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Article

Supporting Spirits in Changing Circumstances: Pandemic Lessons for Long-Term Care and Retirement Homes

by 1,2
1
Schlegel-UW Research Institute for Aging, University of Waterloo, Waterloo, ON N2L 3G6, Canada
2
Conrad Grebel University College, University of Waterloo, Waterloo, ON N2L 3G6, Canada
Academic Editor: Denise Starkey
Religions 2022, 13(7), 584; https://doi.org/10.3390/rel13070584
Received: 18 May 2022 / Revised: 17 June 2022 / Accepted: 21 June 2022 / Published: 23 June 2022

Abstract

The pandemic of 2020–2022 brought both disruption to, and increased need for, spiritual care in long-term care and retirement homes. This paper reports and reflects upon the experiences of spiritual care providers (SCPs) in these settings in Ontario, Canada as they each endeavored to adapt to their circumstances. Qualitative data were gathered from 27 participants through a variety of means, including natural focus group opportunities, email responses to questions, and in-depth virtual interviews. This study learned that during the pandemic, SCPs creatively adapted the care they provide, while finding it challenging to meet needs for touch, community, mental health care, and processing grief. SCPs spoke with confidence about their role as a listening and supportive presence, for team and family reassurance, as well as for residents. Opportunities to personalize spiritual care using technology, and the value of small, intimate gatherings were realized, along with the value of employing an in-house SCP who truly gets to know residents and can continue to creatively adapt to meet changing needs in changing circumstances. Recommendations are made for spiritual care provision that is resilient through outbreak restrictions into the future.
Keywords: spiritual care; long-term care; retirement; pandemic; chaplain spiritual care; long-term care; retirement; pandemic; chaplain

1. Introduction

The pandemic of 2020–2022 sparked a crisis in long-term care (LTC) and retirement homes (RH). During the first wave, more than 80% of Canada’s virus-related deaths occurred within this sector (Canadian Institute for Health Information 2020). Outbreak status in many homes, coupled with government pandemic mandates, has greatly impacted life in these congregate settings for over two years now for those who live and work there. While physical needs, including infection prevention, have been top of mind, needs of the spirit have been pressing as well. With increased isolation and other losses came loneliness and grief. Residents and team members alike have been living with more suffering, more death, and bigger questions than before. Spiritual care has been needed more than ever.
“Spiritual care is care that recognizes and responds to the needs of the human spirit (including the need for connection, emotional support, respect for values and beliefs, and the search for meaning in life/suffering). Spiritual care facilitates religious care from one’s own faith leader/community, meeting needs for relationship and continued participation in religious practices/tradition. Spiritual care includes, but is not confined to, religious care”.
As the crisis of the pandemic spread and persisted around the world, studies in various countries found an increase in time spent praying and other religious practices, and that positive religious coping was associated with less loneliness (Büssing et al. 2020; Yidirim et al. 2021). The importance of spiritual care and the role of spiritual care providers (SCPs)/chaplains (used interchangeably throughout this paper) in society, and particularly in health care, was spotlighted in both academic literature and the media (Giffen and Macdonald 2020; Klitzman 2021; Micklewright 2020; Seidman 2021).
A survey of all the literature on older adults’ responses to the pandemic published in the first year of the pandemic by the Gerontological Society of America (GSA), however, noted a gap. Gerontologists were paying little attention to topics of spiritual resources, religious coping, or religious behaviors (McFadden 2021). What was the role of spirituality in the midst of the pandemic for older adults? Specifically, how did spiritual care in long-term care and retirement homes fare throughout this time?
A study with chaplains during the first wave of the pandemic in the UK led to a discussion of the importance of pastoral presence for those who are suffering (Swift 2020). Additionally, while noting that the impact of the pandemic in their area was relatively less than in other regions of the world, a few Australian studies have looked at chaplains’ experience in aged care during the pandemic, describing adaptations and identifying future issues related to spiritual care (Drummond and Carey 2020; Jones et al. 2020; Tan et al. 2021). Two international surveys have reached chaplains around the world (some of whom work in aged care) to learn about changes in aspects of spiritual care during the pandemic (Snowden 2021; Vandenhoeck et al. 2021). However, research in the Canadian context, particular to aged care, is lacking.
This paper reports and reflects on the experience of spiritual care providers in long-term care settings in Ontario, Canada during the pandemic. It explores what they have learned about spiritual care during the pandemic, leading to recommendations for spiritual care provision that is prepared to meet needs and be resilient through outbreak restrictions into the future.

