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Research
1Alberta Health Services,
Cancer Care, Spiritual Care
Services, Tom Baker Cancer
Centre, Calgar y Alberta, C anada
2Department of Nursing,
University of Calgary, Calgary
Alberta, Canada
3Manitoba Palliative Care
Research Unit, University
of Manitoba, Winnipeg,
Manitoba, Canada
4Division of Palliative
Medicine, Department of
Oncology, Facult y of Medicine,
University of Calgary, Calgary,
Alberta, Canada
5Department of Nursing,
University of Manitoba,
Winnipeg, Manitoba, Canada
Correspondence to
Dr Shane Sinclair,
Spiritual Care Services,
Tom Baker Cancer Centre,
1331 29 Street NW,
Calgar y, Alberta T2N 4N2
Canada; shane.sinclair@
albertahealthservices.ca
Accepted 24 April 2012
Spiritual care: how to do it
Shane Sinclair,1,3,4 Shelley Raffi n Bouchal,2 Harvey Chochinov,3 Neil Hagen,4
Susan McClement5
ABSTRACT
Objective This study explores the provision of spiritual
care by healthcare professionals working at the end of
life.
Design Qualitative–ethnographic inquiry.
Setting Phase 1: fi ve Canadian sites; phase 2: a
residential hospice in Alberta, Canada.
Participants Phase 1: six palliative care leaders; phase
2: 24 frontline palliative care clinicians.
Results Data were collected over a 12-month period
with analysis of fi ndings occurring concurrently. Using
semistructured interviews and participant observation,
11 themes, organised under fi ve overarching categories,
emerged from the data. Five bedside skills were
identifi ed as essential to spiritual care: hearing, sight,
speech, touch and presence. The integration of these
bedside skills with the intrinsic qualities of healthcare
professionals, including their values and spiritual beliefs,
appeared to be essential to their application in spiritual
care. Spiritual care primarily involved the tacit qualities
of healthcare professionals and their effect on patient’s
spiritual well-being, rather than their explicit technical
skill set or expert knowledge base.
Conclusion Participants identifi ed spiritual care as
both a specialised care domain and as a philosophy
of care that informs and is embedded within physical
and psychosocial care. Hearing, sight, speech, touch
and presence were identifi ed as the means by which
healthcare professionals impacted patients’ spiritual
well-being regardless of clinician’s awareness or intent.
An empirical framework is presented providing clinicians
with a pragmatic way of incorporating spiritual care into
clinical practice.
INTRODUCTION
Addressing the spiritual needs of patients is a core
component of comprehensive cancer and pallia-
tive care.1–3 The National Comprehensive Cancer
Network distress management and palliative care
guidelines recommend routine screening and
assessment of patients’ spiritual issues.4 5 Spiritual
care addresses issues associated with individual’s
beliefs, values, behaviour and experiences related
to ultimate meaning.6–9 Most patients, especially
those facing the end of life, want their spiritual
needs addressed by their healthcare profession-
als.10–13 The spiritual domain has been reported
to be of equal importance and, in some instances,
more important than other health domains for
patients facing a life-threatening il lness.4–18 Failing
to address patient’s spiritual needs is associated
with higher patient distress, higher health costs
and adverse clinical outcomes.9–21 These emerg-
ing concerns, and prior recommendations of the
National Consensus Project Guidelines and the
National Quality Forum Preferred Practices and
Conference proceedings, resulted in a national
consensus project on improving the quality of
spiritual care at the end of life to recommend
routine screening for spiritual distress.22 While
addressing patients’ spiritual needs has been
endorsed by professional bodies and healthcare
organisations, there is surprisingly little clinical
guidance on what constitutes spiritual care and
how clinicians might best meet these important
needs.1–5 23 –26 This study investigates the core
elements of spiritual care from the perspective of
palliative care leaders and frontline professionals
in order to provide clinical guidance on how to
integrate spiritual care into routine bedside clini-
cal care.
METHODS
Participants
This study was a part of a larger ethnographic
inquiry, exploring the spirituality of Canadian pal-
liative care professionals. The recruitment charac-
teristics of this multicentre qualitative study have
been described in detail previously.6 Briefl y, t h e
fi rst phase involved a purposive sample of six lead-
ers (19.8 average years of service in palliative care)
in palliative and hospice care at fi ve centres across
Canada. Each key leader consented to waive his or
her anonymity, allowing their expert opinions to
be acknowledged. This option was not available
to frontline staff who participated in the second
phase of the study, as individuals who wished to
remain anonymous could be more easily identi-
fi ed through a process of elimination (table 1).
