Discovering meaning, purpose and hope through person centred wellbeing and spiritual care: framework

1. What is spiritual care and why is it important?

1.0.1 We all have a part of us seeking to connect and discover meaning, purpose and hope in those aspects of our experience that matter most to us. This is often referred to as “spirituality” which is present in our lives; informing our personal values and beliefs, and affirming that tears, laughter, pain, and joy are all part of the human experience.

1.0.2 It is recognised that the spiritual is a natural and integral dimension of what it means to be human. Within health and social care, it is widely accepted that questions of meaning, purpose, hope (or the lack of it), identity and relationship can become acute when wellbeing and stability are challenged or threatened by illness, injury, or loss in oneself or in a loved one. At such times people often need spiritual care^[1].

1.1 Spiritual care at the heart of person-centred care

1.1.2 The Healthcare Quality Strategy for NHS Scotland defines person-centred care as “mutually beneficial partnerships between patients, their families and those delivering healthcare services, which respect individual needs and values”[2].

1.1.3 The Scottish Government recognises that spiritual care is a core part of person-centred care and that:

“Spiritual care can empower and benefit both carer and cared for; nurturing the individual to celebrate and flourish during times of joy and growth, supporting people to find strength and comfort during times of transition, uncertainty, and illness”.

1.1.4 The ethos of spiritual care affirms that people are not merely physical bodies requiring mechanical fixing. Spirituality can help people maintain health and cope with illness, trauma, loss, and life transitions by integrating body, mind and spirit^[3].

1.1.5 During times of change and transition such needs can become more pronounced. Health and social care staff have a role in supporting people to recognise spiritual needs, their benefits, and in partnership, work towards meeting them, as appropriate to their role. Spirituality can be an important part of someone’s life; offering real benefits for their wellbeing and their physical and mental health^[4].

1.1.6 Spiritual needs that might be addressed within the normal, daily activity of care include:

• the need to give and receive love;
• the need to be understood;
• the need to be valued as a human being;
• the need for forgiveness, hope and trust;
• the need to explore beliefs and values;
• the need to find meaning and purpose.

1.1.7 This person-centred approach continues the trajectory of the delivery of spiritual care in Scotland for nearly 20 years. Person-centred spiritual care is consistent with, and supports, the approaches, behaviours, and attitudes of Realistic Medicine^[5].

1.1.8 The delivery of this framework is interdependent with a range of other policies and strategies. This framework should not and cannot stand alone; instead, it complements, links to, and supports the broader health and social care aims of the Scottish Government.

1.2 Why are we taking action now?

1.2.1 The Scottish Government is committed to the delivery of the highest quality of care which takes into consideration what matters most to the individual (including personal values and deeply held beliefs)^[6] and those who matter most and who give support in difficult and challenging times.

1.2.2 The framework reflects the considerable developments resulting from the increased professionalism in spiritual care over the last twenty years and firmly establishes the role of spiritual care as an integral part of health and social care provision.

1.2.3 Within healthcare settings, the delivery of spiritual care has been an aspect of care since the NHS was established. While spiritual care is provided in some social care settings it is not universal. It is recognised that health and social care (including service provision within inpatient hospital care and community health care) are starting from very different places in relation to the provision of spiritual care.

1.2.4 There has been limited strategic oversight in the spiritual care setting for some time. With the launch of this national framework, the Scottish Government and those involved in its creation have:

• articulated shared, national priorities for the next five years;
• shared best practice;
• set out a pathway for improving services equitably across Scotland over the coming years;
• set out our ambition to be a world leader in spiritual care delivery.

1.2.5 The Scottish Government set up a National Programme Board (NPB) and established Expert Working Groups on key topics within spiritual care. Through the expertise of those involved, specific recommendations were developed in four key settings:

• A skilled and compassionate workforce
• The development of spiritual care in community and social care settings
• Data Collection and Evidence Base
• A professional specialist workforce

1.2.6 The recommendations within this document flow from the discussions and findings of these expert working groups and the NPB. Recommendations are set out in text boxes throughout the document and at Appendix A. Responsibility for their implementation is shared between the Scottish Government, local and national health boards, health and social care providers and the Scottish Spiritual Care Professional Leads Group.