2. Method

This qualitative study used a variety of means to gather data about the experience of spiritual care providers in southern Ontario during the pandemic (Swinton and Mowat 2016). Ethics clearance was received through the University of Waterloo as part of a larger study on spiritual care in long-term care (#40919 amended for pandemic research). Natural focus group opportunities arose throughout the months of pandemic, in regular online meetings of a chaplain’s association, where permission was granted to the researcher to listen, learn, and take notes. Fourteen individual chaplains participated in at least one of these meetings. Five chaplains provided an email response to questions about the impact of the pandemic on spiritual care. Interviews, using Zoom or telephone, allowed nine spiritual care providers to talk in detail about their experience. All consented to the recording and use of their comments for this research. It was important and helpful to use various means for gathering data in order to accommodate the preferences of practicing spiritual care providers during this stressful time.
Questions asked included the following:
  • What impact has the pandemic had on spiritual care in your home?
  • Has your role and/or hours changed?
  • How have you been meeting spiritual needs during this time?
  • What has worked particularly well?
  • What spiritual needs have been hard to meet?
  • What have we learned about spiritual care in long-term care because of the pandemic?
  • Any pleasant surprises?
  • What advice would you give to the long-term care sector to ensure that spiritual needs are met as this pandemic continues and into the future?

Participants

All told, the experiences and reflections of 25 spiritual care providers (10 women, 15 men) contributed to this study. All would identify as Christian, from a wide variety of denominational affiliations. All serve in long-term care and/or retirement homes, 4 full-time (3 not-for-profit and 1 municipal home) and the remainder part-time. Email data from two additional persons with responsibility for spiritual care in homes without a spiritual care provider on staff were also included, bringing the number of participants to 27. Alphanumeric codes were kept consistent with the pre-pandemic study of spiritual care in long-term care of which this research is a part.
There was considerable demographic variety among the homes served, including both rural (n = 4) and urban (n = 23), for-profit (n = 14), not-for-profit (n = 9) and municipal (n = 4) homes, and their residents, who are mostly older adults, of several cultures, and mostly, though not exclusively, Christian denominations. It should be noted that throughout the pandemic, I, the researcher, have also been supporting spiritual care in LTC/RH settings, and so have experienced this research as somewhat of a participant observer (Swinton and Mowat 2016, p. 130).
Analysis took place throughout the process of data collection. Notes from the group meetings, email data, and transcripts from the interviews were read, re-read, coded and physically sorted. Emerging themes were noted and data categorized.

3. Results

Four broad themes emerged from the data:
  • The circumstances in the home and experience of the individual chaplain;
  • Practical adaptations in the provision of spiritual care;
  • Needs that have been difficult to meet;
  • Learnings and intentions for the future.

3.1. The Circumstances in the Home and Experience of the Individual Chaplain

Through the waves of the pandemic, life in long-term care was greatly altered. Infection control was prioritized, and for extended times, no outside visitors were permitted. With the availability of personal protective equipment (PPE) and virus testing and then vaccinations, ‘designated caregivers’ gained entrance, so long as the homes were not in active outbreak. At some points outdoor and/or physically distanced visits could be arranged. During outbreaks (identified by a positive COVID-19 test in someone connected to the home) all residents in the identified area were usually confined to their rooms, with meal delivery, for 10–14 days since the most recent positive test. New residents generally lived in quarantine for their first 14 days, excepting those in later stages of the pandemic who were fully vaccinated. Even when homes were virus-free, residents were seated at a distance from one another for meals, and gathering for activities was not permitted, or restricted to small numbers. (Note: this is a simplistic description of circumstances that changed often and varied from home to home.)
As the experience of the pandemic has varied greatly from home to home, so too has the experience of spiritual care providers. Among the participants in this study, some were full-time employees, some part time, and some held contracts at multiple homes pre-pandemic. In the early days, some were present in the home in continued, enhanced or adapted ways, as part of the team. Others were physically absent during the first wave for reasons of personal vulnerability, illness, or because they were not considered ‘essential’ and so asked to stay away to reduce risk for residents. Chaplains serving more than one home had to choose only one to visit, often leaving the others without spiritual care. Within the home, chaplains were sometimes cohorted, along with other employees and residents, to minimize contacts. Others had access to the whole home. Some chaplains who were not in the building made connections from their homes, providing recorded services and literature for the residents, and visiting by phone or Zoom with some (more on adaptations later).
The abrupt changes required by the pandemic quickly surfaced issues for spiritual care providers related to their role, and understanding of that role within the home, their resources and connections in the community, and their provision of care.

