Spiritual Care and Chaplaincy

Annex A
GUIDANCE ON SPIRITUAL CARE AND CHAPLAINCY IN THE NHS IN SCOTLAND

Introduction

1. This guidance is drawn from, and should be used in conjunction with, the attached report ¹ of the Spiritual Care Development Committee ( SCDC) on the development of Spiritual Care and Chaplaincy services within the NHS in Scotland. The SCDC is the national forum for discussion among faith communities, belief groups, healthcare staff, chaplaincy associations, the Equalities and Planning Directorate of NHS Health Scotland and the Healthcare Chaplaincy Training and Development Unit.

2. The SCDC report, which is written with a view to encouraging development in this area, is firmly based on the policy set out in HDL 76 (2002) which recognised the major changes taking place within Scottish society; described the essence and practice of spiritual care in ways which took account of such changes among people with and without any faith commitment; and signalled a significant movement in the understanding and practice of spiritual care and chaplaincy in NHS in Scotland.

3. The report commends NHS Boards on the work done to implement HDL 76 (2002) and affirms the understanding that spiritual care is a necessary and integral part of the whole person care offered by the NHS in Scotland.

4. The report identifies a number of ongoing development actions and the SCDC will continue to work with NHS Boards on these actions. The report's recommendation number is identified where appropriate in the following guidance.

Spiritual and Religious Care

5. It is widely recognised that the spiritual is a natural dimension of what it means to be human, which includes the awareness of self, of relationships with others and with creation.

6. The NHS in Scotland recognises that the health care challenges faced by the people it cares for may raise their need for spiritual or religious care and is committed to addressing these needs.

Spiritual care is usually given in a one to one relationship, is completely person centred and makes no assumptions about personal conviction or life orientation .

Religious care is given in the context of shared religious beliefs, values, liturgies and lifestyle of a faith community.

Spiritual care is not necessarily religious. Religious care should always be spiritual.

Spiritual care might be said to be the umbrella term of which religious care is a part. It is the intention of religious care to meet spiritual need.

Relationship with Healthcare

7. Among the basic spiritual needs ² that might be addressed within the normal, daily activity of healthcare are:

8. The need for spiritual care demonstrates that people are not merely physical bodies requiring mechanical fixing. People find that their spirituality helps them maintain health and cope with illnesses, traumas, losses and life transitions by integrating body, mind and spirit. People, whether religious or not, share deep existential needs and concerns as they strive to make their lives meaningful and to maintain hope when illness or injury affects their life.

Research and Evidence Base (Item 1.5 of SCDC Report)

9. Literature reviews show there to be a growing body of evidence as well as a healthy critical analysis of research in the realm of spirituality and religion. Many of the behaviours associated with faith and belief can be shown as beneficial to well-being.

NHS Boards are asked to:

• promote research which broadens and enlightens the evidence base for the efficacy of spiritual and religious care in health (Recommendation 3); and
• continue the development of professional and research documents, journals and activities, both within Scotland and, where possible in a UK context, which will enable the advancement of NHS Chaplaincy towards self or national registered health profession status (Recommendation 22).

Principles of Spiritual Care Services

10. The principles of all spiritual care services provided by the NHS are that the service should:

• be impartial and accessible to persons of all faith communities and none and facilitate spiritual and religious care of all kinds;
• function on the basis of respect for the wide range of beliefs, lifestyles and backgrounds found within the NHS and Scotland today, in particular in relation to age, gender, ethnicity, sexual orientation, disability and religion/belief;
• value such diversity;
• be a significant NHS resource in an increasingly multicultural society;
• be a unifying and encouraging presence in an NHS organisation;
• never be imposed or used to proselytise;
• be characterised by openness, sensitivity, integrity, compassion and the capacity to make and maintain attentive, helping, supportive and caring relationships;
• affirm and secure the right of patients to be visited (or not visited) by a chaplain or their faith representative by incorporating flexibility into the means of obtaining informed consent to spiritual care both at the time of admission and during a patient's time of treatment;
• be carried out in consultation with other NHS staff; and
• acknowledge that spiritual care in the NHS is given by many members of staff and by carers and patients, as well as by staff specially appointed for that purpose.

Spiritual Care Policies (Item 2.1 of SCDC Report)

11. The review indicated that all NHS Boards had produced a Spiritual Care Policy written with wide consultation among the health service and with the local community.

