Special Issue “International Conference of Spirituality in Healthcare. Sowing the Seeds”—Trinity College Dublin 2015

This is an editorial of a Special Issue concerning the International Conference of Spirituality in Healthcare held in the School of Nursing and Midwifery, Trinity College Dublin, Republic of Ireland (ROI), in June 2015 [1]. This inaugural event was the ﬁrst international spirituality in healthcare conference hosted by Trinity College Dublin, with a second international conference planned for 23 June 2016. Conferences provide an opportunity for sharing and debate among experts or professionals with a particular interest in the topic. The editorial will introduce the subject of spiritualty in healthcare, some arising deﬁnitions and, through an outline analysis of a sample of these papers, explain their contribution to healthcare for the future.


Spirituality in Healthcare
This Special Issue, related to the conference, features an eclectic series of papers.Overall the number of papers devoted to the topic of spirituality is expanding [2,3] and one of the papers in this Special Issue draws attention to this fact [4].Spirituality is being considered in very diverse fields of nursing including for example within prisons [5].A further paper acknowledges the growing interest in this topic by showcasing the development of a Spirituality Interest Group in Ireland [6].The attention being devoted to spirituality in healthcare indicates that this dimension is of importance to nurses and healthcare practitioners, recognising the perceived benefits of supporting patients' spiritual needs [7].One paper in this Special Issue outlines how spiritually self-care practices can have a positive influence on depression and related quality of life [8].While the practice of some organised religions is on the decline internationally, spirituality as a topic in its own right is gaining increased attention [9,10].There is the British Association for the Study of Spirituality-BASS [11] and the European Network of Research on Religion, Spirituality and Health (http://www.fisg.ch/en/home)for example, and evolution of centres for the academic study of spirituality offering MSc and PhD opportunities in the study of spirituality internationally, with growing numbers of alumni, such as, for example, the Spiritual Institute for Research and Education (Spire) in Ireland [12].
However before we consider in more detail the role of spirituality in healthcare, and how this Special Issue may contribute to this, we need to think about the variety of understandings of spirituality and spiritual care.Spiritual care is that which recognises and responds to the needs of the human spirit when faced with trauma, ill health or sadness.Spiritual care can address the need for meaning, for self-worth, to express oneself, for faith support, perhaps in the form of rites, prayer or sacrament, or simply for a sensitive listener [13].Spiritual care begins with encouraging human contact in compassionate relationship, and moves in whatever direction is needed [13].For the purposes of this discussion we refer you to a recent concept analysis of spirituality [14] that suggests that there is a strongly held belief that spirituality concerns reflection own life experiences.Spirituality concerns a sense of connecting with others, transcendence and finding meaning and purpose in life [14].Transcendence in this sense refers to the concept of a higher or greater purpose in life, a sense of what it is important to do and what constitutes a good or a right way to live.This notion of meaning-making is gaining popularity as the central component of spirituality, suggesting that the human need to make sense of life events is an expression of spirituality [15].It is important to remember that spirituality is also a cultural dimension of humanity [16] and it is not static in so far as it may change across the life span of the individual, and/or when facing life changing events or crisis.Whether or not those who lack cognitive capacity have spiritual needs, or require spiritual support in healthcare is a matter for debate, and one that has not been satisfactorily resolved.Rather this debate, like so many aspects of spirituality, relies on particular belief frameworks (e.g., philosophical, psychological or religious).