3.1.1. Their Role

In some homes, there was a perception that with large gatherings suspended, the chaplain would have nothing to do. Several chaplains reported being assigned tasks such as cleaning the fish tank and watering plants, simply because it needed to be done. For most chaplains who work more than a few hours a week, meal service (delivering and helping to eat) became a regular part of their day. While some felt that this indicated a lack of understanding of the value of spiritual care, most were glad to be part of the team and to collaborate. Many found significant meaning in new tasks, such as connecting residents and family members by Zoom, or, in later months, coordinating outdoor visits. Over time, understanding of and appreciation for the role of spiritual care grew in many homes, and are discussed later in this paper.

3.1.2. Resources

The sudden absence of visiting pastors and community volunteers had a significant impact on spiritual care. Many residents lost connection with their familiar outside spiritual resources, leaving their spiritual needs with the chaplain. At the same time, chaplains lost their collaborators in providing spiritual care and it became a lonelier role. Several participants doubt that volunteers will return anytime soon, due to restrictions and personal choices and changes. Finding and equipping new volunteers will take time.

3.1.3. Provision of Care

Spiritual care pre-pandemic was most commonly delivered through gatherings and one-on-one personal conversations. In a pandemic, these means of care became unsafe. While thankful for the availability of PPE, and the protection it affords, spiritual care providers identified PPE, and social distancing, as barriers to providing spiritual care as they used to do it.
The main concern of chaplains was how to continue to provide spiritual engagement and spiritual care in the midst of these new circumstances. This leads us to the many creative adaptations made by spiritual care providers.

3.2. Practical Adaptations in the Provision of Spiritual Care

So how did SCPs adapt their provision of spiritual care to the realities and restrictions of pandemic times?
Several factors dictating what was and was not possible, varied over time, and between homes:
  • Whether or not the SCP was able to be present;
  • Whether the SCP was restricted to a certain area of the home;
  • Whether or not it was safe for residents to gather, and if so, the group size permitted.
When asked about how they were providing spiritual care during the pandemic, SCPs mentioned the following. Of course, no one SCP could do all of this! What follows are ideas gathered from all participants in the study.

3.2.1. Virtual Services

Using YouTube, Zoom, or even Rogers TV access, chaplains prepared worship services to share with residents in their home areas on Smart TVs, or in their rooms on tablets, computers or even smartphones. Residents appreciated receiving ongoing spiritual leadership from the spiritual care provider who was familiar to them, while pre-recording, or connecting virtually in real time allowed chaplains to be in many places at once, even if they were isolating at home.
Powerpoint worship presentations, with links to hymns on YouTube were appreciated, especially in neighborhoods where visuals help encourage engagement. Recreation or other team members could deliver this programming when the chaplain could not be present.
While there are advantages to online leadership, one chaplain who was leading by Zoom commented,
“Some residents keep asking me, ‘When are you coming back?’ So, I take it that, in their minds, the Zoom church service is not the same as going to the chapel”.
(SCP 8)
During the pandemic, services from many of the residents’ home congregations became available online or on television. Residents and SCPs learned to appreciate and access these services, which also became part of meeting needs for connection and community beyond the home. One SCP commented on the value of using technology to bring daily mass to a resident in their own language, and from a familiar place.
“We realized we’re doing something good here when a resident is watching mass virtually from their hometown; they see the church. They see their church, the architecture, the beauty, and the experience they remember from childhood, back home”.
(SCP 37)

3.2.2. Other Virtual Connections

Zoom was also used to host virtual ible studies and reflection times, a ‘Fireside Philosopher’ group, and a virtual piano recital. Memorial services using Zoom welcomed family members from a distance.
Telephones were used to connect older adults in retirement homes for worship. Seniors WithOut Walls (WOW) technology allows people to call in or receive a call, to connect as a group from their own phone.
One SCP used her home’s internal broadcasting system (through residents’ in-room televisions) to play resident requests at Christmas (Handel’s Messiah, for example). These common experiences gave them a sense of community and belonging with each other and something to talk about when they were able to be back in the dining room together again.
“It created some sort of conversation again for them—to pick up something that they had done apart and yet together”.
(SCP 36)
Conscious of avoiding overuse of the home’s public address system, one chaplain wondered if the PA system could be a useful tool to share a brief daily greeting, perhaps a joke, that would reach everyone at once, at an appropriate time of day.

3.2.3. Mini-Services and Groups

Many SCPs commented that the pandemic actually increased the amount of spiritual care programming, as they moved from holding one weekly worship service, hymn sing, or Bible study, for example, to several throughout the home. These physically distanced gatherings happened in various ways:
  • Hallway hymn-sings or services were led from the middle of the hallways, with residents participating from their doorways.
  • Many SCPs took short services to individual home areas (often dining rooms) where they could gather a few residents. These small groups were repeated throughout the home (as many as 7 times in one day).
  • Some chaplains worked more on Sundays during the pandemic, to cover programming that used to be provided by volunteers, and to deliver multiple services throughout the home. (This was not considered sustainable by most);
  • Other staff were invited to help with spiritual care. For example, a local parish priest was willing to train a Roman Catholic staff person to deliver the Eucharist to residents in a home where the SCP was not Catholic, and the priest was not permitted entrance.

