Update on Reconciliation – Yellowhead Institute

Canadian Centre for Diversity and Inclusion (CCDI) Toolkit: Locking in your leadership: Developing a diversity and inclusion strategy

CCDI Diversity and Inclusion Toolkits for the Workplace

*CPR RACISM: A Guide for Health Care Providers to Safely Address Racism in a Health Care Setting | International Journal of Indigenous Health

Compassion as a Tool for Allyship and Anti-racism  (Note: NO Indigenous focus)

Summary-First-Peoples-Second-Class-Treatment-Final.pdf (wellesleyinstitute.com)

NCCIH – National Collaborating Centre for Indigenous Health > Home

Racism in Health Care – Canadian Nurses Association (cna-aiic.ca)

Tools to Take Action Against Inequities and Racism | CMA

Spiritual Care Research and Advocacy

The Character Virtue Development Initiative seeks to advance the science and practice of character, with a focus on moral, performance, civic, and intellectual virtues such as humility, gratitude, curiosity, diligence, and honesty. Character Virtue Development – Funding for Research and Practice (templeton.org)

*Including Spirituality Into a Fuller Picture of Research on Whole Person Health | NCCIH
https://www.nccih.nih.gov/about/offices/od/director/past-messages/including-spirituality-into-a-fuller-picture-of-research-on-whole-person-health

Religion, spirituality, and well‐being: A systematic literature review and futuristic agenda – Koburtay – 2023 – Business Ethics, the Environment & Responsibility – Wiley Online Library
https://onlinelibrary.wiley.com/doi/full/10.1111/beer.12478

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*Summary of Results from a 2020 Canadian research study, shared here, with much gratitude to all who participated, in support of advocacy endeavors to integrate spiritual care services into holistic health care: 

Supporting Spiritual Care in Today’s Healthcare Setting:  Spiritual Care Practitioners’ and Nurses’ Perspectives 

Principal Investigators:  Karen Scott Barss RPN MA and Ann-Marie Urban RPN RN PhD

This qualitative study was funded by a collaborative research grant

from the Saskatchewan Collaborative Bachelor of Science in Nursing program

(Saskatchewan Polytechnic School of Nursing & University of Regina Faculty of Nursing)

Study Participants

31 in total, all from within Canada  (22 spiritual care practitioners and 9 nurses)

Abbreviations used (in alphabetical order)

Health Care Delivery System (HCDS)   Health Care Practitioners (HCPs)  Interprofessional (IP)

Nurses (Ns)    Spiritual Care Practitioners (SCPs)

Themes Identified: Infrastructure; Knowledge; Integration; Spiritual Care for HCPs

Theme 1: Infrastructure

• Absent or inadequate infrastructure (funding and organizational structures) for spiritual care services is noted by participants to interfere with identification and care of patients who require and wish assistance to address spiritual needs as they navigate health crises or challenges.

• Identification and care of patients’ spiritual needs is well-supported in settings with an infrastructure in place for spiritual care services (including effective screening and referral practices) and where spiritual care practitioners (SCPs) are recognized as an integral part of the interprofessional (IP) healthcare team. However, few participants reported that they are working in settings with such an infrastructure.

• Funding and organizational support from government and senior healthcare leadership is identified as essential to integrating the spiritual dimension of care into holistic healthcare.  The few settings identified as currently employing SCPs so are receiving private funding to support it or are in provinces where spiritual care services continue to be viewed and funded as a core service within the public healthcare system. Both SCP and Nurse (N) participants identified overall inadequate funding for frontline HCPs to appropriately offer holistic care. Ns in acute care settings identified that they rarely have time to address patients’ holistic needs, particularly their spiritual needs when spiritual care infrastructure and SCPs are absent. Several SCPs noted that nurses’ heavy workload has often been very observable by them.

• Several participants noted incongruence between HCDS claims of holistic care provision and the actual provision of holistic care services such as spiritual care.  Several participants identified the need for more accountability within the healthcare delivery system (HCDS) to address this incongruence (e.g. the need for healthcare organizations to demonstrate how   related vision, mission, and values statements are being operationalized).  A need also was identified for healthcare services to comprehensively align with the spiritual and holistic care standards identified by external accrediting bodies and established best practices.

• A variety of effective infrastructure designs were identified, involving the presence of …

… a spiritual and cultural care department whose spiritual care providers are part of                                         the IP team assigned to specific healthcare units or areas.