In this second phase of the study, a convenience
sample of 24 frontline palliative and hospice care
professionals (7.2 average years of clinical service
in palliative care) were recruited from a hospice
in southern Alberta, Canada. This study was
approved by the Conjoint Health Research Ethics
Board of the University of Calgar y, the Ottawa
Hospital Research Ethics Board and the Fraser
Health Research Ethics Board.
Method
An ethnographic approach was used in order to
capture explicit and implicit meanings embedded
with in t he cu lture of p al liat ive car e. Semi str uct ured
inter views and participant observation were used
to gather data. A post structuralist approach to eth-
n og rap h y w as em p lo ye d i n th i s s t ud y. 27 In contrast
to classical ethnography which is rooted in real-
ism, ethnography from a poststructural perspec-
tive understands truth as contextual, dy namic and
embedded within the subjectivities of language.28 29
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Published Online First
28 August 2012
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Table 1 Participant demographic data
Participant Cohort Profession Sex Age
Years in
palliative care
Highest level of
education
Ident ify with a
religious tradition Religious tradition identifi ed
Phase 1
Michael
Kearney
Leader Physician M 52 25 MD * *
David Kuhl Leader Physician M 52 15 MD, PhD Yes Christianity, Buddhism and
Judaism
Balfou r Mount Leader Physician M 67 31 FRCS Yes United Church of Canada
John Seely Leader Physician M 68 10 MD, PhD
Mary Vachon Leader Registered Nurse/
psychotherapist
F 61 30 PhD Yes Roman Cat holic (w ith
fl e x i b i l i t y )
Jeremy Wex Leader Chaplain M 55 8 Postgraduate Yes Anglican
Phase 2
Nurse Jocelyn Frontline Registered Nurse F 25 * Undergraduate Yes Roman Catholic
Nurse Lily Front line Registered Nurse F 29 1 Undergra duate Yes Christian
Nurse Nancy Frontline Registered Nurse F 30 1 Undergraduate Yes Christian
MD Mark Frontline Physician M 54 7 MD Yes Christian
Nurse Louise Front line Registered Nurse F 54 20 Undergraduate Yes Roman Catholic
Unit Clerk
Colleen
Frontline Unit clerk F 57 1 Undergraduate
Volunt eer
Marion
Frontline Volunteer F * 1 College Yes Roman Catholic
Volunt eer
Lana
Frontline Volunteer F 57 1.5 * Yes Christian
Assistant
Anita
Frontline Resident assistant F 49 3 High School * *
Administrator
Anthony
Frontline Health
administrator
M68 15 Health
administration
Yes Sal vatio n Army
Chaplain
Connie
Frontline Chaplain F 43 1.5 Graduate Yes Protestantism
Nurse Sharon Frontline Registered Nurse F * 13 Nursing school Yes United Church o f Canada
Nurse Karen Frontline Registered Nurse F 48 5 Nursing school
Chaplain Ellen Frontline Chaplain F 52 3 Graduate Yes United Church of Canada
Cook Sandra Frontline Hospice cook F * 1.5 * Yes Christian
Assistant
Ashley
Front line Resident as sistant F * 14 High school Yes Roman Catholic
Volunt eer
Violet
Frontline Registered Nurse F 53 1 Nursing school Yes Christian
Nurse
Courtney
Frontline Registered Nurse F 32 7 * Yes Baptist
Nurse Sheila Frontline Registered Nurse F 34 1 Undergraduate Yes Roman Catholic
Assistant
Dianne
Front line Registered Nurse F 30 12 * * *
Nurse Fiona Frontline Registered Nurse F 49 2 Nursing school Yes Evangelical
Volun teer
Mary
Front line Reg ister ed Nur se F 71 24 Undergraduate Yes Roman C atholic
Nurse Luella Frontline Regis tered Nurse F 49 26 Un dergr aduat e Yes Rom an Catholic
Assistant
Bernice
Frontline Resident assistant F 63 12 High school Yes Roman Catholic
Part icipan ts included in this table were th ose who p articipated in the pa rticipant observation component of th is stud y. The names of those participants who
part icipated in a for mal recorded inter view ar e italicised.
* Indicates that these fi elds were lef t blank .