3.2.4. Room Visits

Individual visits with residents in their rooms became even more important during the pandemic, especially during the times when residents were confined to their rooms and many were longing for company. So, what happened during these visits?
  • Lots of listening.
  • Offering prayer, or other spiritual resources including readings, and music. Some SCPs assembled a spiritual care cart to take from room to room, with music, literature/readings, something beautiful like artwork or flowers, etc.
  • Tablets were useful to access familiar religious resources (e.g., Rosary prayer) or to share something interesting and uplifting, including music. One SCP commented on the uptake of this technology in long-term care “[Residents] got the idea that we have input into this, we can direct what we are seeing… ask for something...after awhile they would say ‘You know I really want to see something with birds’. So, it became a very engaging experience with the residents!” (SCP 36)
One SCP commented, “[Because I am focusing more on room visits] I’ve been getting to know those who are spiritual but not religious, and haven’t attended programs”. (SCP 43)
When people were lonely, SCPs found they could help make up for the absence of family with their own presence and by facilitating virtual family visits through tablets (Skype, FaceTime, Messenger, Zoom, etc.). In the words of one SCP whose home experienced an extensive outbreak,
“People are happy to have someone to talk to. And it wasn’t about praying or singing hymns. Just someone to come and visit when you’ve been in your room for three or four months… I also saw the importance of connecting with family members on behalf of the residents. When we did FaceTime, family members were saying ‘Thank you, thank you so much! I don’t know what I would do without you, we appreciate it so much!’”
(SCP 8)

3.2.5. Printed Material

Many SCPs produced more printed material during this time, to distribute to residents as a tangible resource for their spiritual practice and a reminder of the SCPs care for them. Printed material included the following:
  • Handouts connected to worship services, or in the place of worship services (some chaplains provided a service to read when they could not come to the home).
  • Regular pamphlets with quotes, meditative thoughts, prayer, focusing on themes such as hope, lament, waiting, worry, etc.
  • Bible study discussion sheets, to replace their weekly gathering, were distributed in at least one retirement home. Interested residents were encouraged to discuss its contents when they were together at mealtime, or to plan a phone call with another resident for discussion.

3.2.6. Sacred Space

The pandemic created the need for more space in residential care settings, and chapels were often commandeered for virus testing, team education, or PPE storage. SCPs recognized the ongoing need for a place for residents and/or team members to reflect.
Many SCPs set up displays appropriate to the religious seasons of their home’s residents, and/or continually changing displays with reflective and inspirational quotes. For Easter, one chaplain set up stations in a large room that residents could visit on their own and find visuals, readings, prayers, etc. Music appropriate to the season played in the background. Similarly, for Christmas, nativity scenes were set up in places residents could visit. Another home had an advent display, with a new battery-operated candle added each week toward Christmas, and a prayer for residents to read. On the longest night of the year, one home set up tables with candles and reflective readings, inviting residents to add photos and mementos to acknowledge and honor their losses over the past year.
Some homes provided a quiet corner for team members with scented hand lotion, soft music, notes of gratitude—a place to take a deep breath and refresh for the work ahead.
In one LTC home that was fortunate to retain the use of its chapel, the SCP commented, “When we were in lockdown, we couldn’t bring people to the chapel in a group. We would still bring them individually for praying, to sit in the chapel and have a quiet moment, and it made a world of difference”. (SCP 37)

3.2.7. Music

Music was mentioned as an important resource by many SCPs. Though gathering to sing was not permitted, music could still be enjoyed. Many made good use of beautiful recordings on YouTube, often accompanied by photos, with individuals or very small groups. Some SCPs continued to use their instruments (guitars were often mentioned) and residents could hum or move along to favorite songs.