NHS Boards should ensure that:

• a senior lead manager for spiritual care is appointed (Recommendation 5); and
• their spiritual care policy is updated in light of local need and this guidance (Recommendation 6).

Spiritual Care Committees (Item 2.3 of SCDC Report)

12. Spiritual care committees are now established in most NHS Boards and have developed their work patterns to meet local need.

NHS Boards are asked to review the role and composition of their Spiritual Care Committee to ensure that it fulfils its primary function, of engaging with local faith communities/belief groups, thus enabling dialogue between health care staff, spiritual care providers and community groups. NHS Boards should also ensure that the work of the Committee continues and develops in the best way for each Board (Recommendation 7).

Healthcare Chaplaincy Training and Development (Item 2.5 of SCDC Report)

13. The Healthcare Chaplaincy Training and Development Unit now sits within NHS Education for Scotland ( NES) alongside the training of other healthcare professionals. Its responsibilities include the provision of spiritual care advice to the Health Directorates and the NHS in Scotland; the provision of chaplaincy training; developing a qualification in chaplaincy; the production and use of chaplaincy service standards; and creating a capability and competence framework for chaplaincy/spiritual care. The Unit's national advisory role has seen it develop strong links with chaplaincy associations throughout the UK as well as with Europe (through the European Network of Healthcare Chaplains), the USA and Canada.

NHS Boards are asked to encourage:

• inter-professional educational initiatives to enable a wider understanding of the context and meaning of Spiritual Care and its relationship to Health among all healthcare staff (Recommendation 2);
• education on equality legislation and promote a service which delivers spiritual care equitably to people of any or no declared faith community or belief group (Recommendation 4);
• use of the Chaplaincy Capability and Competency Framework ³ in professional and personal development in relation to the Knowledge and Skills Framework (Recommendation 17).

Standards for Chaplaincy Services (Item 3 of SCDC Report)

14. The " NHS Standards for Chaplaincy Services" ⁴ document describes the seven main areas in which a spiritual care service is expected to operate. The document includes a rationale, a set of criteria by which a chaplaincy service could be described and self assessment questions.

NHS Boards should use the series of self assessment questions contained within the Standards as the audit tool for the review of the Spiritual Care Service within their area (Recommendation 10).

The Appointment and Employment of Chaplains (Item 4 of SCDC Report)

15. The integration of spiritual care within NHS Boards' responsibilities has provided an impetus for change. In the past the initiative for chaplaincy appointments came largely from the faith communities and the Boards enabled this to happen. The responsibility for a spiritual care service now lies within the NHS. The present chaplaincy and spiritual care workforce is populated by several categories including: whole-time Chaplains; part-time Chaplains; Denominational or Faith Specific Chaplains; Sessional Chaplains; Honorary Chaplains; Volunteers; and Healthcare Staff. Partnership between Boards and local faith communities and belief groups is therefore essential.

• NHS Boards should ensure that the spiritual care/chaplaincy service is resourced, in human, financial, accommodation and support terms, to provide the necessary service throughout the year on a twenty four hour basis. Where this level of service is not currently provided an action plan showing how and when this will be achieved should be developed. (Recommendation 21).

NHS Boards should :

• use business plans, cost benefit analysis and other relevant factors to determine the complement of spiritual care staff, ie not just the size of the unit or the number of beds (Recommendation 11);
• employ Spiritual Care Staff for their qualifications and pastoral abilities. Having or obtaining the new Certificate in Healthcare Chaplaincy, once established, should be a requirement for all new appointments (Recommendation 12);
• use an appropriate chaplain as a professional assessor when employing
  whole-time chaplains (Recommendation 14);
• require chaplaincy staff to work with the whole healthcare community,
  patients, carers and staff, providing spiritual care for all and either providing
  or facilitating the appropriate religious care for those requiring it (Recommendation 12);
• wherever necessary and practicable develop a system of honorary chaplains or faith/belief group representatives to respond to the religious or spiritual need specific faith community/belief group (Recommendation 15);
• consider appointing a paid chaplain on a denominational or single faith basis where a needs analysis shows that numbers and needs of a faith/belief community would justify such an appointment and they are not represented by an employee on the spiritual care team. Any chaplain working in this way would require the direct authorisation of the faith/belief community, but would also be accountable within the NHS to the Head of the Department of Spiritual Care at the Board (Recommendation 13);
• encourage chaplains within their spiritual care team to:
  
  a. maintain their good standing with the faith community or belief group in which they have roots;
  
  b. work harmoniously with those of the wide variety of faith and belief groups within Scottish society;
  
  c. play a meaningful part in chaplaincy professional associations;
  
  d. participate in continuous professional development through attendance at study days, conferences;
  
  e. support the development of relevant research, courses and qualifications for spiritual care staff, volunteers and other interested staff, and the use of reflective practice and pastoral supervision (Recommendations 8, 9 and 16); and