Poststructural ethnography acknowledges the researcher’s role
in the ethnographic report and controls this bias through the
presentation of verbatim data which are constantly verifi ed
through an ongoing process of member checking. Interviews,
ranging in duration from 1 to 2 h, were designed to provide a
deeper understanding of data gained through observation. An
inter view guide was constructed, and the researcher used an
open method of interv iewi ng whereby the par ticipants shared
narratives pertaining to their perspectives on spirituality and
providing spiritual care (Box 1). During the fi rst phase, each
leader was interviewed and observed in their clinical work
for about a week. Interviews were audio recorded and tran-
scribed. Field notes, containing informal discussions and par-
ticipant observation, were captured in two ways: through the
researcher audio recording his or her obser vations and t hrough
written fi eld notes in the researcher’s fi eld journal. The second
phase required the researcher to be immersed in the workings
of a local hospice for 4 months where interviews and partici-
pant observation were also conducted.
Data analyses
In ethnographic research, data collection and analysis occur
concurrently through a ‘back and forth’ process, consist-
ing of an interplay between the emic (interview data from
the perspective of an insider) and etic (participant observa-
tion data from the perspective of an outsider) perspectives.30
Poststructural ethnographers often coalesce emic and etic data
rather than treating them as two distinct data sets.27 31 In this
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Life Force or God. Participants in describing this skill often
used the image of an instrument or vessel. While this connec-
tion often tapped into their unique gifts as individuals, the
source of healing was understood as ultimately transcending
the self. The prayer of St Francis was a powerful exemplar of
th is not ion, w it h its supplication to be a n instrument of peace,
being referred to by a number of participants and displayed in
two participants’ offi ces.
Listening with humility
Intuitive listening required and cultivated humility on the
part of participants, as they located the agency of spiritual
care outside of themselves. Participants desired to be a con-
duit, but not the source of healing, refl ecting a belief that this
aspect of spiritual care could on ly be maintained in a position
of proxy.
Sight: seeing soulfully
The notion of seeing soulfully differed from mere visual per-
ception in intent and focus, as it involved participants look-
ing beyond the surface to the person’s essence and sacredness.
Seeing soulfully also involved paying attention to the aesthet-
ics within a patient’s room – the pictures adorning the walls or
greeting cards on their night table – objects providing further
insights into their patients’ inner world (box 3).
Seeing the whole person: refl ecting the person at the
centre of care
Seeing the whole person allowed participants to better deliver
care from a patient centred perspective. Field observation
se rved as a valu abl e so urce of d ata i n t hi s re gar d, as mem ber s of
the interdisciplinary palliative care team sought to understand
and refl ect back to the patient t hreads of meaning inter woven
throughout the life and their own internal healing resources
during routine care delivery. In applying this holistic lens to
their clinical practice, participants emphasised unconditional
acceptance of the patient, regardless of patients’ awareness of
their issues or their capacity to change.
study, this iterative process involved the researcher continu-
ally validating participant observation data with participants
themse lves i n order t o prod uce ‘a ‘ third dimension’ t hat rou nds
out the ethnographic picture’ (32, p.63). Comparing and vali-
dating interviews, informal discussions and participant obser-
vation allowed for member checking to occur in an ongoing
refl exive manner, enhancing the credibility and validity of the
data, while also informing subsequent data collection in the
process. At the end of each phase of the study, two formal
levels of analysis occurred.33 First, written fi eld notes, tran-
scribed audio-recorded fi eld notes and transcribed interviews
were read independent ly by the researcher (SS) and the audi-
tor (SR) line-by-line with initial codes, words or phrases that
captured the meaning of a section of text being recorded in the
margins. Transcripts were then read a second time, developing
a coding taxonomy, which developed into themes and catego-
ries that were continually refi ned and expanded as data were
collected. The researcher and auditor met on a monthly basis
to share individual analysis and themes, serving as the second
level of analysis. A consensus method of coding agreement
continued until all themes and categories were saturated, with
a fi nal level of member checking being employed when further
clarity of the raw data was needed.
RESULTS
Eleven themes, organised under fi ve overarching categories,
emerged from the interviews and participant observation data.
The fi ve categories described bedside skills essential to spiri-
tual care: hearing, sight, speech, touch and presence (table 2). The
integration of these skills with the intrinsic qualities of health-
care professionals, including their values and spiritual beliefs,
appeared to be essential to their application in spiritual care.
Hearing: listening intuitively
Participants identifi ed listening as an essential skill in effective
spiritual care. Intuitive listening was described as an enhanced
form of hearing, focusing on the subtext of a patient’s life story
as it related to his or her illness. Intuitive listening paid particu-
lar attention to the tone of the conversation, the silence bet ween
sentences and the implicit messages, allowing participants to
elicit a deeper understanding of their patient’s needs (box 2).