3.2.8. Palliative Care

When loved ones were not permitted to enter these homes for fear of the virus entering with them, the role of chaplains in being with the dying became increasingly important, for residents, their families, and other team members.
Though nothing can take the place of the physical presence of loved ones, and PPE made communication difficult, SCPs were able to bring human presence, ensuring residents were not alone. As one SCP shared “yet even with all of that [PPE] there are still sacred moments that come, with a muffled song—it’s such a beautiful thing—they can still look you in the eye, and it means something”. (SCP 43)
SCPs also did their best to connect residents to their families at end of life.
“We moved the palliative care bed in one section right to the window so that family could be standing by the window and just be there. We would open the window, so they could talk with each other and those kind of things. That opportunity of being there, joining with one another in conversation, but also in prayer, during this time was a heartfelt deep experience of presence there and the family still talk about it and say, ‘this was good, this was meaningful, this gave us some peace and closure over all of this’”.
(SCP 36)
Other team members valued the presence of spiritual care for those in their last days. In telling the story of gratitude of staff for her sitting with a dying man, one SCP reflected, “it is huge, what we do for people, in being present”. (SCP 13)

3.2.9. End of Life Rituals

Pre-pandemic, many homes had meaningful practices to acknowledge and honor the end of life, such as dignity walks (also known as honor guards) to accompany the resident’s body out of the home with love and respect, and memorial or celebration of life services where families, staff and residents could gather to remember residents who had passed over the past few months. The pandemic upended these practices, and they were sorely missed. Rules and restrictions took away the beauty of the process of saying goodbye and required team members to do what felt like the opposite of what they wanted to do.
With funeral directors no longer permitted to enter the homes, team members were tasked with preparing and transferring the bodies of their beloved residents themselves, using heightened infection control measures, including prohibition of using their home’s special quilt to cover the sterile bag. Some SCPs were able to soften this experience by being present to offer some words of comfort or prayer. Others left a laminated card with the nursing staff with words that could be said in such a situation, to help it feel more ‘right’ for all involved. One SCP spoke of how she advocated to maintain their practices to the greatest extent possible within the limitations:
“We would gather people in a big socially distanced circle with masks on in the parking lot and the funeral directors were always really supportive as well, in the sense that they would give us the time and the space. And we would have a prayer circle around the resident for the families, and the staff was allowed to join as well that wanted to. And I think actually that was… it was quite beautiful and very deep and meaningful for people to participate in”.
(SCP 36)
With the length of time since the last ‘Celebration of Life’ service increasing, homes were missing the opportunity to say goodbye to many residents. Many SCPs rose to the challenge of leading memorial services using an online platform so families could connect from home. These services were well received and deeply appreciated, especially by families for whom, due to the pandemic, this would be their only ritual acknowledgement of the death of their loved one. Some SCPs also went to the work of creating memorial booklets, with a page for each resident, photos and memories. These too have been treasured by families and team members.
Chaplains have been creative in adapting to meet spiritual needs. Some needs, however, have been difficult to meet.

3.3. Needs That Have Been Hard to Meet

3.3.1. Touch

Being asked to refrain from touch has been very difficult for chaplains, when residents were lonely and hungry for human contact. Handshakes, hugs, and holding hands in comfort or prayer can be an important means of communication, especially with those for whom verbal communication is difficult. Non-verbal communication has been further hampered by masks and face shields. With pandemic precautions loosening, I have been able to hold the hand of an upset resident and feel their physical relief as they said, between tears, “It feels SO good to be touched”.

3.3.2. Community

Two aspects of the need for community have been hard to meet.
  • Loneliness—In the words of one chaplain, “We can do all we can do but—I think of one woman who is dying of cancer and is longing for things to be normal so her family could come in whenever they want. She has 7 children and they come two at a time if they’re lucky. I can help but I can’t alleviate the loneliness”. (SCP 43)
  • Missing cultural and religious connections/festivals/celebrations—People are missing the sense of belonging to the wider community that came with visiting volunteers and special events. They feel cut off from their community.

3.3.3. Mental Health Needs

When residents are isolated and lonely, depression and anxiety can follow, and even existential despair. “The depression that sets in through loneliness was quite evident, that feeling of not being loved” (SCP 36). Increased angst and anxiety connected to uncertainty was obvious, with residents asking more questions, needing reassurance, for things to be written down for them, something to hold onto and refer to, as an anchor. Early in the pandemic, one SCP found residents, especially those who had been through wars and/or concentration camps, to be feeling vulnerable and fearful to the point of not opening their doors. He used his skills to build trust so the team could continue to provide care. Some SCPs felt the need for more specialized training in helping residents with their mental health needs.