… a therapies or healing arts department that includes or works closely with spiritual care providers who are part of the IP team as described above.

… a designated nurse with specialized spiritual care skills who provides mentorship to the nursing team (in addressing patient spiritual needs) and serves as a liaison between patients, Ns and SCPs.

… a spiritual care educator who provides ongoing professional development to SCPs  and ongoing education to HCPs about both the role of SCPs and ways to enhance their own ability to address spiritual care needs within their holistic practice.

… a provincial director or co-ordinator of spiritual care services with the expertise to hire duly qualified SCPs and oversee the delivery of quality spiritual care services in healthcare settings throughout the province.

… enough SCP resources available in each of the above models for SCPs to provide spiritual care not only to patients but to HCPs.  (See Theme #4)

Theme 2: Knowledge

• The need to enhance knowledge about the nature of spirituality and spiritual care was consistently identified by participants as a priority in relation to government, senior leadership, current and future HCPs, and patients. SCPs consistently identified this lack of knowledge as a key contributing factor in absent or inadequate funding for their positions.  They also identified this knowledge deficit as a barrier to being viewed/treated as an integral part of the IP team (e.g. exclusion from organizational and patient-care decision-making; disrespectful non-verbal and verbal communication from some HCPs).  SCPs also regularly acknowledged that HCPs who did understand SCPs’ role conveyed much respect for them and their place on the IP team, more frequently referring patients to them than did other HCPs. Misinterpretations about the nature of spiritual care by HCPs and patients themselves was noted to interfere with patients requesting or consenting to spiritual care as part of their holistic health care.

• Misconceptions frequently identified by participants:

– ‘Spiritual care means religious care.’ (Several participants cited agency and research statistics indicating that 50 to 70% of patients who receive spiritual care are not affiliated with any religious community or traditional practices; SPCs focus on spiritual needs as identified by and/or observed within each individual patient).

– ‘SCPs are volunteers who simply come to visit with patients.’

(Several participants shared examples wherein this assumption resulted in other HCPs     interrupting essential spiritual care encounters/interventions or conveying    minimal understanding the depth of spiritual care that is overlooked when spiritual care services are not used or made available.

– ‘SCPs and denominational clergy have the same qualifications and role as one another’.  (SCPs are employees within healthcare settings who have a very specialized skillset in relation to promoting the spiritual dimension of health and healing; denominational clergy are employees of their respective faith communities who provide specific religious rituals and spiritual support as requested by patients from that denomination.

While some denominational clergy have some spiritual care preparation and work to address spiritual care gaps in agencies without SCPs, this is not generally their role or scope of practice.)

– ‘All First Nations Elders/Knowledge Keepers can provide spiritual care.’ (First Nations Elder SCPs noted the wide range of specialized preparation and expertise amongst various Elders, Knowledge Keepers, and Healers; only some are prepared to offer services and ceremonies of a spiritual nature.)

– ‘SCPs (and denominational clergy) proselytize or impose their religious or traditional beliefs and practices on patients.’ (Participants consistently spoke of their devotion to honouring the spiritual worldview, needs, and strengths of each individual patient. Some participants noted the occasional occurrence of biased, inappropriate communication/care by inadequately trained/vetted personnel from some faith communities which, to their dismay, reinforced related misconceptions about SCPs.)

– ‘Nurses who inquire about or engage in spiritual conversations or practices with patients are breaching their privacy or crossing professional boundaries.’ (While some N participants note a reduced prevalence of such misconceptions in recent years, several stories shared by them revealed within their agency’s organizational culture or formal leadership an ongoing discomfort with their wish to address the spiritual dimension of health.  N participants were noted to consistently convey reverence for patient worldviews and careful attention to appropriate professional boundaries in relation to any of their own spiritual beliefs with potential to inappropriately influence or interfere with relevant patient care.)

– ‘Spiritual or soul-depth pain is non-existent or has minimal impact on the overall healing process.’ (Several participants shared stories that illustrated how patients’ unresolved spiritual pain worsened their physical, mental, and emotional symptoms, interfered with their ability to actively engage in healing/heal to their optimum, or blocked a healthy end-of-life process where physical healing/curing was not possible. Two participants noted that the spiritual dimension is sometimes overlooked in the assessment and preparation process in relation to medical assistance in dying (MAiD), potentially interfering with a patient and family’s ability to acknowledge and address spiritual pain and its impact on decision-making and the overall end-of-life experience.

