Spirituality in Primary Palliative Care and Beyond: A 20-Year Longitudinal Qualitative Study of Interacting Factors Impacting Physicians' Spiritual Care Provision Over Time.

CONTEXT: Spiritual care (SC) is central to palliative care. However, a mismatch between patients' desire for SC and physicians' SC provision remains. The shortage of specialty-trained palliative physicians, necessitates that all physicians provide primary palliative care, including SC. Although several quantitative studies explore physicians' barriers to SC, few qualitative studies and no longitudinal studies exist. OBJECTIVE: To gain in-depth understanding of factors influencing physicians' ability to provide SC over time. METHODS: A 20-year longitudinal, individual interview study. In study year-1, we interviewed all residents in a USA primary care residency (full study-group) regarding SC beliefs, experiences and skills. The longitudinal study-group (PGY1 subgroup) was interviewed again in study-years 3, 11, and 20. Interviews were audio-recorded and transcribed. Four researchers analyzed transcripts using a grounded theory approach. IRB approval was obtained. RESULTS: We analyzed 66 interviews from 34 physicians. Physicians had diverse personal spiritual beliefs. Seven themes emerged from both groups (response rate 89%): patients' needs; practice setting; beliefs regarding physician's role; personal spiritual beliefs; SC training; life experiences (professional, personal); self-care and reflection. Longitudinal interviews revealed thematic evolution and interactions over 20-years: patients' needs and physicians' belief in whole-person care remained primary motivators; cross-cultural SC communication training diminished impact of personal spiritual beliefs and worries; life experiences enhanced SC skills; work environment helped or hindered SC provision; and spiritual self-care/reflection fostered patient-centered, compassionate SC. CONCLUSION: Facilitating SC provision by nonpalliative care specialists is complex and may require both individual and systems level interventions fostering motivation, SC skill development, and supportive work environments.

A 10-Year Longitudinal Study of Effects of a Multifaceted Residency Spiritual Care Curriculum: Clinical Ability, Professional Formation, End of Life, and Culture.

CONTEXT: Although spiritual care (SC) is recognized as important in whole-person medicine, physicians infrequently address patients' spiritual needs, citing lack of training. Although many SC curricula descriptions exist, few studies report effects on physicians. OBJECTIVES: To broadly examine immediate and long-term effects of a required, longitudinal, residency SC curriculum, which emphasized inclusive patient-centered SC, compassion, and spiritual self-care. METHODS: We conducted in-depth individual interviews with 26 physicians (13 intervention; 13 comparison) trained at a 13-13-13 residency. We interviewed intervention physicians three times over 10 years-1) preintervention, as PGY1s, 2) postintervention, as PGY3s, 3) eight-year postintervention, as practicing physicians. We interviewed comparison physicians as PGY3s. Interviews were audio-recorded, transcribed, and analyzed by four researchers. RESULTS: Forty-nine interviews were analyzed. General: Both groups were diverse regarding personal importance of spirituality/religion. All physicians endorsed the value of SC, sharing rich patient stories particularly related to end of life and cultural diversity. Curricular effects: 1) skills/barriers-intervention physicians demonstrated progressive improvements in clinical approach, accompanied by diminishing worries related to SC. PGY3 comparison physicians struggled with SC skills and worries more than PGY3 intervention physicians, 2) physician formation-most physicians described residency as profoundly challenging and transformative. Even after eight years, many intervention physicians noted that reflection on their diverse beliefs and values in safety, coupled with compassion shown to them through this curriculum, had deeply positive effects. High impact training: patient-centered spiritual assessment; chaplain rounds; spiritual self-care workshop/retreats; multicultural SC framework. CONCLUSION: A longitudinal, multifaceted residency SC curriculum can have lasting positive effects on physicians' SC skills and their professional/personal formation.

A qualitative study of physicians' views on compassionate patient care and spirituality: medicine as a spiritual practice?

BACKGROUND: Compassion and compassion fatigue are discussed in the medical literature. However, few studies address physicians and none examine physicians' spiritual beliefs related to their provision of compassionate care. METHODS: This in-depth, qualitative interview study explores practicing physicians' views regarding the relationship between compassion and spirituality in medical practice. Interviews were audiotaped, transcribed verbatim and analyzed using the immersion/crystallization method. RESULTS: Despite diversity of personal spiritual beliefs, all study physicians felt compassion was "essential for a physician." Most linked compassion to underlying spiritual values (religious and secular). Many physicians saw medicine as providing opportunities for them to grow in compassion, essentially employing medicine as a spiritual discipline. Significant barriers to compassionate care included time pressures and values of the current culture of medicine. Facilitators included time for self-care. CONCLUSION: Physicians value compassion, linking it to spiritual values and self-care, but identify challenges in daily practice. Further study is needed to explore how to support physicians' provision of compassionate care and prevent burnout.

Spirituality and coping with chronic disease in pediatrics.

Chronic illnesses represent a growing burden of disease among children and adolescents, making it imperative to understand the factors that affect coping and medical adherence in this population. Spirituality has been identified as an important factor in the overall health and wellbeing of pediatric patients; however, in this regard, most studies have focused on pediatric palliative and end-of-life care. This article reviews childhood spirituality related to chronic disease coping. The existing literature, though sparse, reveals that children have a rich and complex spiritual life; one which often goes beyond religiosity to examine purpose in the context of illness. Studies suggest that spiritual beliefs have the potential to support as well as hinder children's ability to cope with chronic illness. More research is needed to better understand and meet the spiritual needs of children with chronic illnesses.