3.3.4. Grief

The pandemic meant a series of losses for everyone, and loss needs to be grieved. Grief comes with a multitude of emotions, and SCPs felt a responsibility to help not only residents, but also team members, families, and the home as a whole, as each processes the grief with which they are living.
“I think that grief, which there is lots of in the pandemic, needs a person dedicated to it. There’s a lot of pain, loneliness, angst, sorrow, in LTC homes… SCPs are not afraid to sit in that sorrow, and we need them right now”.
(SCP 43)
SCPs found it was simply hard to have enough time for everyone who was grieving. This leads to the significant experiences of SCPs in homes that experienced terrible outbreaks and much loss. One SCP, who herself contracted the virus in the first wave, took our conversation to a whole other level. When she returned, she “just tried to find some uplifting way to encourage people to keep going, because at that point they were so, so, tired and so traumatized that it was really difficult” (1/4 of their residents had died in the first 6 months of the pandemic). Homes where the virus was rampant were in crisis for some time, and the chaplains did what they could to keep everyone’s heads above water.
“It was quite chaotic and hard to see where you fit in, other than to say ‘Here I am; use me for whatever you need to use me’”
(SCP 21)
This chaplain did everything from sorting the belongings of deceased residents, to sanitizing, and hauling garbage, while posting memorial notices and being available for spiritual support.
The availability of vaccines marked a change for that home.
“People were starting collectively breathing again; there was hope there… and I began to gently move people forward in their mourning, so, while we remember those who have died, we need to concentrate on those who are still with us… I post memorials for a shorter time now, to offer a breathing space. When [our memorial board] was empty, that said nobody has died today… a reprieve from the broken heartedness that enveloped our home”
(SCP 21)

3.4. Learnings and Intentions Going Forward

New experiences are opportunities for learning. This study found that during the pandemic, there were lessons learned about the role and importance of spiritual care, about effective provision of care in new ways that challenged our previous assumptions, about the need for team member support, and about the need to be adaptable, creative and innovative going forward.

3.4.1. The Role/Importance of Spiritual Care

The pandemic resulted in the importance of spiritual care becoming better understood. “Having spiritual care available or religious practices that they appreciate and that’s part of their life was very, very important—more than we actually realized at the beginning”. (SCP 37) As mentioned earlier, the presence of chaplains, a listening ear, by the bedside of the dying, provided reassurance, calm, hope. “Having a presence there that listens in a non-judgmental way for residents and staff as well can be very, very helpful in keeping morale up that we were seeing deteriorating quickly” (SCP 36). The same SCP reflected on how the pandemic brought a new appreciation of the role of spiritual care in bringing people together emotionally. “They are in the same physical vicinity the whole time, but how do we bring people emotionally together and aware of each other, and each other’s needs?” (SCP 36). Chaplains fill a vital role within the team, where they are, significantly, not leadership or decision makers, but rather someone who can listen, accompany, and support everyone.

3.4.2. Enhanced Spiritual Care Practice

Several SCPs were surprised to realize they had actually enhanced their provision of spiritual care through changes instigated by pandemic restrictions. Many commented that small is often better, in reference to group gathering sizes.
“What I’ve discovered is that the therapeutic value for a group of residents is higher in a group of 5 than a group of 15. I used to think “there’s only 5 people here, this isn’t good”. But then the quiet person might say something, you can have eye contact with everyone”.
(SCP 43)
“Since we’re not gathering centrally for worship services there is less movement for the residents. So, they don’t have long wait times, portering times, which led some to decline attending. So now when I lead a service on each floor, when there might have been 5 come before, now there are 17, and I can do it right after exercises, and can customize the worship to these particular residents, which I can’t in a larger group…before COVID, that joint worship experience would have been about 35 residents. Now I’m at 42 over in long-term care plus about another 20 in the retirement side. So it’s a shift, right? They’re more alert, it’s more personal”.
(SCP 36)
Homes also learned that they could deliver spiritual care religious practices in residents’ own rooms, in their own languages, even connecting them to their own church community online. Relationships with individuals and families have blossomed during this time. Some homes are re-evaluating the role of community pastors in providing spiritual care. While volunteers are valued and people, particularly in retirement homes, look forward to their visits, there are advantages to having an in-house chaplain responsible for spiritual care programming. An in-house chaplain gets to know the residents and their needs in ways that volunteers cannot and is more likely to be permitted entry in an outbreak. Homes without spiritual care providers on staff found it very difficult to provide spiritual care during the pandemic.

3.4.3. Team Members Also Need Support

SCPs unanimously mentioned the increase in support needed by the team.
“You had staff that were watching people die, and they were… well, whether it was fear or just exhaustion. So you end up being a calming pastoral presence in a very upside-down time and I think that was a huge benefit—to have a chaplain here”.
(SCP 28)
One SCP mentioned how demoralizing it was for staff to witness the deaths of residents for whom they had cared for many years, without their families present. While trying to provide the best care possible, there was something lacking. They could not do what they felt called to do. Besides their work, team members were carrying family stresses, and fears of spreading the virus that led them to approach chaplains for support. Team members appreciated what chaplains brought to the home.
“They felt some degree of comfort from my presence. They would see me and say, ‘Are you coming up today?’ or ‘We didn’t see you for two days, what happened?’. And there was a look of satisfaction when I walked into the neighbourhood”.
(SCP 8)
“The role of supporting staff is different than it used to be. I have put up poetry and prayers in the newsletter. I’m part of a team that’s trying to think abut how we pick up some of the things that are missing, like how do we help people in their grief?”.
(SCP 43)
“We didn’t realize how much our staff needed spiritual oxygen… they appreciated messages of hope, uplifting, inspirational, encouraging messages, that we printed out or put on our big TV”.
(SCP 37)

