Research Commentary [14] December 2017

Dec 12, 2017

This review focuses on religious affiliation which for many people is a broad and fundamental identity marker. It is a key aspect of population diversity.  Increasingly, people born in New Zealand are identifying with non-Christian religious affiliations. For example since 2006, the number of people affiliating with the Sikh religion more than doubled; the number of people affiliating with Hinduism increased 40 percent; and; the number of people affiliating with the Muslim religion increased 28 percent (SNZ, 2013). Religious beliefs can have a critical impact on patients’ healthcare decisions. Providing  a more holistic approach, including an understanding of religious health beliefs and practices and accommodating these in interventions and treatments will lead to better health outcomes for CALD patients.   Religious beliefs may be central to a patient/families' strength and coping skills. Religio-cultural competence is becoming an increasingly important  skill as health practitioners recognise the centrality of religious and spiritual beliefs to patients/family health and end-of-life care decisions.  


Statistics New Zealand (2013). 2013 Census QuickStats about culture and identity. Wellington: SNZ. 

Commentary provided by Dr Annette Mortensen, eCALD® Services Project Manager: Research and Development 

The following articles are reviewed:

Article 1: New Zealand Nurses’ Perceptions of Spirituality and Spiritual care: Qualitative Findings from a National Survey

This is the first national survey of New Zealand nurses’ perceptions and practice of spirituality and spiritual care. Three key themes emerge from the study:

  • Whether cultivating a common understanding of spirituality can be achieved;
  • Attending to the needs of a traditionally secular, but increasingly multi-faith and multi-ethnic-society; and,
  • Creating the conditions for a spiritually supportive environment for staff and patients.

Participants’ comments suggest the need for increased familiarity around spiritual and religious issues, so that standards of appropriate practice can be openly discussed. In the context of our increasingly  multicultural and multi-faith society, the need for health practitioners to develop the cross-cultural skills, attitudes and awareness to work effectively with colleagues and clients from diverse faiths is emphasised. As one participant commented “Nurses are beautifully positioned to provide practical, effective spiritual care intervention and support...It does, however, depend upon organizational support, resource allocation and a requirement for maturity and insight on the part of the practitioner which is a lifetime journey”. 

Participant feedback highlighted  the need for the ongoing engagement of the nursing profession with up-to-date research on the state of spiritual practices in the New Zealand  population, and international understandings of the scope of spirituality and spiritual care. Of note were the increasing cultural, ethnic and religious differences of New Zealand  society. On the one hand the increasing decline in  Christian religious affiliation, and the increasing affiliations with other religions such as Sikh, Hindu and Muslim faiths.  

The authors conclude that New Zealand nurses need research-informed understandings of spirituality and spiritual care, supported by institutions and infrastructure, guided by meaningful policy, guidelines and competencies. The improved provision of resources and educational opportunities tailored to workplace settings is recommended. In this latter respect, eCALD® Services CALD cultural competency training offers  helpful courses and resources including: CALD 7: Working with Religious Diversity; Working with Religious Diversity supplementary resource; and a calendar which lists the religious  festivals celebrated by Asian, Middle Eastern, Latin American and African cultures.

Authors: Egan, R., Llewellyn, R., Cox, B., MacLeod, R., McSherry, W. & Austin, P.

Citation: Egan, R., Llewellyn, R., Cox, B., MacLeod, R., McSherry, W. & Austin, P. (2017). New Zealand Nurses’ Perceptions of Spirituality and Spiritual care: Qualitative Findings from a National Survey. Religions, 8 (79). doi:10.3390/rel8050079.  


Article 2: Integrating Spirituality as a Key Component of Patient Care

Growing evidence demonstrates that spirituality is important in patient care. Yet healthcare professionals (HCPs) do not always feel prepared to engage with patients about spiritual issues. In this study of palliative and older peoples inpatient care settings, health care practitioners (HCPs) attended an educational session focused on using the FICA (Faith, Importance, Community, Address) Spiritual History Tool to integrate spirituality into patient care. The FICA includes questions that help to identify the presence of faith, belief, or meaning; the Importance of spirituality in relation to a patient's life and healthcare decision-making, their spiritual community; and explores interventions that may be helpful in addressing the patient’s spiritual needs. It also offers a flexible interview guide to help HCPs engage in conversations and to invite patients to share their spiritual beliefs and concerns in relation to their illness experience. HCPs later incorporated the tool when caring for patients participating in the study. The findings of the study indicated the positive impacts at organizational, clinical/unit, professional/personal and patient levels when HCPs included spirituality in patient care. 

In the study, the incorporation of spirituality at a unit level was accomplished by integrating the tool into routine professional practice.This was found to be helpful in initiating and guiding spiritual conversations. HCPs stated that they needed more education and greater support to more competently, attend to the spiritual dimension of patient care. Practitioners identified the need for education which included opportunities to (1) enhance self-awareness; (2) improve the ability to differentiate patient distress from their own spiritual discomfort; (3) develop competencies and skills in spiritual history taking, interviewing and interventions; (4) explore ways to adhere to professional boundaries; and (5) practice responding to and reflecting on spiritual issues using a team-based, collaborative approach. (As mentioned in the commentary on Egan et al., 2017 eCALD services CALD Cultural competency training offers online and face to face  courses for health professionals on Working with Religious Diversity). 

Authors: Brémault-Phillip, S., Olson, J., Brett-MacLean, P., Oneschuk, D., Sinclair, S., Magnus, R., Weis, J.Abbasi, M., Parmar, J. & Puchalski, C.M. 