Spiritual Care from Childhood to the End of Life
Although spirituality is often considered in relation to adult patients, spiritual care and spirituality should also be taken into consideration in paediatric and adolescents patients.In this regard, Nascimento [17] describes qualitative research to elicit the meaning of spirituality according to nurses working in paediatric intensive care units and nurses' experiences in providing spiritual care to children and their families.The link between spirituality and care of sick children and their families is explicated vey specifically in this piece; there is also emerging recognition of the spiritual needs of nurses caring for sick children.A point of interest in the Nascimento paper [17] is a discussion comparing and contrasting the essence of the concepts of spirituality and religiosity and how these are often shaped and influenced by culture, the individual's experiences and perceptions of life and living.Difficult ethical questions such as the possible transfer of nurses' own beliefs to patients are raised and also, that most of the participants did not consider the meaning of spirituality for the child they were caring for.Implications for practice, education and research arising from this study are shared.
Addressing peoples' spiritual needs, while receiving healthcare, by connecting with them, supporting their meaning-making, connections and transcendence, can alleviate suffering and provide a sense of wellbeing that may help clients deal with adversity [13,18].Spiritual care is person-centred and usually provided on a one-to-one basis [19,20].Essentially, spirituality is an individual belief system that can vary according to individuals, their particular cultural or religious background and according to the society in which they find themselves.Spirituality involves ones belief system about personal identity, purpose and meaning, what it means to be human to live in a meaningful and a moral way [21].
Within this Special Issue how this meaning can be facilitated is clearly elucidated by Costello [22], founder of the Victor Frankly Institute in Ireland.He outlines Victor Frankl's Logotherapy, and how this can facilitate "healing through meaning" ( [22], p. 1).Logotherapy "starts from man's spirit" and considers the spiritual dimension of man as fundamental to psychological therapy.Costello identifies within this framework to be human is to be spiritual; drawing on Frankl's assertion that existence "is in essence spiritual" ( [22], p. 7).Costello suggests that support with determining life's meaning (through logotherapy) can assist with spiritual crises, which can accompany mental or physical health issues.
Further to this, O'Sullivan [23] poses three questions about spirituality and health care that provide a focus for his paper and they are: (1) what makes a person and a life spiritual so that a strictly medical model of health and care won't do?(2) What is the scope of healthcare? and (3) what makes care in healthcare 'spiritual' precisely?These questions are of significance for health carers and health care-seekers alike.This discussion is relevant to anyone who is interested in the concepts of spirituality and health, together or separately.This paper draws the reader in, bringing a new understanding of holism and connection between the body and soul.O'Sullivan draws from a wide variety of sources and examines phenomena that include dualism, religiosity, authenticity, presence and self-care, many of which are central to contemporary conversations about health care.He shares new insights and personal perspectives and refers to a culture of care and love on a societal and a personal level through our face-to-face interactions with those we meet.You will find yourself returning to this paper with a desire to read it again.He highlights that that there is increasing emphasis on integrating spirituality into healthcare, not least by the practice of kindness and authenticity.He also identifies the necessity for spirituality to become a focus in healthcare because: "a strictly medical model of health won't do because the life of each us is a personal life, with others.As personal we experience our lives against the background of questions like, who am I, where have I come from, why did I come to be, where am I going, why do I have to die . . .how will I be remembered?...our health, what affects it will be more than a medical matter for us and those connected with us." ( [23], p. 2).
Henry and Timmin's [24] paper supports the notion that spiritual and religious needs coexist in palliative care settings, particular during death and dying, and that nurses find themselves having to be very resourceful in such situations.Inbadas [25] further highlights the cultural dimension of spirituality in palliative care.He calls for the need to find practical expressions of spirituality, and underlines the importance of attending to the "cultural embeddedness" of spirituality at such times ( [25], p. 7).He recognises, in keeping with our proposed definition, that meaning, purpose and transcendence are key aspects of personal spirituality.However, to provide spiritual support to patients healthcare workers need to be competent to do so, and also need to address patients' spiritual needs.Catania et al. [26] state that determining how spiritual needs are assessed and defined is a core subject in palliative care.The paper [26] reviews how the documentation of spiritual concerns can alleviate spiritual distress or promote spiritual wellbeing/quality of life.The authors [26] highlight that while spiritual needs are acknowledged within the palliative care setting, focused quality of life interventions did not significantly improve spiritual well-being.The best way to gain an understanding of what is important for patients or provides meaning for them is to ask them.While recognising that spiritual assessment and spiritual care is the specialist professional domain of healthcare chaplains there is much that healthcare staff can do in terms of brief screening of spiritual needs and referral to chaplains.There are several models of assessment used by both chaplains and nurses in healthcare.Usually an informal approach is suggested rather than formal assessment and mnemonics that prompt the asking of key questions are often suggested to elicit the necessary information.Regardless of the limitations of screening and assessment, the authors found when there is a spiritual need, spiritual care should be appropriately planned and delivered.

Educational Aspects and Competencies for Spiritual Care
Nurses, describe the assessment of spiritual needs as one barrier to providing spiritual care.Van Leeuwen and Cusveller [27] suggest that there are six core competencies required to provide spiritual nursing care: handling one's own beliefs, addressing spirituality, collecting spiritual assessment information, discussing and planning spiritual interventions, providing and evaluating spiritual care, and integrating spirituality into institutional policy.Within this list of competencies the importance of assessing and documenting spiritual care needs and interventions are highlighted, but so also is handling one's own beliefs, which can be developed by personal critical reflection.Van Leeuwen, co-authored another of the papers in this Special Issue which specifically addresses spiritual competence of nurses [28].Spadoni and Sevean [4] also describe an ambitious and detailed education package provided to nursing students, and are convinced of the benefit of and need for such education among nurses, a belief that is reiterated throughout the nursing literature [29][30][31].These authors also emphasised the importance of reflection for the development of spiritual competence [4].In van Leeuwen and Schep-Akkerman's [28] study, nurses (n = 449) self-declared themselves spiritually competent, with mental health nurses receiving higher scores.In another paper in this series [32] most South African nurses (n = 280) determined that spiritual care giving was part of the nurse's role, but need greater preparedness.Interestingly praying with patients was "seen as ethically acceptable" by most (83%) of the sample [32].