– Spiritual care is only for dying patients or for those needing last rites/other end-of-life rituals.  SCP participants shared how this misconception is often voiced to them and conveyed through HCPs’ looks of surprise from when they arrive to see patients.  SCPs also noted instances wherein this misconception has led to patients’ fear of them/spiritual care.

• Educational priorities identified by participants:

– The nature of spirituality. (Several definitions and related resources were provided in addition to those within the study’s literature search/annotated bibliography.)

– The nature of spiritual care and the qualifications of its specialized practitioners. (Canadian Association for Spiritual Care (CASC) qualifications and First Nations traditional preparation of Elders who offer spiritual care need to be more broadly shared and understood.  Also, opportunities for relationship-building and experiential learning with SCPs were recommended for future and current HCPs (e.g. shadowing experiences; informal workplace gatherings/information-sharing.)

– The sacred and healing nature of Traditional First Nations and Métis ceremonies and practices, along with the importance of them being more consistently honoured within healthcare. (First Nations Elder SCP participants noted that many Indigenous patients will not self-identify their traditional practices and preferences because they fear disrespectful or racist responses from HCPs. They also noted that many HCPs (Indigenous & non-Indigenous) demonstrate acceptance of/eagerness to learn more about First Nations traditional healing and spirituality.  They stressed the importance of such traditional knowledge being shared by First Nations Elders/Knowledge Keepers – and that they would be happy to do so for all interested.)

– The gap in holistic care in jurisdictions and settings where spiritual care currently is not funded and provided as an integral part of IP care. (Several participants noted that others need to be aware of unfortunate results which they are anecdotally witnessing and hearing about from other members of the IP team.  Such examples ranged from missed opportunities to help patients enhance their wellness/enrich their healing process, to patients becoming traumatized by unresolved spiritual pain and a thwarted healing process.  Some participants noted the difficulty in fully knowing and tracking unmet spiritual needs in settings where the infrastructure for support and documentation of spiritual care is currently absent. They also voiced fear that, as a result, future/new HCPs in such settings may see the current status quo as the norm if they are not made aware of the current gap.)

– The importance of and opportunities to support HCPs’ spiritual literacy and ongoing spiritual growth in promoting their own and others’ holistic wellness. (Several participants spoke of the difficulty caregivers have in gaining spiritual care competence/confidence and sustainable levels of resilience if they have not had/taken opportunities to learn about and explore their own spirituality. See Theme #4)

– A variety of educational opportunities for future/current HCPs and healthcare leaders to develop/deepen a holistic/integrative worldview and cultural humility (e.g. a solid liberal arts foundation; courses and experiences offering deeper understanding of a variety of cultures and lived experiences).  

– Research about the impact of the above-recommended educational approaches on the perception of nurses and other HCPs about holistic care and IP collaboration with SCPs. While some participants were familiar with existing such literature, many felt that an expansion of related evidence-based would be helpful in prioritization of educational approaches that are evaluated as being effective in positively influencing HCPs perceptions and practices in relation to holistic care and IP collaboration.

– Advocacy skills development for SCPs and other IP team members who are devoted to enhancing the integration of spiritual care. (Some participants noted that the ongoing need for such advocacy necessitates related competence and confidence so that spontaneously occurring and planned advocacy/teaching opportunities can be maximized.)

– The integral role of the spiritual dimension of wellness in holistic healthcare, particularly in relation to the impact of spiritual distress on every other dimension of health. Several participants shared stories of witnessing and experiencing the recession or reduction of physical, mental, and emotional suffering when spiritual distress was resolved (See below supporting models.)

Theme 3:  Integration

• Participants unanimously spoke to the need for intentional integration of spiritual care into the HCDS if authentically holistic care provision is to occur. Several voiced fear that, without such focused efforts, spiritual care will continue to be viewed as an ‘add-on’ that is poorly understood and ineffectively or inconsistently available to patients.

• Participants shared several specific ideas for enhancing the integration of spiritual care (in addition to the essential foundation of a supportive infrastructure (See #1):

– Use of holistic models of care to clearly demonstrate and explore the inseparable nature of each dimension of health (e.g. The Bio-psycho-socio-spiritual Model; Integrative Health Care; Traditional Indigenous Medicine Wheels encompassing the mental, emotional, spiritual, and physical dimensions as locally understood; research-based wellness wheels that visually represent several dimensions of well-being, including spiritual wellness).