Citation: Brémault-Phillip, S., Olson, J., Brett-MacLean, P., Oneschuk, D., Sinclair, S., Magnus, R., Weis, J.Abbasi, M., Parmar, J. & Puchalski, C.M. (2015). Integrating Spirituality as a Key Component of Patient Care. Religions, 6, 476–498; doi:10.3390/rel6020476.  


Article 3: A knowledge synthesis of culturally- and spiritually-sensitive end-of-life care: findings from a scoping review

Multiple factors influence the end-of-life (EoL) care and experience of poor quality services by culturally and spiritually-diverse groups. Access to EoL services e.g. health and social supports at home or in hospices is difficult for ethnic minorities compared to European groups. This scoping review was undertaken by the Canadian Virtual Hospice identified barriers and enablers at the systems, community and personal/family levels. Primary barriers included: cultural differences between healthcare providers; persons approaching EoL and family members; under-utilization of culturally-sensitive models designed to improve EoL care; language barriers; lack of awareness of cultural and religious diversity issues; exclusion of families in the decision-making process; personal racial and religious discrimination; and lack of culturally-tailored EoL information to facilitate decision-making. Most research has focused on decision-making and few studies have explored  different cultural and spiritual experiences at the EoL and interventions to improve EoL care. The interventions evaluated were largely educational rather than service oriented. 

Examining educational interventions, of interest, is the finding that cultural competence scores were significantly higher for providers who had experienced specific EoL educational cultural competency training programs and in  particular those who had accessed  online training. For example, findings from one study found that web-based educational interventions to improve cross-cultural communication concerning EoL issues were useful for hospice workers as they introduced culturally-sensitive ways to assess situations and communication strategies with culturally- and spiritually diverse groups at the EoL through online scenarios. As we have found in feedback from participants in CALD cultural competency training, online delivery methods were reported as convenient, user-friendly and interactive. 

Other useful interventions were culturally-tailored material for family members and older persons approaching EoL. Culturally-tailored print and online resources (e.g. in diverse languages) that presented knowledge about EoL care were effective for EoL planning and decision-making. Although the use of cross-cultural workers was found to be more effective than providing written materials.  

The study noted that practice-based interventions were not in evidence in the literature; creating a gap in knowledge regarding good practice in home, hospital and hospice settings. The authors concluded that there is a need for guidelines and recommendations and quality frameworks to evaluate the effectiveness of cultural and spiritual care practices in EOL care.

Authors: Fang, M.L., Sixsmith, J., Sinclair, S. & Horst, G.

Citation: Fang, M.L., Sixsmith, J., Sinclair, S. & Horst, G. (2016). A knowledge synthesis of culturally- and spiritually-sensitive end-of-life care: findings from a scoping review. BMC Geriatrics, 16, (107). DOI 10.1186/s12877-016-0282-6. 


Article 4: Socioexistential mindfulness: Bringing empathy and compassion into health care practice

This article highlights a less common dimension of mindfulness, namely, the socioexistential dimension which enhances health practitioner/patient interactions by strengthening empathy and compassion. Being a health professional is stressful and demanding work. Providing health care and support for patients/families can be demanding, frustrating, overwhelming and painful. Mindfulness can be used for self-care and stress-management. In this sense mindfulness can counteract the effects of health practitioner burn-out.  

A mindful health professional is an empathic and compassionate presence who maintains  an authentic relationship with the patient/family and a secure base for treatment. In this respect, a mindful health professional has the strength and wisdom to avoid a relationship with their patients which is based on apathy, antipathy, over-identification or sympathy. As the authors say it is clinically useful for health professionals to take a dose of mindfulness to support them in their often stressful and demanding work. 

Author: Nilsson, H.

Citation: Nilsson, H. (2016). Socioexistential mindfulness: Bringing empathy and compassion into health care practice. Spirituality in Clinical Practice, 3(1), 22-31.


Article 5: Improving the spiritual dimension of whole person care: reaching national and international consensus

Two conferences, Creating More Compassionate Systems of Care (November 2012) and On Improving the Spiritual Dimension of Whole Person Care: The Transformational Role of Compassion, Love and Forgiveness in Health Care (January 2013), were convened in the USA with the goals of reaching consensus on approaches to the integration of spirituality into health care structures at all levels and development of strategies to create more compassionate systems of care. The 2013 conference produced a set of standards and recommended strategies for integrating spiritual care across the entire health care continuum, not just palliative care. Deliberations were based on evidence that spiritual care is a fundamental component of high-quality compassionate health care and it is most effective when it is recognized and reflected in the attitudes and actions of both patients and health care providers. The conference defined ‘‘Spirituality as 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.’’ 

The recommendations included: 

  • Developing competency standards, that address the attitudes, skills, and behaviors that facilitate achievement of consensus-based standards of care. 
  • Creating curricula that cover the definitions of spiritual care, self-awareness, cultural sensitivity, and assessment and skills 

Health care organizations can be thought of as communities as well as part of the communities they serve. A community engagement action plan should focus on understanding the demographic and cultural aspects of the communities that establish the foundation for implementing compassionate spiritual care. Plans should address the needs and sensitivities of the community and recognize the cultural, familial, and community compassionate care assets. There are lessons here for planning compassionate care for all the diverse communities settled in New Zealand. 

Authors: Puchalski, C.M., Vitillo, R., Hull, S.K. & Reller, N.

Citation: Puchalski, C.M., Vitillo, R., Hull, S.K. & Reller, N. (2014) Improving the spiritual dimension of whole person care: reaching national and international consensus. J Palliat Med,17 (6), 64256.