Spiritual Care and Chaplaincy

1. Purpose

This report is written to describe the present situation, with a view to providing guidance on ongoing developments, in the area of spiritual care and chaplaincy in NHSScotland. It is firmly based on the understandings and changes put forward in the previous guidance contained in HDL(2002)76 'Spiritual Care in NHSScotland' (attached as Appendix 1).

1.1 Context

HDL(2002)76 signalled a significant movement in the understanding and practice of spiritual care and chaplaincy. It recognised some of the major changes that had been taking place within Scottish society, and it described the essence and practice of spiritual care in ways which took account of such changes among people with and without any faith commitment. There are many who believe who do not belong to a particular faith or belief group; hence, for example the discrepancy between those who self nominate as Christian (around two thirds according to the census of 2001) and the much smaller number who regularly attend worship. Some might call our age 'Post Modern' but all would recognise that we have a greater variety of faith, culture and belief throughout all our social institutions than ever before. Spirituality, in the early part of 21 ^st century Scotland has many outlets.

1.2 Equality Legislation

Throughout Scotland, the United Kingdom and Europe there have been legislative changes promoting the equality of human rights for people of every background. The Equalities Act of 2006 and the bringing together of commissions to form the single Equality and Human Rights Commission have created a robust legal framework against discrimination. Discrimination on the grounds of religion or belief is an offence under the law. NHSScotland through its work on Patient Focus and Public Involvement as well as Equality and Diversity has shown the importance it places on treating people as individuals. People have a right to be respected whoever they are and holistic care must be the aim of every member of staff in NHSScotland. More detail of the legislation may be found in the NHS document "Religion and Belief Matter - An Information Resource for NHS Staff".

Recent government documents "Delivering Care, Enabling Health" (Scottish Executive, 2006) and further articulation of "The Kerr Report" in "Better Health, Better Care" (Scottish Government, 2007) have emphasised the development of a patient focussed service which both improves care and upholds the rights of individuals.

1.3 Spirituality

It is widely recognised that the spiritual is a natural dimension of what it means to be human. The awareness of self, of relationship with others and with creation, the finitude of life, the search for meaning, for the transcendent, and the need to be acknowledged, accepted, valued and loved, are all parts of this dimension. Many have reported profound experiences of wonder, joy, inner peace, transcendence and connection to nature and others, in ways they can only describe as spiritual. Many express these understandings and experiences through a belief system, by holding to a set of values, or through belonging with and participating in the life of a faith community.

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

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 express feelings honestly
The need to find meaning and purpose in life ⁵"

The broad word "spirituality" includes religion, and spiritual care includes pastoral care.

The definitions used in HDL (2002) 76 have been useful and a catalyst for much valuable discussion:

"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. "

These have shown that this agenda involves everyone, but they did not attempt to show in full the relationship between spiritual and religious care. 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.

'Pastoral care', another term commonly used, although having Christian roots, is now often used to describe the care given for the well-being of individuals and communities in a broadly spiritual context.

Those who are specialists in providing spiritual care are often known as chaplains, although in some settings they may be known as spiritual care providers. Following much discussion among faith communities and belief groups of differing type, it has been generally agreed that the word chaplain is acceptable across the spectrum. It is the duty of those who wear the title and those who work with them to ensure that the perception of their role is one of person centred care, acceptance and affirmation of those with whom they work. The remit of their work includes patients, their carers and health service staff. All health care staff are expected to provide spiritual care at an appropriate level. ( HDL (2002) 76, Par 5 refers). It is acknowledged that many, including families, carers, significant others, etc, all give care which may be termed "spiritual". NHSScotland is committed to providing or facilitating spiritual and religious care with equal commitment to any within its care.