Instrumental listening
The capacity to listen intuitively also involved an emptying
of self in order to function as a conduit of a Higher Power,
Box 1 Semistructured interview guiding questions
Interview guiding questions
What does a typical day at work look like for you?
▶
What drew you to palliative care? ▶
Do you have a sense of fulfi lment working in palliative care? ▶
What is spirituality? ▶
Have you had what you would consider a ‘spiritual experi- ▶
ence’ in your work or life?
Describe, if any, how your own spirituality connects with
▶
patients?
Have your patients infl uenced your own spirituality; if so,
▶
how?
Table 2 The categories, themes and subthemes derived from the
study data
Category Theme
Hearing: listening intuitively • Instrumental listening
• Listening wi th humility
Sight: seeing soulfully • Seeing the whole person: refl ecting
the per son at the centre of car e
• Seeing the unse en: the di vine wi thin
Speech: taming t he tongue • Commu nicating in the l anguage of the
patient
• The danger of words
Touch: physical means of
spiritual care
• The therapeutic effec t of touch
• Embodied spiritual c are
Presence: essence of spiritual
care
• Being vulnerable
• Professional vulne rability:
relinquishing the expert model
• Personal vulnerabilit y: the precursor
of presence
• The effect of vulnerabili ty in
spiritual care
• Being presen t: spiritual reciprocity in
the clinical encounter
• The essence of being: de fi ning
presence
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than requiring patients to ascribe to the spirituality of partici-
pants. While participants brought their own spiritual beliefs
to their relationships with the dying, they sought to discover
how their own beliefs, experiences and values might be under-
stood from the patient’s vantage point, focusing on broad com-
monalities rather than differences.
The danger of words
A number of participants felt that verbal communication had
equal potential to harm in the provision of spiritual care, espe-
cially when comprised of superfi cial clichés and hollow scripts of
comfort. Participants indicated that t heir words had the potential
to stifl e the fl ow of patient driven and therapeutic conversations.
Box 2 Categories and themes: hearing: listening
intuitively
Category – hearing: listening intuitively
I’m going to go in and just listen. That already is a gift that I
have given that person. (David Kuhl)
So m uc h of it is in tuitive, I’ve learned to trust that ’s how God’s
spirit talks to me, is through my intuition. There’s that inner
knowing…It’s about knowing that God is there in the midst of
that [conversation]. (Chaplain Ellen)
Theme: instrumental listening
I very much feel like a vessel, and just to keep myself open to
being that vessel. That is really impor tant… being a vessel
gives the power to the source that it needs to be, and that’s
what I continue to hold before me. (Chaplain Ellen)
The relationship I have was defi nitely not nothing, it was defi -
nitely something that was valuable and brought some com-
fort but that also something more was needed many times.
(Michael Kearney)
I’m going to go in and just listen. That already is a gift that I
have given that person. (David Kuhl)
Not to do with me, it’s not about ego… But one day the mes-
sage was, ‘I’m sending you the people you need to see. Don’t
think there is anything special about you’…It’s about being
an instrument. I am but a channel, I am but an instrument.
(Mary Vachon)
Theme: listening with humility
When I’m with a patient, the part of me that wants to be pres-
ent is what I give without expecting gratitude. (David Kuhl)
… I never want my name on a [thank you] card… I do every-
thing to serve. Everything I do here I feel is service to others.
(Nurse Luella)
Box 3 Categories and themes: sight: seeing soulfully
Category – sight: seeing soulfully
I try and read the person. I remember a patient who, from the
treatments, she had not a square centimeter of skin left on her
body. She was totally, totally disfi gured. And she was one of
the most beautiful people.... I could look right into her and also
feel that I was totally comfortable with that disfi gured body.
(Jeremy Wex)
It (closing her eyes in therapy) is a part of my centring that
I’m just being grounded, being centred now it was obviously
beyond looking and seeing what’s going on with that person…
so I enter the space. (Mary Vachon)
We need to look at people, look at the person behind the face
of disease and illness. (John Seely)
Theme: seeing the whole person: refl ecting the person at the
centre of care
I feel really strongly about this, the fact of having respect for
one another, no matter what walk of life they come from and
what’s happening in their life. (Assistant Ashley)
At this place we are about loving people where they are at.
(Nurse Louise)
That’s something the person has to fi nd within them self …
what became more interesting to me was how to enable the
person to tap into their own resources, however one under-
stands that. (Michael Kearney)
What I’m doing is I’m taking the lead from the person I’m
working with and refl ecting their spirituality back. That’s the
best I can do. (Jeremy Wex)
You know if we don’t understand the people, we don’t know
where they’re coming from. (Volunteer Mary)
One of the characteristics of the people we care for is that
their superfi cialities have been swept away. (Balfour Mount)
Theme: seeing the unseen: the divine within
My goal was to be in contact with God within him (patient).