– Regular, intentional use and ongoing clarification of language that promotes holism and integration (e.g. frequent conversation about universal spiritual needs such as meaning, purpose hope, interconnection, and creativity; possible inclusion of ‘therapist’ within the professional designation for SCPs, potentially better conveying that they have specialized therapeutic skills just as do other members of the IP team; refraining from using the word ‘visit’ in relation to patient care from SCPs, just as we do with other members of the IP team).

– Encouragement of nurses and other HCPs to view and regularly refer to available SCPs as active allies who can take on some of the responsibility for holistic patient care. (As previously noted, Ns/other HCPs often do not have time, confidence, or skill to sufficiently address the spiritual dimension of care.  Several SCP participants indicated that available SCPs are often under-utilized because other HCPs are not aware of them other services they provide; some Ns indicated they were unsure if there were SCPs in their agency to whom they could refer.)

– Inquiry about spiritual care preferences and needs as part of the admission process.(Several participants reported that HCDS concerns in recent years about patient privacy have resulted in removal or adaptation of related standardized questions that can effectively identify patient preferences in relation to involvement of both SCPs and denominational clergy (e.g. absence of a previously-available list of patients who wish to have spiritual care and/or a visit from denominational clergy or Elders from a specific community)

– Adoption and evaluative research of an inclusive screening or assessment tool that would help identify patient needs and preferences in relation to the spiritual dimension of their care, while helping patients to understand the relevance of such screening /assessment). (Some participants noted ‘FICA’ {‘Faith/Beliefs, [their]Importance/Influence, Community, Action in Care) as an example; however, some noted that the FICA tool may exclude/be irrelevant to those who are not affiliated with a religious community.)

– Standardized chart formats that include designated spaces (vs. ‘tick box’ formats) to document meaningful spiritual assessments and care, with appropriate follow-up by a formal leader (e.g. nurse manager) if these spaces are left incomplete. (Several SCPs and Ns noted that their agency forms either do not contain such designated spaces or that, if they do, they are often blank or contain very brief, superficial information such as the individual’s identified religion, with no clarification as to whether this was important to them and if/how they might wish it integrated into their care.

– Inclusion of SCPs in regular IP rounds.  (Several SCP participants noted that they are not included in these rounds.  Several SCPs and Ns stated they believe it is important for SCPs to be a regular part of such rounds to help identify potential spiritual needs and facilitate timely intervention.)

– Provision of regular spiritual/contemplative/healing practices for patients and families (e.g. meditation sessions; smudging, music therapy and other expressive arts. (Such sessions are being provided in settings where spiritual/cultural care and/or healing arts services are part of the infrastructure.)

– Development and evaluative research of inclusive spiritual care patient resources that can be readily accessed and used by nurses and patients  on an incidental basis, particularly when SCPs or denominational clergy of patients’ choice are not available (e.g. spiritual care ‘tool kits’ containing practical ‘soul care’ items such as a selection of music, comforting symbols, and inclusive meditations or prayers for specific circumstances such as preparation for surgery, navigating a difficult diagnosis, making a difficult healthcare decision, or grieving a current or anticipated loss).

– Greater availability of IP texts and reflective resources in relation to spirituality and spiritual care (in support of HCPs’ ongoing personal/professional development).

– An expanded role for nurses qualified/interested in offering therapeutic modalities that would help tend to the spiritual dimension of care for patients who wish them (e.g. Mindfulness-Based Stress Reduction (MBSR) and other spiritual/contemplative practices, Therapeutic Touch; Healing Touch)

– Encouragement and support of formal leaders to serve as role models and change agents in support of the healthcare culture’s transformation into one that concretely and visibly embraces holistic care (e.g. inviting formal leaders at all levels to engage in ongoing discussions and professional development about spiritual health and care; sharing with them evidence-informed resources that can support the integration and ongoing evaluation of measurable indicators of holistic care provision, including spiritual care delivery).

– Development of interprofessional communities of practice in relation to the spiritual dimension of holistic care (to exchange mutual support, resources, personal/professional development, and engage in advocacy as per the priorities of those involved).

