Why do We Find It so Hard to Discuss Spirituality? A Qualitative Exploration of Attitudinal Barriers
2. Experimental Section
2.2. Sampling Strategy
2.3. Data Collection
3.1. Confusing Spirituality with Religion
‘I think patients can get (spirituality) confused with religion, I think not…just how the question is posed, but…it depends very much on the patient’s own experience. So, when…we make a referral to pastoral care and try to explain what that is…some people, because of their own past experiences or their own belief…immediately relate to that as a religious thing. Now that isn’t necessarily conveyed by the staff but it can be a preconceived idea…For some patients…religion, if it’s not an attractive thing or they’ve had a past experience that’s difficult or they feel some guilt around it, then…there can be some blockage.’—Male GP, 20 years’ experience (i.e., treating advanced cancer patients).
‘I work for a Christian organization (and) some people find that confronting…if they think that people talking about religion are crossing a boundary…they feel vulnerable. And they’re worried that someone might be trying to convert them…On occasion I’ve had people say to me they don’t want to see the pastoral care worker…They might have had a lot of existential distress, but because they come from a strong atheist point of view, it’s a terrifying thing for them to be coming across anyone who has anything to do with religion.’—Female palliative care specialist, 21 years’ experience.
3.2. Peer Pressure
‘In New Zealand…—it’s slightly more difficult…the staff would say, “We’re not really supposed to talk about our personal faith or anything like that here.” Whereas in UK, I was so open about that—if somebody asked you about it, you could talk about it.’—Female palliative care specialist, 10 years’ experience.
‘I’ve never…been involved with doctors who’ve said “I’ll pray for you” because of their religious beliefs…So I don’t know if it’s inappropriate, I don’t know if that’s the right word, but I guess I would find that uncomfortable.’—Female palliative care specialist with 13 years’ experience.
‘I think there’s some anxiety around it, I think people don’t want to be seen to be proselytising and I think people will associate religion with all sorts of structures that don’t fit in the health care sector. Yes, so I think there is a stigma.’—Female palliative care specialist, 19 years’ experience.
‘I think if you start talking about religion and faith in a tertiary hospital, a number of your colleagues will look sideways at you and think, “What’s that got to do with medicine?...But having said that, a couple of the grand rounds that I’ve done have involved a little bit of talking about religion. And it hasn’t been a bad thing. So it may be more theoretical than real. Maybe if we did talk about faith more, people would feel that it’s okay.’—Male palliative care specialist, 36 years’ experience.
3.3. Personal Spirituality
‘I come from a Christian paradigm and…we can’t help but see things through our lens, but I have to be open to what other people experience as their spirituality’.—Male palliative care specialist, 10 years’ experience.
‘Probably the most important thing is that I’m comfortable with my own beliefs and recognising that my beliefs don’t matter to the patient other than that I’m comfortable in them and, therefore, able to talk about death and dying in a way that allows them to support their beliefs, whatever they are, or help them to find a framework within which they can live out their life.’—Female palliative care specialist, 6 years’ experience.
‘I’ve got to admit when I first started out, I felt really uncomfortable because I didn’t want to impose…my beliefs on them. But now I have more confidence in opening up that discussion if they want to and just-well, teasing them with the concepts to see if they want a bite out of it because it’s really up to them to guide where we’re going. I want to talk about what’s important to them, but I also want to make sure that I’ve opened up areas that they may have felt a bit embarrassed to talk about that they really want to talk about.’—Male oncologist, 33 years’ experience.
‘I think (proselytizing) is inappropriate…People have said to me ever since I started doing palliative care and I was a Christian, “Oh, what a wonderful mission field.” And I’ve always kind of gone, “Oh, I’m really uncomfortable about that.” So I see…patients are very vulnerable. So suddenly, if a patient brought up salvation and wanted me to pray for them and wanted to be a Christian, then I’d be very happy to oblige. But I feel very uncomfortable about manipulating people into a deathbed conversion. I view my role as to improve a patient’s experience of having cancer. Palliative medicine specialist; that’s fundamentally what I’m trying to do. And so it might include some attention to spiritual things in the broadest sense. And a lot of the time, I’m actually trying to honour their spiritual traditions. So…if I have a Catholic patient who’s dying, one of the things I would…automatically check for is evidence of the priest having visited. And if they haven’t, I’ll ask them do they want a priest to come. So if I go in there with a mission to proselytise, then I’m not able to do that. And I guess everybody…has to actually…sit and think about where they stand on that. So I’m employed by a secular organisation to provide secular assistance. And…while I’m happy to include spirituality in that because I think that’s part of the patient’s experience, I think it would be almost in breach of contract were I to be there with a primary mission of proselytising. So, I don’t do it.’—Female palliative specialist, 30 years’ experience.