The role of spirituality in diabetes self-management in an urban, underserved population: a qualitative exploratory study.

BACKGROUND: Although many studies examine motivators for diabetes self-management, few explore the role spirituality plays in this disease, especially in low-income urban populations. METHODS: This qualitative, focus group study elicits thoughts of diabetic patients regarding spirituality in diabetes self-care, at an urban primary care practice in Rhode Island. Focus group discussions were audiotaped, transcribed verbatim, and analyzed using the immersion/crystallization technique. RESULTS: Themes included: significant impact of diabetes on daily life; fear and family as prominent self-care motivators; relationships with self, others, nature and the divine as major sources of hope and strength. Patients varied considerably regarding the role spirituality played in their illness, ranging from minimal to profound impact. All appeared comfortable discussing spirituality within the context of strength and hope. CONCLUSION: Patients in this urban, underserved population are willing to discuss spirituality related to their diabetes care. They vary in the role spirituality plays in their illness experience.

Toward competency-based curricula in patient-centered spiritual care: recommended competencies for family medicine resident education.

Spiritual care is increasingly recognized as an important component of medical care. Although many primary care residency programs incorporate spiritual care into their curricula, there are currently no consensus guidelines regarding core competencies necessary for primary care training. In 2006, the Society of Teachers of Family Medicine's Interest Group on Spirituality undertook a three-year initiative to address this need. The project leader assembled a diverse panel of eight educators with dual expertise in (1) spirituality and health and (2) family medicine. The multidisciplinary panel members represented different geographic regions and diverse faith traditions and were nationally recognized senior faculty. They underwent three rounds of a modified Delphi technique to achieve initial consensus regarding spiritual care competencies (SCCs) tailored for family medicine residency training, followed by an iterative process of external validation, feedback, and consensus modifications of the SCCs. Panel members identified six knowledge, nine skills, and four attitude core SCCs for use in training and linked these to competencies of the Accreditation Council for Graduate Medical Education. They identified three global competencies for use in promotion and graduation criteria. Defining core competencies in spiritual care clarifies training goals and provides the basis for robust curricula evaluation. Given the breadth of family medicine, these competencies may be adaptable to other primary care fields, to medical and surgical specialties, and to medical student education. Effective training in this area may enhance physicians' ability to attend to the physical, mental, and spiritual needs of patients and better maintain sustainable healing relationships.

The 3 H and BMSEST models for spirituality in multicultural whole-person medicine.

PURPOSE: The explosion of evidence in the last decade supporting the role of spirituality in whole-person patient care has prompted proposals for a move to a biopsychosocial-spiritual model for health. Making this paradigm shift in today's multicultural societies poses many challenges, however. This article presents 2 theoretical models that provide common ground for further exploration of the role of spirituality in medicine. METHODS: The 3 H model (head, heart, hands) and the BMSEST models (body, mind, spirit, environment, social, transcendent) evolved from the author's 12-year experience with curricula development regarding spirituality and medicine, 16-year experience as an attending family physician and educator, lived experience with both Hinduism and Christianity since childhood, and a lifetime study of the world's great spiritual traditions. The models were developed, tested with learners, and refined. RESULTS: The 3 H model offers a multidimensional definition of spirituality, applicable across cultures and belief systems, that provides opportunities for a common vocabulary for spirituality. Therapeutic options, from general spiritual care (compassion, presence, and the healing relationship), to specialized spiritual care (eg, by clinical chaplains), to spiritual self-care are discussed. The BMSEST model provides a conceptual framework for the role of spirituality in the larger health care context, useful for patient care, education, and research. Interactions among the 6 BMSEST components, with references to ongoing research, are proposed. CONCLUSIONS: Including spirituality in whole-person care is a way of furthering our understanding of the complexities of human health and well-being. The 3 H and BMSEST models suggest a multidimensional and multidisciplinary approach based on universal concepts and a foundation in both the art and science of medicine.

A spirituality and medicine elective for senior medical students: 4 years' experience, evaluation, and expansion to the family medicine residency.

BACKGROUND: Evidence suggests that spirituality is important in patient care and medical education, yet there are few reports of spirituality and medicine curricular evaluation. METHODS: We developed, implemented, and evaluated a 17-hour elective on spirituality and patient care for 4 consecutive years. We presented the elective to 10 fourth-year medical students (MS4s) in years one and two and to eight MS4s and 15 residents, faculty, and staff in years three and four. We evaluated knowledge and skills using pre-course and post-course questionnaires and written cases and learner satisfaction using course evaluations. RESULTS: Students' knowledge improved on the evidence about spirituality, clinical resources, role of chaplains, approaches to patient care, and recognizing spiritual distress. Reported course strengths included diversity of topics and instructors, universal principles, small-group format, case discussions, and opportunity for self-reflection. Comments reflected enhanced value in the "meaning in medicine" and "whole person care." CONCLUSIONS: Senior medical students rated the elective positively and increased their knowledge of spirituality and medicine. It was also positively received by residents, faculty, and staff and paved the way for residency curricula in this subject.