1.3 Language

1.3.1 Language and the words we use can have a powerful impact. Within care settings we have historically spoken about “chaplains” and ”chaplaincy”. Such descriptions have close associations with traditional religious models of care. Within this framework, we have used the term Registered Chaplain to reflect the post (and our aspirations for the profession) and used Spiritual Care Teams and Departments of Spiritual Care to describe service provision.

1.4 Good Spiritual Care in Practice

1.4.1 The responsibility for ensuring service delivery of spiritual care lies with health and social care providers. The provision of specialist spiritual care remains a core task of Spiritual Care Teams. In NHSScotland, Registered Chaplains are employed as specialists in providing spiritual care, although in some settings they may be known as Spiritual Care Providers. However, it is widely recognised that it is the responsibility of all health and social care staff to understand, recognise and meet the spiritual needs of individuals, including their own needs.

1.5 Delivering Spiritual Care

1.5.1 Spiritual care can be delivered in many ways. This section sets out what a core spiritual care service should cover, and how it could operate based on current best practice models from Scotland and internationally.

1.5.2 Spiritual care can be given in one to one or group settings, is person-centred and makes no assumptions about personal conviction or life orientation. It achieves its goals through:

• offering a safe space in which individuals and their needs are regarded as central and characterised by an equitable, respectful, and non-judgemental relationship;
• taking a person-centred rather than staff or system-centred care approach;
• eliciting and honouring an individual’s story;
• accompanying an individual further into pain, darkness, uncertainty or unknowing;
• holding the possibility of other ways of seeing or understanding, without imposing personal views or frameworks.

1.6 Access to spiritual care services

1.6.1 Access to specialist spiritual care services requires good written material with clear verbal back up, and a process for ensuring that information concerning the nature of the service is given to service users at the right time. This needs to take place not only during the admission procedure, or on first accessing care, but also regularly reviewed with the individual during their on-going care.

1.6.2 Staff should ensure that questions about values and faith are asked in line with good practice outlined in “What matters to you”^[7]. For example, it may be more appropriate to ask a person their understanding of their situation, before asking directly if they have specific views, beliefs or religious needs which may impact their care.

1.6.3 When service users indicate or formally record a religious faith or belief preference, it is important to ask if they wish the information to be passed to a representative from their belief community. Spiritual Care Teams should provide advice and facilitate this activity where appropriate.

Recommendation 1: Health and social care providers should ensure that spiritual aspects of care are assessed, recorded and regularly reviewed within care plans in all health and care settings and services.

1.6.4 Spiritual distress can occur at any time; when a person’s situation changes, challenges become more pronounced or when individuals experience a sense of loss of hopelessness. Service providers should consider how spiritual care services can be accessed on a 24/7 basis. Acute settings should ensure that spiritual care services are resourced, in human, financial, and support terms, to enable the provision of a 24/7 service^[8].

Recommendation 2: NHS Territorial Boards should give consideration as to how they provide a 24/7 service within acute settings. Where this level of service is not currently provided an action plan showing how and when this will be achieved should be developed.

1.6.5 In social care, it is good practice to ensure that service users at home or within community settings are informed about what spiritual care provision is available out of hours. Health and Social Care Partnerships (HSCPs) and care providers should consider how service users and care staff can access community based support models in partnership with the third sector and the belief communities.

1.7 Spiritual care as part of a Multidisciplinary Team

1.7.1 It is good practice for members of the Spiritual Care Team to be members of Multidisciplinary Teams (MDTs) and / or Multi-agency Teams to ensure that spiritual care informs an integral holistic response to the needs of individuals. There are already specialties, such as palliative care, where this is common practice, recognising the value Spiritual Care Teams bring to the work of the team and the treatment of individuals.

1.7.2 To ensure person centred care, staff should work in partnership with individuals to develop person-centred personal care plans that take into account individual circumstances, characteristics and preferences including spiritual needs. Good practice suggests that the spiritual aspects of care should be assessed and regularly reviewed.

1.8 Community Chaplaincy Listening (CCL) and Values-Based Reflective Practice (VBRP ®)

1.8.1 CCL and VBRP® have been delivered by some Spiritual Care Teams as an integral part of the spiritual care service provision for their health board areas. These services have been consistently highly evaluated by service users^[9],[10].

