Hospice caregivers play role in spiritual care
Don’t rely only on chaplains to meet spiritual needs
It’s fair to say health care workers know far more about the physical and medical needs of patients than their spiritual needs. With hospice’s focus on holistic care, a patient’s spiritual needs must be addressed in addition to medical necessities to ensure a peaceful death.
The problem is that many hospice workers are ill equipped to handle a patient’s spiritual needs and often defer that responsibility to the chaplain. While the chaplain plays a leadership role, it often falls to nurses and social workers to nurture a patient’s spiritual discovery, perhaps even help the patient to examine his or her own spirituality despite initial indications that spirituality is not an issue. In many cases, the nurses or social workers receive the first signals of spiritual yearning, leaving them to nurture the patient’s inquiries until the patient asks to see the chaplain.
The search for spirituality often heightens as death approaches, causing patients to express their longing for spiritual understanding in formal and informal ways. Patients may openly question their beliefs and seek out the advice of a hospice chaplain and, in many cases, they may subconsciously show signs of spiritual struggles. In the latter case, it falls upon the nurse or social worker to encourage an open discussion of spirituality. Failure to do so leaves care short of hospice’s holistic care approach.
The first step in meeting patients’ spiritual needs is training hospice staff about spirituality. Hospice chaplains play a large role in helping nurses and social workers understand the concept of spirituality.
The most important message, says Jeanne Brenneis, MDiv, STM, director of Bioethics Center and chaplain at Hospice of Northern Virginia in Falls Church, VA, is that spirituality comes in different forms and may not include a formal religion.
"Spirituality is any human being’s sense that is beyond self and beyond human," she says. "It can be a sense of God, sense of universe, or a sense of one’s connection with the universe."
According to Death Studies, a 1990 study of death and dying, spirituality is concerned with the transcendental, inspirational and existential way to live one’s life as well as concerned with the person as a human being.
"The common denominator is the search for meaning in life," says Jay Stark-Dykema, MA, pastoral counselor with CareMed in Chicago. "It’s the understanding of one’s place in the universe."
One of the important lessons in understanding spirituality is that it is a concept so diverse it encompasses both secular and religious beliefs. Caregivers must be able to recognize spiritual needs that fall outside their own belief system. For example, a nurse who comes from a Christian background must be sensitive to a patient who finds spiritual meaning in a garden or fishing. (See related story, p. 17.)
Brenneis and Stark-Dykema offer the following advice to help hospice managers and staff understand and become more sensitive to diverse spiritual needs:
1. Provide training in other faiths.
As part of new employee training and ongoing inservice training, nurses and social workers should receive training in other faiths. This should include the rituals and traditions of different religions and beliefs.
Caregivers working with patients having an affiliation with an organized religion, such as Catholicism, need to understand the rituals and traditions associated with being Catholic.
Take the case of a Catholic man who has divorced and remarried. The Catholic Church doesn’t recognize his second marriage because the first wasn’t annulled. For this reason, the dying man may feel separated from his church and have a need to be reconciled with his church. A caregiver who is not Catholic may not readily spot signs of spiritual distress. A caregiver trained in the basic tenets of the Catholic Church would be able to encourage the man to discuss his feelings with a priest or chaplain. (See related story on hospice programs designed for patients of specific faiths, p. 19.)
Understanding the rituals and traditions from a secular perspective will also be valuable to caregivers as they try to meet the spiritual needs of those who do not have strong religious ties.
"Gardening, for example, is spiritual for some," says Stark-Dykema. "They may find order in the universe through the annual planting and watching things grow. They may find peace by taking a walk in the woods."
While neither gardening nor nature hikes are associated with a formal religion, they are part of the rituals and traditions of an individual.
2. Don’t proselytize.
It’s easy to impose one’s own beliefs on another. It even can be done unintentionally. If caregivers understand their primary responsibility to provide whatever spiritual care the patient indicates or is most compatible with their current belief system, the chances of imposing inappropriate spiritual care is reduced.
"Our job is to listen to the patient so their religious beliefs are understood," Brenneis says.
Using the same Catholic man as an example, a nurse with a Protestant background imposes her belief system on the man if she simply turns a deaf ear to his concerns about his past divorce and how it affects his standing in the church. Her belief system tells her that divorce does not prevent a subsequent marriage from being recognized by her church. If her response to the man’s concern is, "I think God understands," she is imposing her beliefs on him. She would be doing the patient greater service by encouraging him to talk with a priest or chaplain.
"Listen to his beliefs and how he relates to his church," Brenneis advises. "Ask the person if he wants reconciliation with his church. Understand a patient’s needs as the patient perceives them."
3. Establish relationships with community clergy.
Community clergy, along with the hospice chaplain, can provide a wealth of information regarding various faiths and can act as resources when questions arise. Even more important, community clergy can be matched with patients of specific religions or denominations to better meet patients’ spiritual needs.
4. Explain the role of nurses, social workers, and volunteers.
While caregivers are often the first contact in a patient’s spiritual search, they are by no means the last. During new employee orientation and inservice training, chaplains must make other disciplines aware of their role in meeting a patient’s spiritual needs.
"What’s important is the nurse recognize the chaplains’ work," Brenneis says. "Caregivers need to know they need to use the chaplain."
The role of caregivers is to act as a bridge between the patient’s own spiritual yearnings and the spiritual care that can be provided by trained chaplains. It’s important for nurses and social workers to understand how to encourage hospice patients to seek spiritual care from a chaplain.
Brenneis offers the following example: While a nurse is caring for a terminal cancer patient, the patient begins to openly question her impending death. "Why is this happening to me? Is God punishing me?"
The nurse responds, "I don’t know what to tell you. But the chaplain can talk with you about that."
If the patient has been unwilling to seek out the chaplain in the past, she is likely to be put off by the nurses’ response and perhaps even keep her questions about spirituality to herself.
Instead, the nurse should have responded: " I really think you should talk with our chaplain. He’s here to listen and he won’t preach. I’ll have him call you to set a time when he can stop by."
5. Perform a spiritual assessment at admission.
Just as a physical and medical assessment is performed at admission, a spiritual assessment should become part of the admissions and care planning process (See spiritual assessment tool, p. 18.)
6. Adopt an integrated approach to spiritual care.
Understand that everyone on the hospice caregiving team plays a role in meeting a patient’s spiritual needs. Use multidisciplinary team meetings, which should include hospice chaplains, to discuss patient’s spiritual needs.
Sometimes, patients deny visitation of a chaplain, leaving the nurse or social worker to handle the lion’s share of spiritual care. Those caregivers should keep the chaplain informed about the patient’s spiritual condition so the chaplain can provide needed direction.
In the end, Stark-Dykema says, nurses, social workers, and volunteers are providing spiritual care even when they don’t know it. "The process of providing care in a hospice and just being there for the patient is a form of spiritual care."
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