Mednotes

L2 Early Professional Experience Spirituality in healthcare

Properties2
tagsearlyprofessionalexperience, lecture
aliasesL2 Early Professional Experience Spirituality in healthcare

25 min read

Overview

This lecture (Richard Egan, Preventive and Social Medicine, 27 May 2025) makes the case that spirituality is a legitimate, evidence-informed dimension of clinical care, and equips students to recognise and respond to it. It moves from background and self-reflection on the student’s own spirituality, through a five-part conceptual framework for understanding spirituality (scope/definitions, principle/model, evidence informed, zeitgeist, numinous), and then into practical spiritual care: its ethics, who provides it, who wants it, and how to assess spiritual needs and refer on.

Learning objectives and background

The lecturer’s background is as a public health practitioner and a researcher focused on spirituality, health promotion and psycho-social-spiritual (PSS) cancer care.

By the end of the lecture students will begin to:

  • Identify the evidence for spirituality and healthcare
  • Recognise the importance of their own spiritual well-being
  • Understand the ethical considerations of spiritual care
  • Identify spiritual assessment approaches
  • Identify referral options for specialist spiritual care

A framing point runs through the lecture: students already know quite a lot about this, and should build on existing strengths.

Session plan: 1. Background; 2. Understanding our own spirituality; 3. A framework to understand spirituality (scope/definitions, principle/model, evidence informed, zeitgeist, numinous); 4. Spiritual care (ethics, needs and assessment); 5. Final comments.

Understanding your own spirituality

Students are asked to describe spirituality in two or three words, and to reflect on how they look after their own spiritual wellbeing, phrased several ways: what keeps your “soul” singing, what keeps you spiritually fit, what looks after your spiritual (or existential) wellbeing, or what gives your life meaning.

Sir Richard Faull (Te Ati Awa, Ngati Rahiri) frames why this matters clinically: the human body has great mana in both life and death and is multidimensional, having a physical side and, most importantly, a spiritual side which in part reflects our culture. Our spiritual side is who we are, is vital to our very existence, and must never be forgotten when looking after people.

The Association of American Medical Colleges (AAMC) guidelines (Puchalski, 2006) state that with regard to spirituality and cultural issues, before graduation students will have demonstrated to faculty satisfaction:

  • The ability to elicit a spiritual history
  • Knowledge of research data in the area
  • An understanding of, and respect for, the role of clergy and other spiritual leaders
  • An understanding of their own spirituality

Warning

The transcript records this AAMC list only partially; some items are elided on the slide (”…”).

Framework part 1: Scope and definitions matter

Illness and hospitals raise many spiritual questions for patients, for example: what is happening to me? I miss my family. Why did this happen to me? Have I been a bad person?

Lay one-line definitions from research participants show how varied the concept is:

  • “I really struggle with the definition of the word” (Carl, 62, education, cancer)
  • “Never gave it a thought” (Frank, 75, photography, cancer)
  • “How one looks at the world and oneself” (Henry, 76, finance, cancer)
  • “It extends to my whole being, relationships and where I am in this world” (Ida, 45, hospice nurse)
  • “I think being spiritual is being a good Christian” (Aida, 65, hospitality, family member)
  • “It is the essence of who I am” (Abigail, 64, chaplain)

Egan et al. (2011), from a New Zealand hospice study, map the terrain: spirituality means different things to different people and may include a search for one’s ultimate beliefs and values; a sense of meaning and purpose in life; a sense of connectedness; identity and awareness; and, for some people, religion. It may be understood at an individual or a population level.

The international consensus definition (Puchalski et al., 2014): spirituality is a dynamic and intrinsic aspect of humanity through which persons seek ultimate meaning, purpose, and transcendence, and experience relationship to self, family, others, community, society, nature, and the significant or sacred; it is expressed through beliefs, values, traditions, and practices.

A 2021 systematic review of healthcare definitions (de Brito Sena et al.) covered 166 articles and identified 24 spiritual dimensions, most commonly related to connectedness and meaning of life. Frequencies of the dimensions:

Dimension%
Connection/Relation53.001 (as printed)
Meaning/purpose51.80
Divine/god/higher power39.75
Transcendence/immaterial38.55
Others/community relationship37.95
Beliefs29.51
Self connection25.90
Nature connection24.09
Values23.49
Individual/personal19.87
Experience19.87
Practices/behaviors18.67
Peace/well-being15.06
Human aspect13.85
Power/force/inner energy13.85
Sacred12.04
Personal growth10
Immanence5.42
Support/sustain element5.42
Dynamic process4.81
Necessity3.61
Spiritual beings3.01
Art connection1.80
Life after death1.80

Warning

The “Connection/Relation” percentage is printed on the slide as 53001%, very likely a decimal or formatting artefact for 53.001% or 53.01%; reproduced as shown.