(MD Mark)
There is something else you can connect to… There’s a feel-
ing, that gentle feeling to a person at that particular moment,
it just happens. (Assistant Ashley)
What matters is a sense of connection in the core of your
being with something bigger than ourselves. (David Kuhl)
I think that really that there was something else possibly
another, that was caring for (them). (Assistant Ashley)
Seeing the unseen: the divine within
As described by participants, ‘seeing the unseen’ was an
attempt to discern and align with the divine within the
patient, or as some participants described, the ‘divine spark’.
In contrast to the category of hearing, which focused on tran-
scendent aspects of spirituality, sight focused on immanent
features of spirituality, embedded within the patient and t he
clinical encounter. Participants felt that their belief in a sacred
element within the patient enhanced their respect, compas-
sion and perceived dignity toward them.
Speech: taming the tongue
Reliance on verbal communication was often reported to
inhibit effective spiritual care. When words were necessary
in spiritual care, participants stressed the importance of being
brief and choosing them wisely. Participants preferred instead
to engage spiritual issues in a more experiential and subtle
manner, assessing a dying person’s sense of peace for example,
fi rst through non-verbal cues and intuition, rather than direct
verbal engagement (box 4).
Communicating in the language of the patient
Communicating spiritual care in a language most meaningful
to the patient involved a desire to understand each patient’s
spiritual background and to build from that perspective, rather
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Embodied spiritual care
Investing physical tasks with virtues of acceptance, love,
respect, dignity and compassion extended their therapeu-
tic effect to the spiritual domain. In this study, spiritual
care expressed through physical acts was evident in: a nurse
removing a mirror from a patient’s room, because it served as
a constant reminder of the toll of cachexia; a nursing assistant
massaging an achy back; and a physician laying a gentle hand
of comfort on the shoulder of a dying man. Although embod-
ied spiritual care was frequently associated with disease man-
agement, it also involved physical acts intended to enhance a
patient’s dignity and sense of self (personhood).
Presence: the essence of spiritual care
The fi fth bedside skill, presence, was the foundation upon
which the other four categories were grounded. Presence was
seen as the outward radiance of an individual’s essence or
soul. Presence was not based on technical competence, spiri-
tual awareness or self-assessed spirituality, but the expres-
sion of clinicians’ character, beliefs, behaviour and giftedness
within their clinical practice. Participants believed that pres-
ence was an innate aspect of humanity, experienced relation-
ally in terms of ‘being with’ rather than ‘doing for’. The effect
Touch: physical means of spiritual care
Clinicians recognised touch as an essential bedside skill in the
provision of spiritual care. This included empathetic touch:
holding a patient’s hand or a gentle hand of reassurance on a
patient’s shoulder, for example. Physical care often established
a natural foundation of intimacy and trust for conversations
that were more spiritual in nature to transpire (box 5).
The therapeutic effect of touch
Although spiritual care was primarily associated with non-
tactile bedside skills, the manner in which physical care was
prov ided was felt to have a n effect that extended well beyond
the patient’s body, modifying the patient’s spiritual well-be-
ing. Participant obser vation served as a valuable source of data
in this respect as the researcher observed practices that were
considered routine to participants (eg, a physician holding
a patient’s hand when breaking bad news, a nurse’s tender-
ness in wound care), yet were often informed by participants’
beliefs and values. The researcher learnt that a ‘spa day’, for
example, occurred in the newly renovated hospice bathing
room when patients were in need of a little extra tender-
loving-care.
Box 4 Categories and themes: speech: taming the
tongue
Category – speech: taming the tongue
I began to realize that we can reach people through our atti-
tude and nature and that spiritual development enables us to
extend spiritual support without words.… I also started to
integrate spirituality or spiritual awareness into my work with
people suffering from cancer, not by preaching but through
the virtues of love and respect. (Mary Vachon)
I say as little as possible. I try and get away with saying noth-
ing. (Jeremy Wex)
We communed in silence. (MD Mark)
That is an expression of our spirituality because we are con-
necting on the deepest level. We may not use words, we may
not use par ticular words, there’s that human connecting.