• encourage co operation with other Allied Health Professions and to work as members of the multi professional healthcare team whenever possible (Recommendation 23).

Spiritual Care in the Community (Item 6 of SCDC report)

16. The majority of healthcare takes place in the community. Therefore, spiritual care must find its place in settings other than hospitals. This is perhaps most clearly seen in mental health services where fewer people require in-patient care. Consequently, several mental health chaplains are working in day centres and in the community as well as in their local hospital. This will increasingly be the norm as Community Health Partnerships become major providers of health care.

17. There is also interest in some GP practices in implementing better spiritual care through using the resources and partnership of local faith/belief communities. There needs to be close partnership between chaplains based in the community and those based in acute in-patient units. Such care must be exercised in as seamless a way as is possible.

NHS Boards are therefore encouraged to develop new ways of providing spiritual care to health service users in community settings (Recommendation 19).

Data Protection and Patients Confidentiality (Item 10 0f SCDC Report)

18. The NHS in Scotland is committed to providing spiritual and religious care to patients who wish it, as part of a holistic health service. In this it is in full agreement with the World Health Organisation who wrote in 1998, "Patients and physicians have begun to realise the value of "spiritual" elements such as faith, hope and compassion which emphasise the seamless connections between mind and body".

19. While patients have a right to receive appropriate spiritual care as part of their health care, they also have a right of confidentiality and data protection. NHS Boards have a duty to ensure that both of these rights are met. Achieving this balance requires good communication to improve the understanding of these issues by the healthcare staff involved throughout a patient's journey of care.

20. The legal position is that a patient's faith or belief stance is sensitive information that may only be made available to another party with informed consent.

21. However, while it is important that a patient's right to confidentiality is respected, it is also important to ensure that this does not result in a failure to provide patients with the available spiritual or religious care. In exceptional circumstances where informed consent is impossible to obtain, eg if a patient is unconscious or impaired, then the views of carers, and common sense, should prevail.

22. NHS Scotland has received supportive guidance from the UK and Scottish Information Commissioner's offices to the effect that consent to make available information as to a patient's faith or belief stance, may be given by patients either in writing or orally at any time throughout the care process. The time of admission to hospital is important, but is not always the time when a patient's broader emotional or spiritual needs are evident.

23. It is important to recognise that such consent may be given by patients at any point of their health care journey and needs to be listened for rather than demanded. It may, for example be given to a chaplain through a decision to enter into conversation, providing the chaplain has indicated his or her role. What is important is that all NHS staff remain sensitive to patients' spiritual and religious needs and respond appropriately by making the necessary chaplaincy referral.

24. The needs and rights of members of faith communities/belief groups for appropriate care, often of a sacramental or religious nature, should not be underestimated and all staff should be aware of how important it is to offer to facilitate this by sensitively asking and seeking appropriate help.

25. The Healthcare Chaplaincy Training and Development Unit will make more information on this available for patients and staff through leaflets and other general information channels. Boards should also take steps, eg the use of patient experience questionnaires, to ensure that patients' spiritual and religious needs are being both properly assessed and addressed.

NHS Boards should ensure the right of patients to be visited (or not visited) by a chaplain or their faith/belief representative by incorporating flexibility into the means of obtaining informed consent to spiritual care both at the time of admission and during a patient's time of treatment (Recommendation 20).

Further Support and Assistance

26. Further advice and support on any of the issues raised in this guidance is available from Reverend Chris Levison, Chaplaincy Training and Development, NHS Education for Scotland, 3rd Floor, 2 Central Quay, 89 Hydepark Street, Glasgow G3 8BW. Email: anne.richardson@nes.scot.nhs.uk, Telephone: 0141 223 1443.

Patients and Quality Division
November 2008