Framework part 2: Principle and model matter

Which model of health you hold determines whether spirituality is visible at all. The spectrum runs from bio-reductionist to bio-psycho-social-spiritual, with whole person principles and approaches on the latter end: holism, Total Care, Te Whare Tapa Whā, Fonofale. The slide calls for cross-paradigm dialogue (Chuengsatiansup, 2003) rather than one paradigm displacing the other.

Models presented:

  • Te Whare Tapa Whā (Māori contribution, Mental Health Foundation NZ): a house whose four walls are taha wairua (spiritual), taha hinengaro (mental and emotional), taha tinana (physical) and taha whānau (family and social), standing on whenua (land, roots) as the foundation.
  • Fonofale model (Samoan contribution, Fuimaono Karl Pulotu-Endemann, 2001): a Samoan fale whose pillars are physical, spiritual, mental and other (including sexuality, gender, age, socio-economic status); the roof is culture and the floor is family, with time, context and environment as the encompassing dimensions.
  • Hospice framework: palliative care services integrate physical (tinana), social (whānau), emotional (hinengaro) and spiritual (wairua) aspects of care to help the dying person and their family/whānau attain an acceptable quality of life (NZPC Strategy 2001). Hospice practice sits under this holistic framework, drawn from Te Whare Tapa Whā (Mason Durie): all four walls are needed for strength and balance.
  • Netherlands oncology guidelines (“the position of spirituality”): concentric circles with spiritual at the centre, surrounded by psycho-social and then physical, with arrows pointing inward from the physical and psycho-social toward the spiritual centre.

Framework part 3: Evidence informed

Volume of research: a Scopus search on 26 May 2025 for TITLE-ABS-KEY(spirit* OR relig*) AND TITLE-ABS-KEY(health) returned 87,587 documents. Output rose slowly to about 1990, then steeply from roughly 2000, peaking near 6,000 documents per year around 2023 to 2024.

What difference does it make (by domain):

  • Cancer: 2020 review (Kelly et al.) concluded religion and spirituality had a positive impact on cancer care, and that their integration may result in more patient-centred care.
  • Heart disease: 2022 review (Tobin et al.) suggests spirituality serves as a target to improve quality of life and patient outcomes in heart failure.
  • Hospital care: 2022 review (Dos Santos et al.) concluded spiritual interventions are associated with improved psychological and spiritual patient outcomes.
  • Patient satisfaction: a large 2015 US study (n = 8978) concluded chaplains’ integration into the healthcare team improves patients’ satisfaction with their hospital stay.
  • Quality of life: an 18-country study (n = 5087) showed spirituality, religion and personal beliefs (SRPB) was highly correlated with all WHOQOL domains (p < 0.01).
  • Health behaviours: a Canadian 2022 review (Litalien et al.) concluded religion and spirituality do influence health behaviours and increasingly impact healthcare services in Canada (covering mental health, heart disease, cancer, addictions, quality of life, chronic disease).

Research limitations and challenges still remain.

The key recent review is Balboni et al., JAMA 2022, “Spirituality in Serious Illness and Health”. Its eight findings:

  1. Spirituality is important to most patients with serious illness (literature estimates 71 to 99%).
  2. Spiritual needs are common in that setting (estimates 23 to 98%).
  3. Spiritual care is frequently desired by patients with serious illness (estimates 50 to 96%).
  4. Spirituality can influence medical decision-making in serious illness.
  5. Despite this, spiritual needs of patients with serious illness are frequently unaddressed within medical care.
  6. Spiritual care is infrequent in the care of such patients (estimates of patients not receiving spiritual care 49 to 91%).
  7. Provision of spiritual care was associated with better end-of-life outcomes.
  8. Unaddressed spiritual needs can be associated with poorer patient quality of life.

Further reading: the Oxford Textbook of Spirituality in Healthcare (Cobb, Puchalski and Rumbold, Oxford University Press).