3.4. Institutional Factors
‘So it’s a bit more that the chaplain has a job and that’s what they do and the doctor has a different job. Whereas in (my last job), I kind of combined both because our chaplain wasn’t as available.’—Palliative care specialist, 10 years’ experience.
3.5. Historical Factors
‘I think even asking about it is taboo, because it’s not in our concept of healthcare...One of the problems in the medical model is this thing that’s always credited to Descartes, of the mind-body split and dualistic medical thinking, where we focus a lot on the body, and the mind is the realm of psychiatrists. And the connections between the mind and the body, Descartes didn’t know about, and it’s only very recently that our level of knowledge got to the point where we’re starting to understand mind-body connections. But actually, if you read Descartes’s original stuff, he actually talked about mind, body, and spirit. But the medical profession just conveniently forgot about spirit, I think, because it was all too hard. And certainly, today I don’t think we understand what spirit is, and I certainly don’t think we understand the connections between the mind and the body and the spirit in our understanding of a human being. And so I don’t know that we know how to diagnose a broken spirit. So I think the whole area of spirituality is taboo because it’s ignored, because it’s something we haven’t come to grips with. And I don’t think we know how to come to grips with it—it’s not something we can measure on a functional MRI…’—Female palliative care specialist, 30 years’ experience.
‘My understanding, because I believe in holistic care, is that if I need to talk about sexuality, I should talk about sexuality. If I need to talk about faith, I should talk about faith. If I need to talk about bowels, I should talk about bowels, and I'm not going to bring those conversations into every consultation. Some people would say that in every initial consultation a question about people's sexuality…is standard. Well—that's not what I've done either. So, there's a few things where I wait for signals from patients before taking these things on as a really important conversation, but they're not necessarily things that I will talk through every time or with every patient.’—Male oncologist, 23 years’ experience.
Conflicts of Interest
- Cobb, M.; Puchalski, C.M.; Rumbold, B. Oxford Textbook of Spirituality in Healthcare; Oxford University Press: Oxford, UK, 2012; p. 512. [Google Scholar]
- Best, M.; Butow, P.; Olver, I. Do patients want doctors to talk about spirituality? A systematic literature review. Patient Educ. Couns. 2015, 98, 1320–1328. [Google Scholar] [CrossRef] [PubMed]
- Ellis, M.R.; Vinson, D.C.; Ewigman, B. Addressing spiritual concerns of patients: Family physicians' attitudes and practices. J. Fam. Pract. 1999, 48, 105–109. [Google Scholar] [PubMed]
- Phelps, A.C.; Maciejewski, P.K.; Nilsson, M.; Balboni, T.A.; Wright, A.A.; Paulk, M.E.; Trice, E.; Schrag, D.; Peteet, J.R.; Block, S.D.; et al. Religious coping and use of intensive life-prolonging care near death in patients with advanced cancer. J. Am. Med. Assoc. 2009, 301, 1140–1147. [Google Scholar] [CrossRef] [PubMed]
- Ellis, M.; Thomlinson, P.; Gemmill, C.; Harris, W. The Spiritual Needs and Resources of Hospitalized Primary Care Patients. J. Relig. Health 2013, 52, 1306–1318. [Google Scholar] [CrossRef] [PubMed]
- King, S.D.W.; Dimmers, M.A.; Langer, S.; Murphy, P.E. Doctors’ Attentiveness to the Spirituality/Religion of their Patients in Pediatric and Oncology Settings in the Northwest USA. J. Health Care Chaplain. 2013, 19, 140–164. [Google Scholar] [CrossRef] [PubMed]
- Ramondetta, L.M.; Sun, C.; Surbone, A.; Olver, I.; Ripamonti, C.; Konishi, T.; Baider, L.; Johnson, J. Surprising results regarding MASCC members’ beliefs about spiritual care. Support. Care Cancer 2013, 21, 2991–2998. [Google Scholar] [CrossRef] [PubMed]