3.4.4. SCPs Need to Continue to Be Adaptable, Creative and Innovative to Provide What Is Needed

Restrictions forced SCPs to imagine and implement spiritual care in new ways, searching out and learning to use resources, including technology, to uphold spirits. In the experience of losing valued practices, such as dignity walks, they have learned the power of ritual, and the need to find ways to enable meaningful practices in their homes. They have learned the importance of connection and are challenged to find ways to nurture experiences of belonging, community, and being remembered and loved, amidst the necessity of physical distancing. Chaplains can give thought and energy to the little things that make all the difference for people who are stressed and isolated. One spoke of her role as an advocate for meeting spiritual needs,
“[I’ve learned] to say, those are the restrictions, what can I still do with this? How can I find another way of doing something that’s creative and spiritually life-giving for our residents?”
(SCP 36)

3.4.5. SCPs Need Support as Well

Just as residents and team members struggled and were supported by SCPs during the pandemic, SCPs also felt the need for supportive people and spaces. Some mentioned feeling overwhelmed when they felt they had not been able to help residents as they would have liked (SCP 13), needing to mourn those who had died, grieve over pervasive illness, and even feeling traumatized (SCP 21). Often the only SCP in the home (a lonely role), it seemed they carried the burden for spiritual care provision for everyone. One said, “just watching my own mental health has been increasingly difficult. Sometimes, I feel like I’m bearing the weight of all the staff and all the residents and… the families too”. (SCP 13). Some longed for more training, especially in meeting mental health needs, and for spiritual care colleagues with whom to consult and commiserate.