Interventions and Outcomes
The concept of prayer is taken up by two of the papers in this Issue.Lycett et al. [33] describe a planned methodology for a ten-week "church based, health, intuitive eating programme" aimed at assisting weight loss.They provide convincing evidence of the need for this type of study and demonstrate how local churches may become active in health promotion.This community-based programme may be more responsive than more traditional medical approaches, and several reliable measures are proposed that will likely produce interesting results.The authors [33] hypothesize positive results with their intervention.The subject of prayer is also addressed by Simão et al. [34].This team reviewed 12 RCT studies, two involving petition prayer (by patients' themselves and so unblinded), and 10 involving blinded intercessory prayer (prayer provided by another person).The results in seven of the twelve show that the use of prayer may promote different positive effects such as the reduction of anxiety and depression; a higher pregnancy rate for women receiving IVF; better physical functioning; fewer deaths in patients with bloodstream infections; fewer days in the Coronary Care Unit for patients with cardiac problems.Results seem to indicate that "belief" in the power of prayer increases efficacy but this raises the possibility of belief or "faith" as a relevant but non-randomised confounding variable.The reviewers note that there is a need to standardise interventions, but overall suggest integration of prayer in clinical practice, for effective holistic care.No guidance is offered on how to integrate prayer into holistic care.Are nurses to encourage believers to ask others to pray for them?Or simply to respect and leave space and opportunity for believing patients to pray themselves?It can hardly be considered a universal requirement for nurses themselves to pray for patients.Those inclined to do so might need to ask patients whether they would feel that was appropriate, but even then, such a request could be construed as professionally inappropriate proselytising.Indeed any request for prayer should be expressed and led by the patient not by the nurse or healthcare professional.
Spirituality and Religion are inextricably connected and sometimes it is difficult to separate the two [13].Understanding of different religious faiths and needs is essential for the nurse healthcare professional when providing and supporting effective spiritual care.However, there is a risk, in healthcare, if spirituality is approached too broadly, without specific reference to or understanding of people's religious preferences, that the approach is too superficial [35].Without specific consideration of a person's religion, specific beliefs are hard to establish with sensitivity or accuracy and so it is difficult to provide effective interventions.One original research paper, Guilherme et al. [36] describes the pilot study for a Randomised Controlled Trial to evaluate the effect of a spiritual support intervention, consisting of meditation, guided imagery, music, and respiratory relaxation, on spirituality and the clinical parameters of women who have undergone mastectomy.Primary outcomes of interest are spirituality, hope and optimism; and physiological measurements of blood pressure, heart rate, and oxygen saturation.The measurement of quantifiable physiological outcomes may appeal to researchers of post positivist persuasion, bringing spirituality as a concept further into quantitative discourse.The results of this research will also be of interest to practitioners and clinicians caring for women preparing for and recovering from surgery of this nature.Perhaps the overall strength of this paper however, is the gentle insight it conveys into the spiritual and holistic needs of the person affected by mastectomy.This is a very interesting and informative piece that takes the whole needs of the woman into account and therefore, could be of relevance and significance for all women undergoing this life-altering surgery.This research highlights novel and individual approaches to interventions that may support real life healing and rehabilitative needs.

Moving beyond From "Sowing the Seeds" To "Nurturing the Spirit"
This conference brought together researchers, healthcare workers and students from different countries worldwide.Interestingly the discussion regarding spirituality goes beyond countries, genders and ethnicities.The common interest is focused on working together to integrate spirituality in clinical practice, in the certainty of its humanizing character.The growing interest of the scientific academy and the many studies are being conducted around the world indicate that the change we seek and anticipate may be slow but it will be evidence based.This was the first conference organized by this innovative group (SIG) and its theme was "sowing the seeds".The second conference (2016) has as its theme "nurturing the spirit" and again a collection of peer reviewed papers from the conference will appear in this journal in 2017.These yearly conferences in Dublin are a great contribution to this topic, particularly in the discussion and implementation of spiritual care and have created an additional platform for discussion and debate on spirituality.