- Best, M.; Butow, P.; Olver, I. Spiritual support of cancer patients and the role of the doctor. Support. Care Cancer 2014, 22, 1333–1339. [Google Scholar] [CrossRef] [PubMed]
- Brett, A.S.; Jersild, P. Inappropriate treatment near the end of life: Conflict between religious convictions and clinical judgment. Arch. Intern. Med. 2003, 163, 1645–1649. [Google Scholar] [CrossRef] [PubMed]
- Padela, A.; Killawi, A.; Forman, J.; DeMonner, S.; Heisler, M. American muslim perceptions of healing: Key agents in healing, and their roles. Qual. Health Res. 2012, 22, 846–858. [Google Scholar] [CrossRef] [PubMed]
- Pathy, R.; Mills, K.; Gazeley, S.; Ridgley, A.; Kiran, T. Health is a spiritual thing: Perspectives of health care professionals and female Somali and Bangladeshi women on the health impacts of fasting during Ramadan. Ethn. Health 2011, 16, 43–56. [Google Scholar] [CrossRef] [PubMed]
- Balboni, T.A.; Paulk, M.E.; Balboni, M.J.; Phelps, A.C.; Loggers, E.T.; Wright, A.A.; Block, S.D.; Lewis, E.F.; Peteet, J.R.; Prigerson, H.G. Provision of spiritual care to patients with advanced cancer: Associations with medical care and quality of life near death. J. Clin. Oncol. 2010, 28, 445–452. [Google Scholar] [CrossRef] [PubMed]
- Best, M.; Butow, P.; Olver, I. Doctors discussing spirituality: A systematic literature review. Palliat. Med. 2016, 30, 327–337. [Google Scholar] [CrossRef] [PubMed]
- Best, M.; Butow, P.; Olver, I. Palliative Care Specialists’ beliefs about spiritual care. Support. Care Cancer 2016, 24, 3295–3306. [Google Scholar] [CrossRef] [PubMed]
- Balboni, M.J.; Sullivan, A.; Enzinger, A.C.; Epstein-Peterson, Z.D.; Tseng, Y.D.; Mitchell, C.; Niska, J.; Zollfrank, A.; VanderWeele, T.J.; Balboni, T.A. Nurse and physician barriers to spiritual care provision at the end of life. J. Pain Symptom Manag. 2014, 48, 400–410. [Google Scholar] [CrossRef] [PubMed]
- Balboni, M.J.; Sullivan, A.; Amobi, A.; Phelps, A.C.; Gorman, D.P.; Zollfrank, A.; Peteet, J.R.; Prigerson, H.G.; Vanderweele, T.J.; Balboni, T.A. Why Is Spiritual Care Infrequent at the End of Life? Spiritual Care Perceptions Among Patients, Nurses, and Physicians and the Role of Training. J. Clin. Oncol. 2013, 31, 461–467. [Google Scholar] [CrossRef] [PubMed]
- Balboni, M.J.; Balboni, T.A. Reintegrating care for the dying, body and soul. Harv. Theol. Rev. 2010, 103, 351–364. [Google Scholar] [CrossRef]
- Brewer, C. Secularism needs a distinctive medical voice. Br. Med. J. 2011, 343, 1155. [Google Scholar] [CrossRef] [PubMed]
- Cassell, E.J. The nature of suffering and the goals of medicine. N. Engl. J. Med. 1982, 306, 639–645. [Google Scholar] [CrossRef] [PubMed]
- Curlin, F.A. Commentary: A case for studying the relationship between religion and the practice of medicine. Acad. Med. 2008, 83, 1118–1120. [Google Scholar] [CrossRef] [PubMed]
- Cusveller, B.; van Leeuwen, R.; Schep-Akkerman, A. Being the Minority: Christian Healthcare Professionals in the Netherlands. J. Christ. Nurs. 2015, 32, 26–30. [Google Scholar] [PubMed]
- Steinhauser, K.; Christakis, N.; Clipp, E.C.; McNeilly, M.; McIntyre, L.; Tulsky, J.A. Factors considered important at the end of life by patients, family, physicians, and other care providers. J. Am. Med. Assoc. 2000, 284, 2476–2482. [Google Scholar] [CrossRef]
- Best, M.; Butow, P.; Olver, I. Creating a safe space: A qualitative inquiry into the way doctors discuss spirituality. Palliat. Support. Care 2015, 1–13. [Google Scholar] [CrossRef] [PubMed]
- Braun, V.; Clarke, V. Using thematic analysis in psychology. Qual. Res. Psychol. 2006, 3, 77–101. [Google Scholar] [CrossRef]
- Tong, A.; Sainsbury, P.; Craig, J. Consolidated criteria for reporting qualitative research (COREQ): A 32-item checklist for interviews and focus groups. Int. J. Qual. Health Care 2007, 19, 349–357. [Google Scholar] [CrossRef] [PubMed]
- Best, M.; Butow, P.; Olver, I. The doctor’s role in helping dying patients with cancer achieve peace: A qualitative study. Palliat. Med. 2014, 28, 1139–1145. [Google Scholar] [CrossRef] [PubMed]