Spirituality research is an emergent field; Egan and colleagues are developing the spirituality, health and public health field, with studies including: spirituality in New Zealand hospice cancer care; psycho-social-spiritual supportive care in cancer; spirituality in ODHB oncology ward; spirituality in medical education; spirituality in aged residential care; renal specialists and spirituality; spirituality and dementia, and Armed Forces; a spiritual care professional development project; spiritual care in cancer care across 16 countries; spirituality in NZ nursing care; spirituality in the Salvation Army Bridge Programme; co-design work on spirituality in elder and cancer care and chaplaincy; spirituality in public health, Oranga Tu Māori prostate cancer; and a current HRC national study on spiritual care in healthcare.

Evidence impact on policy

  • New Zealand Health Strategy: the Crown is obliged to ensure all health services are provided in a culturally appropriate way that recognises and supports the expression of hauora Māori models of care.
  • Pae Tū: Hauora Māori Strategy (2023): the concept of hauora reflects a holistic view by encompassing the physical, mental, spiritual, social and environmental dimensions of wellbeing.
  • Te Mana Ola: The Pacific Health Strategy (2023): encourages not only Pacific peoples but all parts of the health system to value the physical, mental and spiritual wellbeing of Pacific peoples for equitable health outcomes.
  • Guidance for Improving Supportive Care for Adults with Cancer in New Zealand (MoH, 2010): it is essential that all staff working in cancer treatment services have a basic understanding of the spiritual needs of people with cancer, possess the skills to assess those needs, and know how to contact spiritual caregivers when required; training specific to the cultural and spiritual needs of Māori is essential.
  • He Ara Waiora (Treasury wellbeing model): a framework helping Treasury understand waiora, often translated as a Māori perspective on wellbeing. It is a concentric diagram with wairua at the very centre, surrounded by taiao and ira tangata, with an outer band of kotahitanga, tikanga, he tangata, whanaungatanga, tiakitanga and manaakitanga (and terms mana tauutuutu, mana tuku iho, mana āheinga, mana whakāke, he kāinga), with waiora on the outer ring.
  • Te Ao Māori Framework (Te Tāhū Hauora / Health Quality and Safety Commission): wairuatanga sits at the centre, surrounded by rangatiratanga, pātuitanga, whānau and a further term; a video on the wairuatanga concept is recommended.

Note that in both He Ara Waiora and the Te Ao Māori Framework the spiritual dimension (wairua/wairuatanga) occupies the centre of the model.

Framework part 4: Zeitgeist

The cultural moment matters because it shapes what patients bring.

Beliefs in Aotearoa, 2001 to 2023 (census data): “No religion” rose from about 30% in 2001 to about 54% in 2023; Christian affiliation fell from about 59% to about 33%; Hindu rose slightly to about 3%; Muslim and Buddhist remained low and roughly flat at about 1%.

Spirituality and religion: the relationship is contested. Features include low religious attendance and the rise of the “nones”; the disentwining thesis, that is, the growth of contemporary spiritualities separate from religion; and the common position “I’m spiritual, not religious”.

Demographics and plurality: New Zealanders are getting older (mostly) and more multicultural. There is “the long dying”, a move from communicable to chronic diseases dominating death (Murray et al., 2005), illustrated by the trajectory of a short period of evident decline, typical of cancer, in which function stays relatively high with specialist palliative care input available and then declines steeply near death. There is also spiritual plurality and democratization.

Vacuum or gap? Growth of meaninglessness; materialism not being enough; this being both an individual and a societal issue, and therefore a public health issue; and possible re-emergence of spirituality.

Māori contribution: taha wairua is generally felt by Māori to be the most essential requirement for health (Durie, 1999). Spirituality is inextricably linked to ways of being for many indigenous people (Valentine et al., 2017); a participant in that study said “you can’t talk Māori health unless you talk wairua, it’s as simple as that”. There is an appropriation warning (Moewaka Barnes et al., 2017).

Learning from Aotearoa New Zealand Pacific peoples (Tamasese, Parsons and Waldegrave, 2014): spirituality and its various expressions are central to the role of Elders and a core part of their own activities, with many Elders guiding younger family members in spiritual practices; spirituality plays a significant role in maintaining Elders’ overall wellbeing. Spirituality is not just an element of age or the ageing process and is not equivalent to elements such as housing, electricity and power, information and transport; it is the key constituent force in the whole life process. The mainstream cultural view of the self as an individuated part contrasts with Pacific views of the self as a total being existing in relationship to other people; Pacific concepts of Elders, Eldership and ageing derive from their sense of meaning, wholeness and sacredness of place of belonging, family, genealogy, language, culture and environment, and Elders are increasingly valued as they age.

Warning

On the rendered slide the large quote box overlaps and obscures that final paragraph; its wording was recovered from the underlying text layer, but the exact on-slide formatting is uncertain.

