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L7 Early Professional Experience Spiritual care in clinical practice

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aliasesL7 Early Professional Experience Spiritual care in clinical practice

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Overview

This lecture introduces spiritual care as a required competency in clinical practice, using a five-part framework: definitions/scope, principles/models, evidence, the current zeitgeist around religion and spirituality, and the numinous. It then moves from theory to practice: how spiritual care is delivered clinically (screening, history-taking, assessment), the FICA tool and conversation openers, ethical guidelines, what spiritual distress and spiritual suffering look like, advance care planning, and the role of chaplains and other spiritual care resources.

Defining and Scoping Spirituality

There is no gold-standard definition of spirituality. The consensus definition used is:

“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. Spirituality is expressed through beliefs, values, traditions, and practices.” (Puchalski et al., 2014)

Spirituality is multidimensional, covering three areas:

  • Existential challenges: identity, meaning, suffering and death, guilt and shame, reconciliation and forgiveness, freedom and responsibility, hope and despair, love and joy.
  • Value-based considerations and attitudes: what matters most to the person, how spirituality shapes healthcare decisions, and their relations to self, family, friends, work, nature, art, culture, ethics and life itself.
  • Religious considerations and foundations: faith, beliefs and practices, and relationship with God or the ultimate.

“It is critical to comprehend that in care situations, it is the patient who tells us the form their own spirituality takes.” (Best et al., 2020)

The American Medical Association has mandated spiritual care as a core requirement in US medical education. It defines spirituality as meaning, purpose and connectedness, treats it as a recognised determinant of health, and expects clinicians to be able to ask, listen and assess (e.g. using FICA). Benefits include better patient care and reduced student distress, but a gap remains: many clinicians still feel unprepared and need training.

Reasons students should learn about spirituality: to understand how a patient’s spiritual beliefs may influence their healthcare decisions and health outcomes; to understand how the student’s own beliefs may influence the care they provide; and to develop the skills to assess patients’ spiritual needs, recognise spiritual distress and respond appropriately.

Why Spirituality Matters in Healthcare

Spiritual care is important for coping with chronic illness, life-threatening disease, medical crises and mental illness. It influences decision-making (e.g. avoiding burdensome or futile treatment), and is associated with improved quality of life, hope, optimism, gratefulness and emotional wellbeing, as well as improved relationships between patient, whānau and healthcare providers.

Evidence base:

  • A Canadian review analysed 151 articles (128 relevant) and found that religion and spirituality do influence health behaviours and wellbeing, though more gender- and ethnicity-based research is needed.
  • The NERSH data pool (six new surveys, N=1,068, complete pool of 7,323 observations: 4,070 female, 3,253 male) found most physicians (83%, N=3,700) believed religion/spirituality had “some” influence on patients’ health (95% CI 81.8-84.2%). Conclusion: health professionals believe religion/spirituality is important for patient health but lack formal training in it.

Policy impact in New Zealand: spiritual health (taha wairua) is recognised as a key component of health and wellbeing (Durie 1985; Capstick et al. 2009; Ministry of Health 2001). Most people affected by cancer have spiritual care needs, particularly at end of life but also across the wider cancer continuum.

Ministry of Health guidance: "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 go about contacting spiritual caregivers when required. Training specific to the cultural and spiritual needs of Māori is essential." (MOH, 2010)

Frameworks for Whole-Person Care

The model of health and healthcare used matters. Whole-person principles and approaches include holism, Total Care, Te Whare Tapa Whā and Fonofale, contrasted against a narrow biomedical-only model. Te Whare Tapa Whā has four dimensions: taha wairua (spiritual), taha hinengaro (mental and emotional), taha tinana (physical) and taha whānau (family and social), all resting on whenua (land) as the foundation.

In the MBChB, spirituality features in: the bio-psycho-social-spiritual model of care (EPE3 Unit 1); student health, wellbeing and hauora; Hauora Māori (Te Whare Tapa Whā and other models); Pacific Health (Fonofale and other models); palliative and end-of-life care (Total Pain); and is growing across specialities (e.g. renal) and health-sector policies. MidCentral DHB’s strategy states an aim “to be recognised as a leader in the field of spiritual care within the New Zealand health sector through a renewed understanding of spirituality as an integral part of care.”

