GPs´ Personal Spirituality, Their Attitude and Spiritual Competence: A Cross-Sectional Study in German General Practices

Most General Practitioners (GPs) acknowledge that spirituality should be an integral part of primary care (Appleby et al., 2019; Assing Hvidt et al., 2016; Monroe et al., 2003). At the same time, GPs report lacking competencies to fulfil this task. The latter include discerning, addressing and meeting patients’ spiritual needs, being knowledgeable about the meaning of spirituality and religion, as well as being empathetic and appreciating patients’ thoughts and feelings (Frick et al., 2019; Hodge, 2007). Many patients and healthcare providers have voiced their desire to increase doctors’ spiritual competence (Balboni et al., 2007; Bar-Sela et al., 2019; Best et al., 2015; Büssing et al., 2009; Ellis et al., 1999; Frick et al., 2006).

In the late 1990s, the Association of American Medical Colleges encouraged physicians to talk about spirituality with their patients. However, the willingness to implement SC seems to depend on the physicians’ religious/spiritual (r/s) orientation. Religious physicians are more likely to discuss r/s issues with their patients (Curlin et al., 2006). Even though medical practitioners mostly name lack of time as the biggest obstacle for implementing spiritual care, previous research has shown that the spiritual competencies and personal spirituality of medical personnel best predict the implementation of these practices (Balboni et al., 2013; Bar-Sela et al., 2019; Best et al., 2015; Kristeller et al., 1999; Meredith et al., 2012; Olson et al., 2006).

In contrast to other medical skills, such as showing empathy or offering psychological interventions, SC has to do with the inner person of the recipient as well as of the caregiver. Thus, we presume that there is a connection between one´s own spirituality and one´s attitude and practice concerning SC. Awareness of and fostering one’s own spirituality has been associated with competencies in implementing appropriate and effective interventions in previous studies (Appleby et al., 2018; Assing-Hvidt et al., 2018; Baumann et al., 2011; Frick et al., 2019; Leeuwen, 2008; Marquardt & Demling, 2016). In a representative study in the USA with 1144 physicians, Franzen (2015) showed that their religious/spiritual orientation relates closely to religious and/or spiritual patient interactions: “The more central religion is for the physician, as reflected by their religious/spiritual orientation, intrinsic religiosity, and religious coping, the greater their perception of religion’s impact on health outcomes and their inclusion of religion/spirituality within clinical interactions” (Franzen, 2016, p. 1). Franzen in a later article also states that “‘religious and spiritual’ physicians include religion/spirituality most often” (Franzen, 2018, p. 1581). He also showed that training has an important direct effect on physicians’ actions. But he also showed that training is not associated with thinking that religion impacts patient health. “This means that training leads to greater inclusion but apparently not because of a shift in physicians’ thinking religion/spirituality impacts the health outcomes of their patients” (Franzen, 2016, p. 23).

The impact of physicians’ r/s orientation on their medical practice differs between cultures (Kørup et al., 2019). Recent literature also shows that the personal spirituality of health personnel is critical for SC: A study that included nine Middle Eastern countries (Bar-Sela et al., 2019) concluded that even across cultures, considering oneself not spiritual or only slightly spiritual was key for not providing SC. In fact, personal spirituality was the strongest factor that increased the number of cases in which SC was provided. In line with this, Curlin showed that physicians with heightened awareness of their own spirituality more often encourage patients to engage in spiritual conversations (Curlin et al., 2006; Rasinski et al., 2011) and enquire about spiritual issues (Curlin et al., 2006).

Worldwide research studies have shown that it is not only health professionals’ awareness but also their attitude towards spirituality that influences their interaction with patients. A meta-analysis concluded that physicians’ religiosity influences their clinical practice, thereby significantly altering patients’ health outcomes (Kørup et al., 2019). But not all findings point in this direction. A recent study has investigated SC practices among physicians in Brazil (Esperandio & Machado, 2019): Only a small percentage of the mainly Christian and highly religious physicians reported discussing spirituality with their patients.

Using his questionnaire on “Religion and Spirituality in Medicine: Physicians’ Perspectives” (Curlin et al., 2005), Curlin since 2002, and later other researchers, investigated not only whether physicians should inquire about patients’ religious and spiritual identity but also how doctors’ attitudes towards spirituality influence their interaction with patients (see the NERSH datapool, (Kørup et al., 2019)). In general, it seems that physicians who describe themselves being spiritual or religious are more likely to provide SC in different ways and acknowledge the rather positive effect spirituality can have on their patients (Curlin et al., 2005; Curlin et al., 2007a, 2007b; Kørup et al., 2019; Smyre et al., 2018). How proactively physicians should approach patients is discussed in literature. While some physicians are afraid to cross professional boundaries, others fear isolating patients from the SC they may need (Balboni, 2015; Balboni et al., 2011, 2013; Curlin et al., 2006; Scheurich, 2003; Smyre et al., 2018). According to Monroe et al. most primary care physicians do not consider patients' spirituality in routine medical care. However, if patients broach the subject themselves, most primary care physicians will give support (Monroe et al., 2003).

In this study, personal spirituality is defined as the individual’s approach to spiritual questions, regardless of whether they consider themselves religious or not.

As SC is a factor which affects the caregiver’s inner person, we hypothesised that in this field, there is an interrelationship between personal spirituality, spiritual competency and one’s attitude towards enquiring about spirituality in practice. This hypothesis is assessed in the present study which to our knowledge is the first one to test the hypothesis on German GPs.

The research questions posed are:

The sample description is shown in Table 1.

It would be desirable to conduct a follow-up study to re-assess our findings with a larger sample size, but there is no funding for it yet. Given the innovative character of the study, being the first to focus on German GPs and their spirituality, we consider the results nevertheless valuable. However, one should not rely on the point estimates alone in the interpretation.

The present study suggests interrelation between German GPs' personal spirituality, their spiritual competence and their readiness to accept SC as their duty. The results support the conclusion that if professional training and evaluation in General Practice aim to strengthen SC, spiritual competence and reflection on personal spirituality should be addressed at all stages of medical education as well as in quality management.