(Chaplain Ellen)
I believe it doesn’t always have to be words. I mean yes,
we need those, but there’s just that sense that comes from
within. (Assistant Ashley)
Theme: communicating in the language of the patient
I have a very fl exible approach… my role will change with
people. (Mary Vachon)
Using language that offers an opportunity for them to express
what’s really going on for them is important. (Nurse Luella)
Yes we bring our skills and yes we bring our training and our
experience, but we also bring an open and ready spirit to meet
people where they are. (Chaplain Ellen)
Theme: the danger of words
I have this conviction that words get in the way sometimes.
(Jeremy Wex)
The god that can be defi ned is not god. (David Kuhl)
I remember saying, ‘ You’re going to be fi ne, don’t worry,
they’re looking af ter you well’… he died about fi ve days later.
(John Seely)
Box 5 Categories and themes: touch: physical means
of spiritual care
Category – touch: physical means of spiritual care
So (through the provision of physical care) your sense of
safety with this doctor is increasing, so that if there is some-
thing you wanted to explore, you’re going to say to him, ‘you
know, there’s something I’ve been wanting to talk to some-
body about for a long, long time and I think I can trust you
now’. (David Kuhl)
The best part of my day after morning med rounds is getting
to actually participate in hands-on care… Little things mean
every thing… I love doing even the nastiest of jobs – anything
that has to do with touching and cleaning and making beauti-
ful. (Nurse Luella)
Theme: the therapeutic effect of touch
The nurses touch patients on this unit, they communicate
respect. (Jeremy Wex)
I think a lot of that came up because we had to do the hands-on
care. I’d often establish really good relationships with the cli-
ents, with the family by doing that. (Volunteer Mary)
Sometimes it is in a prayer, but sometimes it is in a held hand.
(Nurse Lily)
Theme: embodied spiritual care
People have that sense that you’ll go out of your way to do
something, and I don’t think of it as going out of my way…
That’s service, anything that I can do to make them comfort-
able. I’ll run down three blocks and get them an ice cream
cone if that was going to make them feel comfortable. (Nurse
Luella)
I remember this one resident who was deplored that she was
incontinent and needing me to clean her up. I said to her, ‘I’m
the pooping queen!’ and from that point on we were on a com-
pletely different level. (Assistant Dianne)
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Box 6 Categories and themes: presence: the essence of spiritual care
Category – presence: the essence of spiritual care
Your presence is the best gift you can give anybody. (David Kuhl)
Not necessarily somebody who was saying anything or teaching anything with their words, just the quality of presence. (Michael
Kearney)
To be able to provide support and care to people as they conclude their earthly life and prepare for whatever they believe is ahead and
provide a gentle presence in the midst of that helps contribute to making this a meaningful time. (Chaplain Ellen)
Theme: being vulnerable
My guess is that being vulnerable and being open is an important part of being in touch with one’s spirituality, and that is not neces-
sarily a comfortable place to be. (John Seely)
You are basically handing over that power, that need for control, requiring humility, open spirit, open heart, all of those things. (Chaplain
Ellen)
Subtheme: professional vulnerability: relinquishing the exper t model
It is particularly uncomfortable as a physician when you are not able to provide the answers. I am constantly fi ghting that myself.
(John Seely)
There is a risk of giving answers to the question, and what I do know about my job is that there are no answers.
(Jeremy Wex)
It would be hard to work in palliative care and not be aware of one’s vulnerability. (Balfour Mount)
Subtheme: personal vulnerability: the precursor of presence
The healing part is what I bring as a person... Any question you ask another person, you have to fi rst ask yourself.
(David Kuhl)
It requires a part of our personhood whether it’s refl ecting on our own spirituality, or in talking to a patient, sharing parts of
ourselves or laying down our role as professionals… It speaks of a requirement of ourselves as being, as sharing ourselves, as
risking ourselves. (Mar y Vachon)
The other thing I link to these refl ections is some kind of practice towards self-knowledge, a refl ective practice towards
self-knowledge. (Balfour Mount)
Subtheme: the effect of vulnerability in spiritual care
If one is open to that kind of experience you can get to an incredibly meaningful space with another person. (John Seely)
Theme: being present: spiritual reciprocity in the clinical encounter
It’s hard to describe, but that feeling is within a person, within the resident and within the carer. (Assistant Ashley)
It’s that sense of simply witnessing, simply continuing to show up in life. (Mary Vachon)
Just being. Just being with them. (Nurse Sharon)
Theme: the essence of being: defi ning presence
I think my spirituality connects when I am non-judgmental, show love, show compassion… Those times I was able to express or feel
love and compassion for everyone else and in those times you feel your heart is expanding, your self is expanding, and I could recognize
that was happening. (John Seely)
Stop the iatrogenic suffering, meaning both the suffering that you experience and the suffering you project onto the patient. How you
speak and how you conduct yourself, can contribute to suffering… Being non-judgmental is a huge part of it…. When I’m not self-
conscious is when I totally feel most connected. (David Kuhl)
If we have to choose we will err on the side of compassion. (Chaplain Ellen)
of presence was not restricted to individuals who ascribed to
its existence or to a personal spirituality; rather, participants
believed a clinician’s presence affected patients whether cli-
nicians were aware of it or not. In short, presence was what
clinicians brought and lef t in a patient’s room (box 6).