1.8.2 The time is right to embed both these programmes in a consistent way throughout Scotland and ensure that governance and operational management of these services is the responsibility of health boards through Heads of Spiritual Care. This will allow services to grow and develop under local leadership whilst supporting local priorities.

1.8.3 CCL is a national spiritual care initiative that promotes spiritual wellbeing by offering a listening service for people:

• who are affected by issues of loss and transition, such as grief, relationship problems, stress of work or unemployment; and
• who need someone to listen to them in confidence^[11].

1.8.4 CCL is currently delivered locally in a variety of health and social care settings. It is an assets-based intervention using spiritual listening to support people identify and draw upon personal assets that can improve their wellbeing and promote self-management.

1.8.5 Spiritual listening is distinct from, yet complementary to, those offered by counselling and psychological therapies^[12].

Recommendation 3: NHS Territorial Health Boards should establish, or maintain, Community Chaplaincy Listening as a referral based, spiritual care listening service, delivered by trained and supported volunteers and managed by Spiritual Care Teams.

Recommendation 4: Health and Social Care Partnerships and care providers should consider establishing partnerships with existing listening services and the third sector to extend listening services into community settings; working collaboratively to establish the service where not available.

1.8.6 VBRP® aims to help staff stay connected to their own values and beliefs, helping them to thrive at work and learn and grow by sharing their experiences in a safe, structured reflective space. VBRP® uses the principles of reflective practice to support practitioners deliver safe, effective, and person-centred care.

1.8.7 Building capacity and embedding VBRP® and CCL will support individuals to use personal and community assets to build resilience and enhance wellbeing. There is a need to work in partnership with third sector organisations and the belief communities to maximise available resources and avoid duplication.

Recommendation 5: The Scottish Spiritual Care Professional Leads Group in partnership with NHS Education for Scotland and Spiritual Care Teams should take a lead role in the continued development and expansion of Values Based Reflective Practice® through their learning, facilitating the learning of others and promoting Values Based Reflective Practice® across the wider health and social care system.

1.9 Bereavement Services

1.9.1 Bereavement can have a profound and long-term effect on people’s health and wellbeing. In addition to the usual difficulties associated with bereavement, the Covid-19 pandemic has left many bereaved people with unresolved issues that are having a negative impact on their wellbeing.

1.9.2 Within health settings, Spiritual Care Teams support bereavement services and are key in providing specialist spiritual support as part of end-of-life care. Spiritual care has a unique and valuable role to play in supporting staff and service users to explore a person’s values, beliefs and preferences in relation to end of life care^[13].

1.9.3 It is good practice for Spiritual Care Teams and bereavement services to be closely linked. Learning from the Covid-19 pandemic would suggest that alignment of both services would bring benefits to service users and staff within social care settings.

1.9.4 Health and social care providers should consider how staff access bereavement services to support service users and staff. In addition future work to improve spiritual care provision should recognise that Spiritual Care Teams have a significant role to play in:

• supporting the bereavement needs of individuals and families using health and social care services;
• supporting staff providing palliative and end of life care across all settings; and
• supporting staff who have been bereaved.

Recommendation 6: Health and social care providers should promote bereavement support for staff, particularly those providing palliative and end of life care across all settings.

1.10 Staff Support

1.10.1 The workforce is our most valuable resource for health and social care in Scotland. Ensuring their wellbeing whilst developing their capacity to respond appropriately to the spiritual needs of patients and service users makes good sense both fiscally, and in terms of delivering excellent care in all health and social care settings.

1.10.2 It is widely recognised that in addition to physical, emotional, and social needs; organisations and employers should ensure that the spiritual needs of staff are recognised and met. Emotional and spiritual wellbeing can be improved through formal connections such as regular meetings, supervision, and reflective practice alongside informal, social connections and listening services.

1.10.3 To look after the emotional wellbeing of staff, an organisation needs to consider the emotional labour involved and seek to understand the social and spiritual needs of individuals when at work. A holistic and coordinated approach to valuing staff includes protecting professional time to consider how we relate to others, to develop an awareness of self and our sense of our position in the wider world and supporting staff to connect with core values and beliefs^[14].

1.10.4 VBRP® offers a flexible approach to support staff to be reflective and connect with their values within the reality of their working environment / context.

1.10.5 Spiritual Care Teams have developed staff-support models, aimed at giving the right support to staff at the right time, and setting out clearly the range of support options, formal and informal, available to staff experience varying degrees of need.

