Providing Spiritual Care to In-Hospital Patients During COVID-19: A Preliminary European Fact-Finding Study

Spirituality is widely recognised as an important aspect of holistic healthcare (McSherry et al., 2021). There is convincing evidence that many patients and their families have spiritual needs, that if addressed within healthcare, improve care (Selman et al., 2018) and cost benefits (Hall & Powell, 2021). If spiritual and religious needs are supported, this can support effective recovery or lead to a peaceful death (Swift, 2014). Spirituality is understood in this context as a search for connectedness and meaning, transcendence and belonging (Weathers et al., 2016). One can be spiritual without being religious, but those who are religious are generally considered to be spiritual (Mercadante, 2014, Fuller, 2001). Being religious is the outward practice of spiritual beliefs in the context of an organised religion.

Spiritual care is understood as addressing “patients’ spiritual struggles, fears and worries, [listening] to their spiritual needs, and [supporting] their underlying spirituality, whatever this may mean to them” (Büssing, 2021:3732). Religiosity, spirituality and religious coping are associated with increased life satisfaction and quality of life (Tan et al., 2021), in the context of chronic illnesses for example (Nkoana et al., 2021; Taskin Yilmaz et al., 2021). The reliance on spiritual or religious coping is especially important when receiving bad news, noticing a serious health condition, or when facing serious or tragic events (Koenig, 2013). Spirituality can also foster hope among patients with chronic illness, an important concept for well-being (Sabanciogullari & Yilmaz, 2021) and be a source of support when moral injury occurs (Carey & Hodgson, 2018). While there is an emphasis within the nursing literature on the support of both spiritual and religious needs, it is important to note that these concepts are often understood more broadly as pastoral care needs (Guthrie, 2014; Wells et al., 2021). Both spiritual and religious needs can be effectively supported through pastoral care (Wells et al., 2021). This service is usually provided by Healthcare Chaplains or Pastoral Care Workers to address the overarching spiritual needs of patients in healthcare settings (Wells et al., 2021). Ultimately, pastoral care contributes in a meaningful way to the holistic care of the person and encompasses the many facets of spiritual, religious, sacramental, emotional, psychological care within the context of an increasingly secularised society without an overemphasis on the spiritual or religious, which can serve to lessen tensions and ambiguities that can exist around the care offered to patients to help them address existential concerns.

The COVID-19 pandemic raised our awareness of the need and requirement for pastoral and spiritual support for patients in hospital settings (Carey, 2021). The emerging literature evidenced the creative efforts made by Healthcare Chaplaincy and Pastoral Care services globally to support patients who were isolated and distressed (Carey et al., 2021; Bowers et al., 2021). It was revealed that the stress induced by the pandemic led to people seeking support through spiritual and religious means (Rigoli, 2021). COVID-19 has also reminded populations of the importance of rituals (Imber-Black, 2020). Indeed, Healthcare Chaplains reported an increased and intensive demand on their services (Busfield, 2020) that presented challenges globally (Carey et al., 2020). Indeed, they often struggled “to create some dignified space in which the dying process [for example], could be acknowledged” (Busfield, 2020:219). For some Pastoral Care Workers, access was denied during this time (Hall et al., 2020). Therefore, the exploration of the nurse’s role and indeed the mobilisation of the nurse to provide spiritual and pastoral care is now becoming more prevalent and topical (Chirico & Nucera, 2020). However, to provide effective support a good understanding of spirituality and spiritual care provision is needed, and this is often where gaps exist.

In the hospital, and to a lesser extent the community, the Healthcare Chaplain has traditionally been accepted as the expert in spiritual care, providing support that is both pastoral but also religious/faith based if required (Kirchoff et al., 2021; O’Donovan, 2011; Shields et al., 2014). Support from Healthcare Chaplaincy services and Pastoral Care Workers is known to have beneficial effects in terms of assisting patients to navigate important life journeys in the hospital setting and improving their perception of this experience (Kirchoff et al., 2021). However, increasingly spiritual support is understood as a multidisciplinary responsibility (Timmins et al., 2017). In modern dynamic healthcare environment disciplines are no longer monopolised by single practitioners; rather, there is greater necessity for collective, collaborative and co-responsible care so that that all care needs, including pastoral care needs, are met in a meaningful way (Timmins et al., 2017). That said, there are emerging tensions, as identified by Carey (2012), who highlights concerns within the spiritual care domain by questioning:

There is also a point to note regarding the visibility of Healthcare Chaplains or Pastoral Care Worker, both within the clinical practice setting but also within the healthcare literature (Timmins et al., 2017). Added to the uncertainly that nurses feel about their roles, is their limited understanding of the role of Healthcare Chaplaincy and Pastoral Care Services. This is likely compounded by the dearth of research in the Healthcare Chaplaincy field, most notably in the area of their scope of practice and impact of services (Timmins et al., 2017). Certainly, there are logistical and historical reasons for these gaps; however, there is a need to recalibrate that imbalance, through increased collaborative working, so that more is known about their work, their capacity to provide pastoral support within a more secularised context and their ability to work as co-collaborators with nursing and other allied health professionals in relation to their service provision. While adequate training for nurses in relation to spiritual care provision is important, part of this focus needs to be on greater understanding of Healthcare Chaplaincy and Pastoral Care and an encouragement towards a focus on co-responsibility and a greater understanding of respective roles and boundaries within pastoral care support and delivery.

Certainly, there are fundamental questions regarding the nature of support for religious activity and spirituality, and the role, if any, that nurses and the healthcare services should provide (Carey, 2012; Pesut et al., 2012). However, at the same time there is growing interest in the provision of spiritual care by nurses (EPICC 2021). While the support that patients require arguably occurs more broadly in the pastoral care space, the language that is used by nurses, policy makers and within the nursing competency framework that is developed for European nurses refers to spiritual rather than pastoral care (EPICC, 2021), and overall, this is a welcome initiative. However, there is also limited evidence of spiritual care education and training among nurses (Amiri et al., 2021, McSherry et al., 2020, Castaldelli-Maia & Bhugra, 2014), and limited direction in practice for assessing spiritual needs and providing spiritual care. At the same time, if nurses are sensitive to and provide spiritual care, patient well-being (Karaman et al., 2021) and satisfaction (Harorani et al., 2021) increase.

There is increasing impetus to support and educate nurses, midwives and other health professionals to provide spiritual care to patients receiving healthcare (Hawthorne & Gordon, 2020). It is reassuring therefore to find that spiritual care provision is a prominent feature at the five study sites during this time. Healthcare Chaplaincy provision was also evident across all the sites, a feature of healthcare provision common across many countries internationally (Timmins et al., 2018). Certainly, the COVID-19 pandemic highlighted the support that Healthcare Chaplaincy can provide, especially when visiting was forbidden or restricted (Tracey et al., 2021). COVID-19 resulted in both an increase demand for Healthcare Chaplaincy services (Giffen & Macdonald, 2020) and a serious depletion of these services in some areas (Vandenhoeck, 2021) with a recommendation for a more cohesive and far-reaching way to provide patients with spiritual support, especially for such crisis events (Papadopoulos et al., 2021). Indeed recognised as a “collective trauma” it is likely that there were more far-reaching consequences, related to the pandemic including moral injury (Carey & Hodgson, 2018) and psychological effects (Abbott & Franks, 2021). Indeed, some studies indicated an increase in loneliness and depression, among institutionalised older adults (Van der Roest et al., 2020). Thus, psychological and spiritual support among communities, and especially those receiving healthcare, is an ongoing and future requirement (Carey & Hodgson, 2018).

It was reassuring that this study finds that nurses provide spiritual support to patients, although it is remarkable that assessment of spiritual needs and/or religious affiliation is lacking. However, this is something that resonates within the literature on the topic (Timmins et al., 2017) and this is often due to lack of confidence, embarrassment around the topic, and/or the lengthy nature of suggested assessment tools (Timmins & Kelly, 2008). Some innovative approaches to this have recently been put forward by experts in the field, suggesting a simple 2-question approach (termed 2-QSAM) that simply prompts nurses to ask “‘What’s most important to you right now?’ and ‘How can I help?’” (Ross & McSherry, 2018). This approach will likely be very useful to future educational programmes that equip nurses for spiritual care practice.

COVID-19 has also challenged the nursing profession from several points of view. It has brought challenges that led to a reimagining of healthcare roles in the context of life changing events such as cancer (Carey et al., 2021). End of life care was also extremely challenging (Bowers et al., 2021). In some cases, patients were more fearful at this time, with older people exhibiting high levels of death anxiety (Rababa et al., 2021). Certainly, major life challenges became more magnified (Carey et al., 2021). Nurses such as those identified by Criptoph & Smith (2020) highlighted the loneliness and isolation experienced when facing deaths during COVID-19 and their efforts to support both the dying and bereaved in a dignified way. However, the ability to assess patients’ spiritual needs is fundamental to the provision of good spiritual care (Karadag et al., 2021).