Being vulnerable
An essential ingredient within participants’ conceptualisa-
tion of presence was vulnerability. Vulnerability allowed par-
ticipants to recognise their shared humanity with patients,
requiring them to temporarily put their white coats, titles,
professional and personal credentials aside in order to interact
with each patient as a fellow human being. In participant’s
recalling instances of excellence in the provision of spiritual
care, they identifi ed a willingness to acknowledge and occa-
sionally disclose personal vulnerability as an essential factor.
Participants indicated that although their sense of vulnerabil-
ity did not diminish over time, their capacity to cope increased
through clinical exposure. Three subthemes emerged: profes-
sional vulnerability, personal vulnerability and the effect of
vulnerability on spiritual care.
Professional vulnerability: relinquishing the expert model
Entering the place of shared humanit y – where the tough ques-
tions of life and death were raised and rarely answered – was
described by the majority of participants as a deeply uncom-
fortable experience. While participants acknowledged initial
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training or prescriptive technique and more to do with their
distilled spiritual beliefs permeating their presence and senses
in the clinical encounter.10 17 18 34–42 The literature also indi-
cates that presence plays a signifi cant role in shaping patient
outcomes and complaints in general.18 33 45–49 While the rel-
evance of presence to effective communication, spiritual care
and psychosocial care is self-evident, this study affi rms the
central role of clinician presence in interactions with patients
across all care domains in end of life care.3–37 45 50
This study suggests that clinicians are involved in spiri-
tual care less by their willingness and aptitude and more by
the intrinsic qualities and spiritual beliefs they bring to the
clinical encounter. The precise contents of clinicians’ and
patients’ spirituality were identifi ed by participants as sec-
ondar y to their effects in the clinical encounter, whether their
beliefs were rooted in humanism, religion or spirituality.51 52
This study suggests that clinicians may be better equipped
at the bedside if they develop a refl ective practice, exploring
the impact of their intrinsic qualities and spiritual beliefs in
clinical care: as the medium, in relation to spiritual care, is
the message.53
Although each clinician’s personal spiritual beliefs will likely
be as diverse as that of their patients, participants felt their
beliefs informed clinical practice through fi ve bedside skills.
The fi ve senses of spiritual care model (Figure 1) and associ-
ated key questions (box 7 ) are based on the fi ve categories:
discomfort in relinquishing their roles as experts, ironically,
this was identifi ed as underpinning effective spiritual care at
the bedside and the spiritual growth of clinicians.
Personal vulnerability: the precursor of presence
Whereas professional vulnerability involved encountering
their shared humanit y with patients, personal vulnerability
involved a deeper process, whereby participants attempted to
integrate the life lessons of their patients into their personal
lives. Caring for dying people caused participants to refl ect
on their own mortality and the mortality of those closest to
them6. Participants identifi ed personal vulnerability as an
antecedent to effective use of presence in spiritual care.
The effect of vulnerability on spiritual care
Participants felt that personal vulnerability, including death-
related fears and life questions, informed and enhanced their
care for patients. The perceived therapeutic effect of profes-
sional and personal vulnerability within the clinician–patient
relationship was described by clinicians as a sacred relational
space or place of healing, where patients’ spiritual resources
and distress could be effectively engaged.
Being present: spiritual reciprocity in the clinical encounter
Awareness of their own presence allowed participants to
attune to the patient’s presence, allowing participants to feel
that they were more attentive to their patients’ needs in the
clinical encounter. This extrasensory perception was born out
of an intentional, yet non-prescriptive desire for participants
to deeply connect to their patient’s essence in each moment,
without a need to provide answers, direct the conversation or
have a specifi c predefi ned end point.