1.10.6 There is growing evidence around the importance of ‘right touch’ support being given at the right time. A peer-to-peer conversation or listening support from a member of the spiritual care team, given at the right time, can help prevent the escalation of need, the development of trauma, sickness absence and psychological interventions.

1.10.7 To enhance the provision of spiritual care available to staff, it is good practice to include Spiritual Care Teams in the planning and delivery of services which aim to support staff wellbeing. In particular, Occupational Health Services, Human Resource Departments and Spiritual Care Teams should work together to provide a coordinated response and develop an agreed pathway to ensure collaboration services and prevent duplication.

Recommendation 7: Where established, health and social care providers should include Spiritual Care Teams in the planning and delivery of staff support to enhance the emotional and spiritual wellbeing of staff.

1.11 Critical / Major Incidents

1.11.1 Spiritual Care Teams have a significant contribution to make following a major event, incident, or disruption of service delivery. This could be a national event or a local event such as the death of a member of staff.

1.11.2 Coping with major change such as service closures, dealing with high numbers of anxious relatives or a communal need, are situations where Spiritual Care Teams can have a significant and valued role. Good practice in relation to the development of responses to critical / major incidents should recognise the unique contribution of spiritual care staff in supporting responses to such incidents as stated within the Scottish Government's “National Plan for Major Incidents with Mass Casualties”^[15].

Recommendation 8 : Health boards and agencies with responsibility for planning responses to critical / major events and local incidents should adopt good practice by ensuring Spiritual Care Teams are integral in planning for, and responding, to such events and incidents.

1.12 Equality and Diversity

1.12.1 All staff should promote equality, diversity and contribute to creating inclusive workplace cultures for staff and those using services and take a rights-based and person-centred approach.

1.12.2 The Scottish Government recognises the importance of an individual’s beliefs and values. The role of spiritual care and spiritual care spaces / quiet rooms / sanctuaries should be available equally regardless of any particular characteristics or beliefs individuals, family or carers may have.

1.13 Volunteers

1.13.1 Volunteering to support the work of spiritual care departments is an important way of harnessing the energy, experience, and commitment of those who feel they have much to offer. Whilst volunteers cannot, and should not, replace professional staff, Spiritual Care Teams and service-users have benefitted hugely from the pastoral contribution of volunteers.

1.13.2 CCL has its own formational training programme for volunteers, which is standard throughout Scotland. However, other volunteers in Spiritual Care Teams are trained in a variety of ways and to a variety of standards. Good practice suggests the development of a national approach to the training and formation of spiritual care volunteers. Such an approach is a key component of the NHS Scotland Volunteering Programme Strategy^[16].

Recommendation 9: The Scottish Spiritual Care Professional Leads Group should explore the development of a national approach to training for spiritual care volunteers with the NHSScotland Volunteering Advisory Board.

1.14 Belief Communities

1.14.1 Religion and culture can be central to a person's wellbeing and have a direct impact on their needs, care, and ability to cope. At times of transition, such as illness or a change in circumstances individuals may require additional support and care. Individuals may receive comfort and benefit from practicing their faith, and having their religious and cultural needs recognised, respected, and met.

1.14.2 Scotland has many vibrant belief communities. The needs and rights of members of belief communities for appropriate care (such as ritual, sacramental care or meditation), should not be underestimated. Health and social care staff should be aware of the importance in facilitating this by sensitively asking service users and seeking appropriate help.

1.14.3 It is important to recognise the role of representatives from belief communities in supporting the spiritual, religious and pastoral needs of service users. Often these are unique pastoral relationships which have been established over many years. As such representatives from belief communities may be best placed to offer religious or pastoral care.

1.14.4 However, representatives from belief communities (e.g. members of the clergy, celebrants etc) are not members of staff and service providers should not share information about an individual without explicit consent.

1.14.5 Consent to make available information relating to a patient’s or service user’s faith or belief stance, may be given, either in writing or orally, at any time throughout the care process. In exceptional circumstances where informed consent is impossible to obtain, (e.g. if a patient or service user is unconscious or unable to give consent ) then the views of carers, family and staff should be sought, and common sense should prevail.

Recommendation 10: Health and social care providers should engage with local belief communities, to enable dialogue between staff, spiritual care providers and community groups.