- Sloan, R.P.; Bagiella, E.; VandeCreek, L.; Hover, M.; Casalone, C.; Jinpu Hirsch, T.; Hasan, Y.; Kreger, R.; Poulos, P. Should Physicians Prescribe Religious Activities? N. Engl. J. Med. 2000, 342, 1913–1916. [Google Scholar] [CrossRef] [PubMed]
- Ellis, M.R.; Campbell, J.D. Concordant spiritual orientations as a factor in physician-patient spiritual discussions: A qualitative study. J. Relig. Health 2005, 44, 39–53. [Google Scholar] [CrossRef] [PubMed]
- Foster, D.W. Religion and medicine: The physician’s perspective. In Health/Medicine and the Faith Traditions; Fortress Press: Philadelphia, PA, USA, 1982; pp. 245–270. [Google Scholar]
- Kuczewski, M.G. Talking about spirituality in the clinical setting: Can being professional require being personal? Am. J. Bioeth. 2007, 7, 4–11. [Google Scholar] [CrossRef] [PubMed]
- Alcorn, S. “If God wanted me yesterday, I wouldn’t be here today”: Religious and spiritual themes in patients’ experiences of advanced cancer. J. Palliat. Med. 2010, 13, 581–588. [Google Scholar] [CrossRef] [PubMed]
- Vermandere, M.; Choi, Y.N.; de Brabandere, H.; Decouttere, R.; de Meyere, E.; Gheysens, E.; Nickmans, B.; Schoutteten, M.; Seghers, L.; Truijens, J.; et al. GPs’ views concerning spirituality and the use of the FICA tool in palliative care in Flanders: A qualitative study. Br. J. Gen. Pract. 2012, 62, e718–e725. [Google Scholar] [CrossRef] [PubMed]
- Meldrum, H. Spirituality in Medical Practice: How Humanitarian Physicians Draw Their Boundaries With Patients. Integr. Med. 2011, 10, 26–30. [Google Scholar]
- Wilson, K.; Lipscomb, L.; Ward, K.; Replogle, W.H.; Hill, K. Prayer in medicine: A survey of primary care physicians. J. Miss. State Med. Assoc. 2000, 41, 817. [Google Scholar] [PubMed]
- Whitford, H.S.; Olver, I.N. The multidimensionality of spiritual wellbeing: Peace, meaning, and faith and their association with quality of life and coping in oncology. Psycho-Oncology 2012, 21, 602–610. [Google Scholar] [CrossRef] [PubMed]
- Sulmasy, D.P. A Biopsychosocial-Spiritual Model for the Care of Patients at the End of Life. Gerontologist 2002, 42, 24–33. [Google Scholar] [CrossRef] [PubMed]
|1||Spirituality is an important domain in the quality of life of many cancer patients. What do you think might be meant by the term spirituality in relation to your work with cancer patients?|
|2||Tell me about your views on discussing spirituality with patients who have metastatic disease.|
|3||If you wanted to discuss spiritual needs with a patient, how would you go about doing it? What would help you?|
|4||What would make it difficult?|
|5||Imagine you could give your younger self tips as you start out in medical practice about discussing these issues with your patients. What advice would you give yourself?|
|6||We’re just about finished—is there anything else you would like to add?|
|Characteristic||Total n = 23 (%)|
|Mean age (years)||55.2|
|Mean years’ experience||21.5|
|Previous formal training in SC||7 (30.4)|
|Palliative Medicine||15 (65.2)|
|General Practice||3 (13.0)|
|Country of Birth|
|New Zealand||2 (9.7)|
|Self-Reported Religiosity and Spirituality|
|How important is religion to you?|
|Not at all||8 (34.8)|
|How important is spirituality to you|
|Not at all||0|
© 2016 by the authors; licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC-BY) license (http://creativecommons.org/licenses/by/4.0/).
Best, M.; Butow, P.; Olver, I. Why do We Find It so Hard to Discuss Spirituality? A Qualitative Exploration of Attitudinal Barriers. J. Clin. Med. 2016, 5, 77. https://doi.org/10.3390/jcm5090077
Best M, Butow P, Olver I. Why do We Find It so Hard to Discuss Spirituality? A Qualitative Exploration of Attitudinal Barriers. Journal of Clinical Medicine. 2016; 5(9):77. https://doi.org/10.3390/jcm5090077Chicago/Turabian Style
Best, Megan, Phyllis Butow, and Ian Olver. 2016. "Why do We Find It so Hard to Discuss Spirituality? A Qualitative Exploration of Attitudinal Barriers" Journal of Clinical Medicine 5, no. 9: 77. https://doi.org/10.3390/jcm5090077