The Changing Religious Landscape and the Numinous

The current “zeitgeist” around spirituality and religion is described as: contested; marked by low religious attendance and a rise of religious “nones”; captured by the phrase “I’m spiritual, not religious”; shaped by an ageing and increasingly multicultural New Zealand population; associated with “the long dying”; marked by spiritual plurality and democratisation; and by “ontological fragility”. Durie (1999) notes taha wairua is generally felt by Māori to be the most essential requirement for health, linked to the fourth Te Tiriti article.

One source slide (an illustrated poster on framings of spirituality) has its middle panel's text visually obscured/overlapped in the source and could not be fully transcribed; only the "exploring your creativity" and "believing in something bigger than yourself" panels were legible.

An oncologist’s reflection captures the numinous quality of clinical work: “The transcendent, spiritual nature of medicine is found in the crevices of daily practice. The spiritual nature of medical care begins when we acknowledge how much patients and healthcare professionals suffer.” (Sedhom, 2020)

The numinous derives from the Latin numen, meaning something “arousing spiritual or religious emotion; mysterious or awe-inspiring.” Sources of the numinous given include: experience, land, music, substances, religious practice, sea, I-thou/connection, meditation, and things that are inarticulate.

An image-only collage slide (praying hands, family on a beach, a waterfall, Earth from space, a "music is the voice of the soul" graphic, a person meditating by the sea, a Māori wharenui, and clasped hands) had no captions in the source; it appears to illustrate the sources-of-the-numinous list above, but this link is inferred from its placement rather than stated on the slide.

Viktor Frankl is quoted: “Man is not destroyed by suffering: he is destroyed by suffering without meaning.”

The Clinical Process: Screening, History-Taking, Assessment

Spiritual care follows a three-tier clinical process, paralleling general clinical assessment:

  • Spiritual screening: at initial contact, brief, a small number of questions, can be done by any trained clinician. Example prompts: “Are you at peace?”; the 2Q-SAM (“What is most important to you right now?” / “How can we help?”).
  • Spiritual history-taking: at initial contact, brief, done by the primary care provider, using structured tools such as FICA, HOPE or SPIRIT.
  • Spiritual assessment: at initial contact and with ongoing reassessment, takes longer, forms a conceptual framework for developing the care plan, and is carried out by a trained chaplain or spiritual care expert.

Assessment Tools and Conversation Openers

Simple assessment prompts cited include: “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 (Puchalski, 2006) is a formal spiritual history:

  • F: Faith, Belief, Meaning. Distinguishes religiosity (beliefs, behaviours, values, rules of conduct and rituals tied to a specific tradition) from spirituality (attitudes/beliefs about transcendence or nonmaterial forces of life and nature, and what gives ultimate meaning). Prompts: 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. Prompts: What importance does your faith/belief have in your life? On a 0-5 scale, how important is it? Have your beliefs influenced how you handle stress? What role do your beliefs play in health care decision making?
  • C: Community. Prompts: Are you part of a spiritual or religious community? Is it a source of support, and how? Is there a group of people you love or who are important to you?
  • A: Address in Care. After discussing spirituality/religious beliefs and their role in coping with illness, ask: How can your health care providers best support your spirituality? How would you like this information used in your care?

Suggested conversation openers: “Tell me about…”, “I’m wondering about…”, “I’ve noticed that…”, alongside questions such as: What has sustained you or helped you cope through hard times in the past? What is most important to you right now? What worries you most? What gives your life meaning and purpose? If you could have/achieve one thing, what would it be? Who are the people most important to you? What/who inspires you? What gives you hope, what keeps you going? (Hospice New Zealand Spiritual Care Resources)

Ethical Considerations

Five guidelines govern spiritual care (Winslow & Wehtje-Winslow, 2007):

  • Identify the person’s spiritual needs, resources and preferences (spiritual assessment).
  • Follow the patient’s wishes for spiritual care; be guided by them.
  • Do not prescribe spiritual practices or urge patients to relinquish religious beliefs or practices.
  • Understand your own spirituality, but do not impose your own spiritual practices and beliefs on the patient.
  • Proceed with integrity.