1.4 Relationship with Health

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 strikes. Often this striving or searching leads towards deeply spiritual questions such as; "Why do I exist?", "Why is this happening to me?", "What will happen to me when I die?". Institutions that ignore the spiritual dimension in their regular provision of care increase the risk of becoming, as one commentator suggested, only "biological garages where dysfunctional human parts are repaired or replaced" (Gibbons and Miller 1989)

In recent times several health care authors have put this into words in different ways, e.g.:

"Spirituality is part of health, not peripheral but core and central to it. It pervades our every thought and action, each caring moment. Spirituality and health are bonded to each other, inseparable companions in the dance of joy and sadness, health and illness, birth and death." (Stephen Wright "Reflections on Spirituality and Healing. 2005)

"Traditional spiritual practices such as the development of empathy and compassion are being shown to be vital active ingredients, even prerequisites, in effective health care - in the carer and the cared for they build wellness and happiness. Effective and efficient health care must now (re)take into account these core values." (David Reilly in foreword to Reflections on Spirituality and Healing. 2005)

The World Health Organisation has made many statements describing the need for holistic care and the integral nature of this spiritual dimension:

"Until recently the health professions have largely followed a medical model, which seeks to treat patients by focussing on medicines and surgery, and gives less importance to beliefs and to faith. This reductionism or mechanistic view of patients as being only a material body is no longer satisfactory. Patients and physicians have begun to realise the value of elements such as faith, hope and compassion in the healing process. The value of such "spiritual" elements in health and quality of life has led to research in this field in an attempt to move towards a more holistic view of health that includes a non-material dimension, emphasising the seamless connections between mind and body." ( WHO 1998)

The Scottish Executive echoed this holistic meaning of healthcare by describing spiritual care as "an integral part of the health care offered", and that spiritual caregivers (chaplains), are "members of the professional care team" ( HDL (2002) 76 Par 20), providing in most cases a twenty four hour, seven days a week service.

"Illnesses are deeply meaningful events within people's lives, events that often challenge people to think about their lives quite differently. Spirituality sits at the heart of such experiences. A person's spirituality, whether religious or non-religious, provides belief structures and ways of coping through which people begin to rebuild and make sense of their lives in times of trauma and distress. It offers ways in which people can explain and cope with their illness experiences and in so doing discover and maintain a sense of hope, inner harmony and peacefulness in the midst of the existential challenges illness inevitably brings. These experiences are not secondary to the "real" process of clinical diagnosis and technical care. Rather they are crucial to the complex dynamics of a person's movement towards health and fullness of life even in the face of the most traumatic illness." (J. Swinton in Mark Cobb: The Hospital Chaplain's Handbook 2005).

Major societal health concerns include: long term conditions, sexual health issues, obesity, stroke, cancer and depression. Much attention is being paid to self care and rehabilitation. These are all areas in which spiritual well being, self worth, motivation and the confidence of a caring environment are of crucial importance. The health and ill health of Scottish society will be significantly affected by the quality of caring relationships both within and without the Health Service.

1.5 Research and Evidence Base

There is an increasing level of research activity concerning the positive relationship between faith/belief and health. Evidence exists which shows that the vast majority of those who have a faith/belief which is shared and enacted within a faith/belief community obtain health benefits, resulting in less stress, better sense of self worth and of meaning in life. Life years are increased, disease is better coped with and healing can be enhanced. Developments in psychoneuroimmunology show that stress, low self esteem, lack of control, lack of coherence, as well as poverty, frequently have a negative impact on people's health. (McEwan, Steptoe, Carlisle; Glasgow Centre for Population Health Lecture Series 2005-7).

In Scotland the research base has grown, including the significant 'What do chaplains do?' by Dr Harriet Mowat and Professor John Swinton and the Ethos Project led by Rev Bob Devenny. A number of chaplains have undertaken research as part of post graduate qualifications, and a course teaching methods of research in spiritual care is now established with a growing number of participants. "Religion and Belief Matter" as previously referenced also contains a summary of some research evidence. The recent study 'The Potential for Efficacy of Healthcare Chaplaincy and Spiritual Care Provision in the NHS ( UK)', again by Dr Harriet Mowat, although commissioned in England, is also relevant to the Scottish context.

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 among which there is material of varying quality.

1.6 Abiding Principles

The principles of all spiritual care services provided by the NHS remain, and include that such services 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 any chaplain;
• 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.