Reclaiming Pākehā contributions, Sir Paul Callaghan: “with the cancer, I resolved that I would not waste a day, that every day I would fill with purpose and spirit”. He also said he is an atheist in the sense of not believing in an omnipotent, all-knowing, omnipresent creator, but that this does not mean he is not a spiritual man; he acknowledges the mystery, in the sense that there are questions not answered by simple paradigms around evidence and consistency, which is the way science works, questions around values and why we are here at all. This illustrates that spirituality is not confined to religious belief.

Modern clinical practice (Sedhom, 2020): a medical oncology fellow asks whether oncology is a spiritual practice, having engaged with the existential questions dying patients ask, such as what is the meaning of my illness and why am I suffering. Recognising illness as a spiritual event came not from any classroom experience but from experiential learning; the transcendent, spiritual nature of medicine is found in the crevices of daily practice, and spiritual care begins when we acknowledge how much patients and healthcare professionals suffer.

Framework part 5: Numinous

Numinous derives from the Latin numen and means arousing spiritual or religious emotion; mysterious or awe-inspiring.

Sources or triggers of numinous experience listed: experience, land, music, substances, religious practice, the sea, I-thou connection, meditation, and the inarticulate.

Spiritual care: ethics

Five ethical guidelines (Winslow and Wehtje-Winslow, 2007):

  1. Identify the person’s spiritual needs, resources and preferences (spiritual assessment).
  2. Follow the patient’s wishes for spiritual care.
  3. Do not prescribe spiritual practices or urge patients to relinquish religious beliefs or practices.
  4. Understand your own spirituality, but do not impose your own spiritual practices and beliefs on the patient.
  5. Proceed with integrity.

Spiritual care: definitions and provision

Two definitions (Spiritual Health Association, 2019):

  • Clinical definition: spiritual care is the provision of assessment, counselling, support and ritual in matters of a person’s beliefs, traditions, values and practices, enabling the person to access their own spiritual resources.
  • Consumer definition: spiritual care can help you feel more connected with yourself, other people or something beyond; it may involve your religious beliefs and practices or the values that are important to you; it is about supporting what gives meaning and purpose to your life.

Who provides it, in three tiers:

  • Expert spiritual care / chaplains: hospital chaplains (under $5 million and 91 chaplains, InterChurch Council); Catholic priests and volunteers; chaplains in other healthcare settings.
  • Other healthcare providers: hauora providers, and (with a question mark on the slide) counsellors, psychologists, social workers.
  • All healthcare providers: acting as spiritual care generalists, offering compassionate presence, awareness of spiritual needs (assessment) and referral.

The role of healthcare chaplaincy has changed a great deal, from being the sole providers of traditional religious ritual to being a resource to people undertaking a much wider search for meaning within the illness or dying process (Speck, 2004).

Who wants it:

  • At end of life: 69% of people (Egan et al., 2016).
  • General population: a recent Australian study found 1 in 2 (54%) people want spiritual care when in hospital, and 75% believe spiritual care should be offered in public hospitals (Spiritual Care Australia, 2021).
  • Healthcare professionals: attending to the spiritual wellbeing of healthcare professionals improves caring capacity (Ausar et al., 2021).

Spiritual care: assessment and conversation openers

General stems: “Tell me about…” and “I’m wondering about…”.

Open questions (Hospice New Zealand Spiritual Care Resources):

  • What has sustained you through hard times in the past (sources of strength)?
  • What is most important to you right now?
  • What worries you most?
  • What gives you meaning and purpose in life?
  • If you could have or achieve one thing, what would it be?
  • Who are the people who are most important to you?
  • What things or people inspire you?
  • What gives you hope?
  • What is it that keeps you going?

Single-question openers from the literature:

  • “What lifts your spirits?” (Rumbold, 2012)
  • “Are you at peace?” (Steinhauser, 2006)
  • “What role does spirituality or religion play in your life?” (Sulmasy, 2002)
  • “What do I need to know about you as a person to give you the best care possible?” (Chochinov et al., 2014)

The FICA tool

FICA is a formal spiritual history framework (Puchalski, 2006; evaluated by Borneman, Ferrell and Puchalski, 2010):