Of concern is the preponderance within this study of single faith service provision, or the appearance of this through the religious services and sacred spaces provided. While there is limited exploration of this aspect of spiritual support within the literature, this finding is consistent with other work in the field (Timmins et al., 2017). At the same time, multifaith Healthcare Chaplaincy services can coexist with this mono religious approach (Brady et al., 2021, Timmins et al., 2017). However, this does lead to concern by the public, who without more in-depth information are influenced by surface appearances (Irish Independent, 2019), for example, the presence of a chapel has singular religious connotations when this may not necessarily be the case. Multifaith approaches are common and deemed important among modern Healthcare Chaplaincy services (Brady et al., 2021). Certainly, our Erasmus project will clearly address a multicultural and multifaith perspective for nursing students (From Cure to Care, 2021).

It is of concern, therefore, and in keeping with the literature on the topic (Austin et al., 2016) that nurses in this study received little ongoing professional education and training related to spiritual care. Additionally, there was little by way of local policy or spiritual care definitions to guide care delivery, something which is not consistent with previous findings on the topic (Timmins et al., 2017), although surprising given that there is international direction on spiritual care standards (EPICC, 2021, van Leeuwen et al., 2020, Herdman & Kamitsuru, 2014, RCN, 2011). However, this supports the view of Jones et al. and others (McSherry et al., 2020) who believe that there is an urgent need for education for nurses, with a preference for online education, something which our Erasmus Plus project will ultimately provide (From Cure to Care, 2021).

At the same time, some emerging trends need consideration. Pesut et al. (2012) reported in a Canadian study that the Healthcare Chaplain’s role in healthcare services has changed significantly in the context of managerial and fiscal constraints, and increasingly pluralistic and secularised society, resulting in some cases in permanent withdrawal of these services (Pesut et al., 2012). For this reason, there needs to be more collaborative work by health professionals with Healthcare Chaplains, Pastoral Care Workers and faith leaders to support patients and families (Moreira‐Almeida et al., 2016). Certainly, the provision of spiritual care support by nurses is deemed important and can have an important effect of the patient, family and nurse coping (Lalani et al., 2021) and good quality care (Kudubes et al., 2021).

However, what is not always clear is how interdisciplinary roles interface with one another. A series on faith-based healthcare published in the Lancet in 2015, for example, made no reference to the Healthcare Chaplain’s or Pastoral Care Worker’s role yet urged healthcare practitioners to address patients’ spiritual and religious needs (Duff & Buckingham, 2015; Olivier et al., 2015; Tomkins et al., 2015). This blurring of role boundaries has the potential to induce conflict in the healthcare area, perhaps eroding an already depleted Pastoral Care service. We are at a point where a clear understanding of healthcare roles in the provision of healthcare would be very useful to the development of spiritual care for the future, especially in the context of changing demographics and increased interest in involvement of non-Healthcare Chaplains in spiritual care matters.

It is interesting that there was little use of technology by nurses to support spiritual care provision. As a matter of fact, COVID-19 highlighted the crucial role technology can play in facilitating remote communication among health workers and between them and their patients and families (Harrison & Scarle, 2020). Connecting with technology was also a common theme for older people during the pandemic (Pettis, 2020). Mobile technology interventions such as those with a “body mind-spirit intervention” were also advanced during this time with success to improve psychological well-being (Rentala & Ng, 2021:1). Indeed, COVID saw Healthcare Chaplains began to use technology for support services the first time (Drummond & Carey, 2020; Giffen & Macdonald, 2020).

At the same time, Healthcare Chaplains found that end of life and other sensitive conversations were sometimes challenging through this new and sudden use of technology (Drummond & Carey, 2020; Harrison & Scarle, 2020). Naturally, the advancement of digital technology to support nurses’ provision of spiritual care to patients proposed by this Erasmus project will also be of benefit in determining sensitive ways of digital technology usage (From Cure to Care, 2021).

This paper highlights the issue of spiritual care provision in contemporary healthcare facilities. It demonstrates the ad hoc nature of spiritual and pastoral care provision and the need to try to redress this imbalance and to prepare for a more enhanced service delivery in this regard. Nurses are currently unprepared to appropriately identify and address specific spiritual needs in healthcare, and there is an urgency to recalibrate this imbalance. The development of a new digital educational and pedagogical tool will help to address this and offers a fresh and innovative way to try to navigate the current limitations in nursing education in this domain.

Although the study findings may support many international initiatives on the topic, our sampling is relatively small and non-representative. It will serve as a baseline for the project work that will follow later to develop educational resources for nurses.