The essence of being: defi ning presence
The majority of participants found presence at the bedside dif-
fi cult to describe. When participants were asked to articulate
what they considered to be the key components of presence,
this inevitably led to discussions of healthcare professionals’
virtues and vices – the intrinsic qualities that the care giver
brings to the clinical encounter. Participants identifi ed virtues
of hope, compassion and acceptance in their descriptions of
presence and at the same time included darker attributes of
despair, apathy and disregard. They felt both virtues and t hese
darker attributes had an equal, albeit opposite effect, on the
patient’s spiritual well-being.
DISCUSSION
This study is consistent with the fi ndings of earlier studies
exploring the spiritual needs of patients. These publications
describe qualities related to clinicians’ presence as essential
in qualit y spiritual care.34 –44 The current study builds on this
knowledge through its focus on participants’ perspective and
practice of spiritual care; its cross-sectional and interdisciplin-
ary sample of national leaders and frontline clinicians; and
its design which attempts to suspend assumptions regarding
spiritual care, allowing participant perspectives to inform the
data.
Addressing spiritual needs has been identifi ed as an impor-
tant aspect of comprehensive cancer care, especially at the end
of life.1–5 9 23 –26 Clinicians are given little clinical guidance
however on specifi cally how to effectively provide spiritual
care at the bedside.2 3 In essence, experienced leaders and cli-
nicians working at the end of life felt the role they played in
the provision of spiritual care had less to do with professional
Box 7 The fi ve senses of spiritual care
Hearing: listening intuitively
Key questions
Is there a sacred component to the patient’s story and how
▶
can I honour this in my care giving?
How can I attune to the work that God, Higher Power, Spirit
▶
might be doing in this patient?
Sight: seeing soulfully
Key questions
Who is the person behind the disease?
▶
What visual cues of the patient’s story are available to ▶
inform my care giving?
Presence: the essence of spiritual care
Key questions
How is my presence permeating my clinical care?
▶
How is my patients’ presence affecting the clinical ▶
encounter?
Speech: taming the tongue
Key questions:
How can I communicate in a language that is understand-
▶
able and meaningful to the person in my care?
What are the issues in this clinical encounter I can address
▶
with words and what are the issues that are best met with
silence?
Touch: physical means of spiritual care
Key questions:
How is my physical care impacting spiritual well-being?
▶
What intrinsic qualities are refl ected in my physical care?
How can I ef fectively and respectfully provide comfort
▶
through physical means?
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hearing, seeing, speech, touch and presence, and their respec-
tive themes and subthemes that emerged from the qualitative
analysis (table 2). While this framework may initially seem
simplistic, its application in clinical practice is more challeng-
ing, as tacit skills are known to be diffi cult to incorporate
within the demands of clinical practice.10 17 18 34 38– 42 54 55
This study has several limitations. It assessed perspectives
on spiritual care using an interdisciplinary sample of pallia-
tive care professionals which may not be the same as advanced
bedside skills employed by experienced spiritual care profes-
sionals. Study participants worked exclusively at the end of
life; therefore, their perspectives do not necessarily refl ect
those of healthcare professionals working in other clinical
settings. Finally, this cross-sectional study aimed to provide
a Canadian perspective and may not be generalisable to other
countries or cultures. Further research is required to determine
the validity and utility of this conceptual model – and whether
or not it helps enable healthcare providers to provide more
effective spiritual care.
While spirituality is a burgeoning fi eld in healthcare, with a
growing evidence base, clinicians have been given little guid-
ance on how to i ncorporate this vita l doma in of c are into their
clinical practice. This qualitative study identifi ed fi ve bedside
skills that are core to the provision of spiritual care: listening,
sight, touch, speech and, above all else, presence.
Acknowledgements The authors would like to gratefully acknowledge the
participants in this study, including the key leaders: Dr Balfour Mount, Dr Michael
Kearney, Dr David Kuhl, Dr John Seely, Dr Mary Vachon and Jeremy Wex. This
work was supported through a Canadian Institutes of Health Research-Wyeth
Pharmaceuticals postdoctoral fellowship at the University of Manitoba.
Contributors Shane Sinclair; Shelley Raffi nBouchal, Neil Hagen;
Susan McClement; Harvey Max Chochinov.
Competing interests None.
Ethics approval Approval provided by the Conjoint Health Research Ethics Board
of the University of Calgary, the O ttawa Hospital Research Ethics Board and the
Fraser Health Research Ethics Board.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement These data are a subset of a larger ethnographic study
investigating the spirituality of palliative care professionals in Canada which was
the topic of Dr Shane Sinclair’s PhD Thesis. The thesis is available through the
University of Calgary.
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Shane Sinclair, Shelley Raffin Bouchal, Harvey Chochinov, et al.
Spiritual care: how to do it
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