4. Discussion

The pandemic of 2020–2022 brought both disruption to, and increased need for, spiritual care in long-term care and retirement homes. SCPs in these settings reported a variety of experiences as they each endeavored to adapt to their circumstances. During the pandemic, SCPs provided spiritual care through virtual services, and other virtual connections, mini-services and gatherings, room visits, printed material, sacred space, music, palliative care, and end-of-life rituals. They found it especially challenging to meet needs for touch, community, mental health care, and processing grief.
This study found that during the pandemic, there were lessons learned about the role and importance of spiritual care, effective provision of care in new ways that challenged previous assumptions, the need for team member support, and the need to be adaptable, creative and innovative going forward, while maintaining their own wellbeing as spiritual care providers.
It is interesting that while spiritual care providers work independently, their individual adaptations were remarkably similar to those of their fellow chaplains. The adaptations reported by these chaplains in Ontario were not unlike those seen in the United States (Seidman 2021), Australia (Drummond and Carey 2020), and around the world (Vandenhoeck et al. 2021).
While the practices of those SCPs reported in this paper remained quite robust, this paper does not equally reflect the experience of those homes where spiritual care was deemed ‘non-essential’. A similar dearth of spiritual care under these circumstances was anticipated in Australian aged care (Tan et al. 2021). Also to be considered are the 51% of homes in this area which did not employ a chaplain pre-pandemic (Kuepfer et al. 2022). With the loss of community volunteers, these homes were either left entirely without spiritual care throughout the pandemic, or with spiritual care in the hands of a team member (often recreation) who is unlikely to have the training or experience to provide appropriate spiritual care. While this study showed remarkable consistency in the content of spiritual care provision, as mandated by the Ontario Long-Term Care Homes Act (2007), across homes with spiritual care providers, many homes employ no one to provide this care.
Adaptation of spiritual care to the circumstances of the pandemic provided opportunities for learning and improving accessibility and resilience of spiritual care practices into the future. The chaplains in this study were not alone in their experience of adaptation. An international survey of 1657 chaplains from 36 countries about how and to whom they delivered spiritual care during the first phase of the pandemic noted that every chaplain surveyed experienced a change in the way they worked as a function of the pandemic (Snowden 2021). Jones et al. (2020) found that the change in the healthcare environment and the impact of the virus created a context in which the need for chaplains to adapt to new ways of providing spiritual care became paramount. Additionally, a survey of chaplains around the world to learn about changes in aspects of spiritual care during the pandemic (Vandenhoeck et al. 2021), concluded that chaplains show strong resilience and capacity to adapt. This study resonated with their findings that a flexible and creative attitude, along with the use of technology, allowed for effective spiritual care, and that increased contact and connection, particularly with families and colleagues was a positive outcome of the pandemic.
This paper described many practical adaptations used by SCPs in Ontario, identifying some additional important learnings. Through the pandemic we realized the importance of chaplains in maintaining morale and bringing people together emotionally as a listening and supportive presence. The opportunity to personalize spiritual care using technology, and the value of small, intimate gatherings was realized, along with the value of employing an in-house chaplain who truly gets to know residents and can continue to creatively adapt to meet changing needs in changing circumstances.
Some of the needs these chaplains found difficult to meet are being recognized in other places as well, particularly noting lack of closure around deaths and the need for public and private rituals to allow for grieving and support (Drummond and Carey 2020).
With Jones et al. (2020), this study found both pros and cons to using electronic devices, with advantages including allowing provision of pastoral care without risking infection or needing to use PPE and making contact with family members easier. Physical presence is often preferable in spiritual care, however, in order to build rapport and pick up signs of distress. Additionally, residents are not always interested in or able to use new means of communication. This study found admirable initiative among SCPs to learn and make use of the technology available to them, and surprising levels of uptake among residents and families looking to connect in any way possible. As researchers continue to make technology more accessible for older adults, of varying cognitive ability, SCPs will do well to maintain the skills learned and discern how technology can be a useful tool into the future.
The pandemic established the role of spiritual care in long-term care and retirement homes as essential, not optional (Tan et al. 2021). The findings of this study resonated with Jones et al. (2020) who described the chaplain’s role during the pandemic as providing a calm presence, being available, holding out hope, and introducing creative ways to provide spiritual care, while seeking spiritual nourishment themselves. Interestingly, Snowden’s survey (2021) found that chaplains around the world felt widely misunderstood, undervalued and underused during the first wave of the pandemic. Most reported that they were not considered essential, and these chaplains themselves felt unclear about their role at times. The chaplains in this study, while open to discern how to be most helpful, especially in early days, spoke with confidence about the importance of their role as presence, for team and family reassurance, as well as for the residents. Swift’s (2020) discussion of pastoral care in residential care facilities in the UK during the pandemic similarly suggests that presence and in-person encounter remain key aspects of being, and that the experience of the pandemic clarified the importance of embodied support for those who are suffering.
The place of spiritual care as an integral part of the team has been demonstrated in many homes. An increase in the provision of staff support also heightened awareness of spiritual care and its value (Drummond and Carey 2020; Snowden 2021; Tata et al. 2021; Vandenhoeck et al. 2021) in ways that will carry into the future. The experience of the pandemic has highlighted the need for and importance of spiritual care, both in homes that have it, and for homes that are without. Contrasting homes with and without spiritual care during the pandemic would be worth further study.
The limitations of this study include the relatively small sample, drawn from a limited geographical area, and the lack of information from homes without a spiritual care provider on staff.

5. Conclusions

Spiritual care has been filling an important role during pandemic, when need has been felt and expressed by residents, families and team members. As in other parts of the world (Jones et al. 2020; Swift 2020; Tan et al. 2021; Tata et al. 2021), chaplains in long-term care and retirement homes in Ontario, Canada, have played a significant role during the pandemic, and management needs to ensure their availability into the future.
Going forward, to ensure adequate spiritual care provision in times of crisis or prolonged outbreak it is recommended that homes do the following:
  • Employ an in-house spiritual care provider (avoiding reliance on volunteers);
  • Encourage meaningful spiritual care practices, community rituals and ways of connecting that are adaptable to infection control protocols;
  • Ensure their SCP is both creative and adept with technology, and have enough team member support to get residents connected;
  • Ensure enough spiritual care time to provide for multiple small gatherings, one-to-one connections, and team member and family support.
In an era when we realize circumstances can change quickly and dramatically, it is vital that we are prepared to support the spirits of those in residential care.

Funding

The study was conducted in accordance with the Declaration of Helsinki, and approved by the Research Ethics Board of the University of Waterloo [(#40919, approved 4 October 2019, amended 2 September 2020)]”.Informed consent was obtained from all subjects involved in the study Data is available from the author.

Acknowledgments

This research is a collaboration with the Schlegel-UW Research Institute for Aging (RIA), at the University of Waterloo. To learn more about the RIA’s work to enhance quality of life and care for older adults: www.the-ria.ca (accessed on 15 March 2022). The author is grateful for the research assistance of Chi-Ping Loreta Sinn.

Conflicts of Interest

The author declares no conflict of interest.

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