  • F, Faith, belief, meaning: distinguishes religiosity, which pertains to beliefs, behaviours, values, rules for conduct and rituals associated with a specific religious tradition or denomination (O’Brien, 1999), from spirituality, generally an individual’s attitude and beliefs related to transcendence (God) or to the nonmaterial forces of life and of nature, the dimension of a person concerned with ultimate ends and values, and meaning (O’Brien, 1982; Taylor, 2006). Sample questions: do you consider yourself spiritual or religious? Do you have spiritual beliefs that help you cope with stress? What gives your life meaning?
  • I, Importance and influence: what importance does your faith or belief have in your life? On a scale of 0 (not important) to 5 (very important), how would you rate the importance of faith or belief in your life? Have your beliefs influenced how you handle stress? What role do your beliefs play in your healthcare decision making?
  • C, Community: are you part of a spiritual or religious community? Is this of support to you and how? Is there a group of people you really love or who are important to you?
  • A, Address in care: “we have talked a lot about your spirituality and/or religious beliefs and how they may or may not be of help to you during your illness. How can your healthcare providers best support your spirituality?” How would you like your healthcare provider to use this information about your spirituality as they care for you?

The lecture’s own shorthand for FICA is: F, faith? I, importance to you? C, community to support you? A, action to be taken (if any).

Limitations

  • “We are dealing with a field of experience where there is not a single conception that can be sharply drawn” (William James, 1901).
  • “So much depends on our perspective, and on the evidence on which we draw” (Eckersley, 2004).
  • Research limitations persist across the field.

Take home messages

  • Remember the framework for understanding spiritual care in health: scope and definitions; models; evidence-informed; zeitgeist; numinous.
  • You already know a lot; build on strengths and develop your own toolbox.
  • It is important to your own wellbeing (spiritual and existential).
  • Spiritual care is important for many patients, especially in ageing and at end of life.
  • Know basic assessment approaches and refer on as necessary.
  • Further New Zealand research, policy and practice is needed.

The lecture closes with Glenn Colquhoun (2016): the spiritual life is the cheapest, most accessible and most effective medicine we have after warm houses, good food and clean hands; when we truly connect with another individual the intimacy is rewarding of itself, but if we are lucky there can also be for a moment a glimpse of the interconnectedness of all things beyond this, a sense that we are part of a larger whole, which is a healing intuition and a powerful succour for individual loss.

Self-test

  1. State the consensus definition of spirituality given by Puchalski et al. (2014).
  2. List the five elements that Egan et al. (2011) describe spirituality as potentially including.
  3. List the five components of the lecture’s conceptual framework for understanding spirituality.
  4. Describe the structure of Te Whare Tapa Whā, naming each dimension and the foundation.
  5. Describe the Fonofale model, naming its pillars, roof, floor and encompassing dimensions.
  6. Distinguish a bio-reductionist model of health from a bio-psycho-social-spiritual one, and name two whole person approaches.
  7. Explain how the Netherlands oncology guideline diagram positions spirituality relative to psycho-social and physical dimensions.
  8. What did the 2021 systematic review of healthcare definitions of spirituality find, and which two dimensions were most common?
  9. State four of the eight findings of the Balboni et al. (2022) JAMA review, including at least one on unmet need.
  10. What proportion of patients with serious illness report spirituality as important, and what proportion do not receive spiritual care?
  11. Describe how religious affiliation in New Zealand changed between 2001 and 2023.
  12. Explain what the disentwining thesis refers to and how it relates to the phrase “I’m spiritual, not religious”.
  13. Explain what is meant by “the long dying” and why it matters for spiritual care.
  14. Explain why the growth of meaninglessness is framed in this lecture as a public health issue and not only an individual one.
  15. Distinguish the clinical definition of spiritual care from the consumer definition.
  16. List the five ethical guidelines for spiritual care and explain why guideline 4 is needed.
  17. List the three tiers of spiritual care provision and state what is expected of all healthcare providers.
  18. Describe the four components of the FICA tool and give one sample question for each.
  19. Distinguish religiosity from spirituality as defined within the FICA tool.
  20. What is the meaning and derivation of “numinous”, and list three things the lecture names as sources of numinous experience?
  21. What proportion of the general population in the Australian study wanted spiritual care in hospital, and what proportion thought it should be offered in public hospitals?
  22. Describe how the role of healthcare chaplaincy has changed, according to Speck (2004).
  23. A 74 year old man with metastatic cancer says “why did this happen to me, have I been a bad person?” Describe how you would respond using conversation openers and an assessment tool from this lecture, and state what your ethical limits are.
  24. Explain how the framework’s “principle/model matters” and “evidence informed” components together justify the New Zealand policy statements quoted in the lecture.

Answers

Graph View

Backlinks