Spiritual Distress and Spiritual Suffering

Spiritual distress is suffering due to unresolved needs or questions, an inability to find meaning, purpose and hope, and an inability to express or experience spirituality. Causes/domains include:

  • Relationships: loss of role in the family, loneliness (loss of connection to self, others and/or the sacred).
  • Loss of independence: loss of identity, dependence on others, fear of being a burden.
  • Fear of death: of the dying process, what happens after death, and how loved ones will cope.
  • Loss of control: over physical and mental health and life events.
  • Loss of meaning and purpose: “why is this happening to me?”, inability to engage in meaningful activities.
  • Life situation in conflict with values or beliefs (e.g. a life-changing diagnosis, death of a child or other trauma).
  • Inability to find comfort in usual sources of strength.

Spiritual distress can also affect family/whānau members, not just the patient.

Spiritual suffering (Jaman-Mewes et al., 2025) is defined as a profound disruption in meaning, identity and connection that challenges a person’s sense of integrity and inner peace. Its characteristics: existential questioning, belief conflict, hopelessness, difficulty accepting circumstances, relational disconnection. A concept model places “spiritual suffering in the palliative care context” at the centre, connected to three components:

  1. Disruption in existential meaning: loss of meaning/significance/purpose, hopelessness, existential doubts and concerns, conflict with belief systems.
  2. Disruption in personal identity: loss of self (control, sense of usefulness), difficulty accepting the situation, with variable intensity between individuals.
  3. Deterioration of relational connection: disconnection/sense of abandonment, loss of relationships with oneself, others and/or a higher power, and unresolved emotional responses (fear, guilt, regret, anger, despair, among others).

Advance Care Planning

The Health Quality & Safety Commission’s “My advance care plan” resource (tō tātou reo / te whakamahere tiaki i mua te wā taumaha) lets a person plan the health care they want in future and at the end of life.

Chaplaincy and Spiritual Care Resources

The role of health care chaplaincy has changed from being the sole provider of traditional religious ritual to one of supporting people through life’s challenges, helping them explore ways of coping, and encouraging their search for meaning, connection and hope. It operates on a generalist-specialist model: any clinician provides generalist spiritual support, and specialist support (the chaplain) is sought for spiritual distress. The lecture included a guest segment from a hospital chaplain (Cam Boyd, Lead hospital chaplain).

Spiritual care resources identified:

  • You (the treating clinician).
  • Chaplain (inter-faith/interdenominational).
  • Te Ara Hauora (Māori Health Liaison Service).
  • Interpreter services.
  • Community resources, e.g. local kaumātua, ministers of religion, hospice spiritual care coordinator, Red Cross (refugee resettlement programme).
  • The patient’s own resources: whānau, pastor, cultural group, mentor etc.

Take-Home Messages

  • Spirituality provides meaning, purpose and connection in a person’s life; it influences values, beliefs and may influence healthcare decisions.
  • It is important for wellbeing and quality of life.
  • Spiritual assessment is the first step towards providing spiritual care.
  • Know how to identify spiritual distress and who/how to refer on.
  • Know how to provide spiritual support and access resources for spiritual care.
  • You are more than biomedical technicians.

Self-test

  1. Define spirituality using the consensus definition given in the lecture (Puchalski et al., 2014).
  2. Describe the three dimensions of the “spiritual care scope” identified in the lecture.
  3. List three reasons cited for why medical students should learn about spirituality.
  4. Describe the four dimensions of Te Whare Tapa Whā and what forms its foundation.
  5. What did the NERSH data pool study find about physicians’ beliefs regarding religion/spirituality’s influence on patient health, and what gap did it identify?
  6. Distinguish the three tiers of the clinical process for spiritual care (screening, history-taking, assessment) in terms of who performs them and their depth.
  7. List the four components of the FICA spiritual history tool and what each explores.
  8. List the five ethical guidelines for providing spiritual care.
  9. Define spiritual distress and list four of its causes.
  10. Distinguish spiritual distress from spiritual suffering as described in the lecture, including the three components of the spiritual suffering concept model.
  11. What is meant by “numinous” in this lecture, and what are examples of sources of the numinous?
  12. Describe how the role of health care chaplaincy has changed, per the lecture.
  13. List the five categories of spiritual care resources identified by the lecture.
  14. A patient with a life-changing cancer diagnosis tells you they feel disconnected from their faith and their family. Using the frameworks from this lecture, describe how you would screen, take a spiritual history, and decide when to refer to a chaplain.

Answers

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