– Research that fosters the appropriate sharing of patient, family and caregiver stories about their experiences when spiritual care was and was not effectively integrated into their healthcare. (Several participants, both nurses and SCPs, shared several powerful such stories and voiced their belief that stories like these are the most effective way to help others understand and support the integral role of spirituality within the healing process. Some participants noted that patient/family stories may most influence governments to support spiritual care infrastructure, given the voting power of healthcare consumers.) Storytelling was also noted as an approach that deeply reflects and honours Indigenous ways of knowing.  Such stories also lend themselves to development of holistic educational resources (e.g. patient care/‘case studies’ and audio-visual resources that touch learners/HCPs on multiple dimensions).

– Research that demonstrates cost-savings associated with the effective integration of spiritual care through shorter hospital stays, fewer readmissions, reduced use of sick time by staff. (Some participants expressed the belief that resulting data might be the key motivator for funders and budgetary-decision-makers to enhance or re-instate spiritual care infrastructures. Some participants acknowledged that some such data exists but felt local research of this nature would have the most impact. Others expressed frustration about the need to carry out such research when many other therapeutic services are not required to justify their contributions in this manner. Others spoke of the difficulty quantifying and measuring some of the ineffable, intangible elements of enhanced or compromised spiritual health.

– Research that demonstrates the impact of giving/receiving spiritual care on the resilience/reduction of compassion fatigue and burnout amongst nurses and other HCPs. Some participants voiced a belief that being able to effectively tend to patients’ spiritual needs would enhance their own job satisfaction and decrease their own levels of moral and spiritual distress, placing them at less risk of compassion fatigue and burnout. They noted that research demonstrating such positive outcomes would offer another layer of support for the integration of spiritual care.

Theme 4: Spiritual Care for HCPs

• SCP and N participants both identified the need to address the spiritual needs of the IP team in a timely, accessible manner.  (While some acknowledged that HCPs have access to services such as Employee and Family Assistance (EFAP) and counselling through their healthcare benefits, most such services do not address the spiritual dimension; nor are such services readily available in the context of addressing the many spiritual and existential issues and questions prompted by providing patient care on a given day.  Both nurses and SCPs identified unresolved moral and spiritual distress as key risk factors for HCP compassion fatigue and burnout.)

• SCPs consistently spoke of spiritual care of their colleagues on the IP team as being an integral part of their role. Many also spoke of their sadness and frustration in being able to effectively fulfill this vital dimension of their role due to limited time, resources or awareness of their availability in this regard.

• Ideas shared to help better address HCPs’ spiritual needs:

– Enhanced funding and a provision of a clear mandate for SCPs to play an active role in addressing the spiritual needs of the IP team. (Some participants identified settings in which they had previously worked or in which they were aware that some SCPs had a specifically assigned role to provide spiritual care to HCPs. Most had not. The few participants who identified that they currently work in an agency offering some spiritual care to HCPs indicated that related funding does not allow them to fully address current HCP spiritual needs.

• – Regular opportunities for SCPs to be present to other HCPs on an incidental basis so that relationships and trust are built in a way that fosters integral spiritual support to HCPs when needed(e.g. sharing in rounds; regular gatherings to talk about anything that incidentally comes up on a given day).

– Regular integration of individual and communal rituals that help nurses and other HCPs tend to their spiritual well-being or grieve the ongoing losses they experience(e.g. availability of smudging and other spiritual practices of HCPs’ choice on their breaks; regular meditation classes/sessions; having an active, comforting roles and rituals in helping prepare deceased patients for transfer to the care of funeral homes). (Such opportunities were present in some settings, particularly those wherein spiritual/cultural care and/or healing arts services were supported by the infrastructure.)

– Research that measures outcomes associated with the provision of spiritual care for HCPs (e.g. impact on sick time, attrition, self-report with regard to job satisfaction, compassion fatigue and burnout).

Note: 

This research project took place during the Covid 19 pandemic.  Several participants noted that the above-described challenges and barriers have been long-standing issues, exacerbated by the pandemic, particularly in relation to increased spiritual care needs of patients and staff. SCPs’ and Ns’ supportive roles also have had to be expanded and adapted, given the necessary absence of/ reduction in visits from family/personal supports.

Please share and use these results in support of the spiritual dimension of health care. Available upon request are …

… its Annotated Bibliography (featuring literature that was foundational to the study).

… an accompanying PowerPoint Presentation (highlighting the research process and results).

***

Note: Recommendations and relevant literature from this study have been integrated into this handbook.