Towards National Consensus: Spiritual Care in the Australian Healthcare Context

The Enhancing Quality and Safety: Spiritual Care in Health National Consensus Conference brought together key stakeholders from across Australia to agree a national framework to ensure quality and safety in spiritual care services through a nationally consistent approach to the provision of spiritual care in Australian hospitals. A working group planned the conference that was held over two days. Invitations were distributed to a wide range of stakeholders to ensure a diversity of voices contributed to the outcomes. The conference proceedings included presentations, small group work and facilitated discussion to enable progress on the conference objective. A conference report of the key outcomes was produced and widely distributed. The national consensus conference outcomes described five principles for the design and delivery of spiritual care services for the Australian context. Ten policy statements described key deliverables that could be used to benchmark and measure a nationally consistent approach to spiritual care.


Introduction
The last two decades has seen increased attention given to quality and safety in health care in response to endemic failures in the system to protect patients from harm (Wilson 2005;Hamilton 2000;Hamilton et al. 2014, Duckett 2016).Within this context it is recognised that safety and quality of care require more than attention to the medical and technological aspects of care.Patient-centred care that incorporates concern for the patient's beliefs and values has been identified as a key component for safe and high quality care (Australian Commission on Safety and Quality in Health Care 2011).Beliefs and values are recognised as fundamental elements of current understandings of a person's spirituality and therefore important to any assessment of spiritual needs (Puchalski et al. 2014).While current data reveals Australia to be an increasingly secular society (Australian Bureau of Statistics 2016), research demonstrates that patients want their spiritual needs considered as part of their overall health care (Best et al. 2014).The provision of spiritual care in response to spiritual needs has increasingly appeared in state and government reports in Australia, and while spiritual care is being provided in Australian hospitals, there has been little attention given nationally to how it is provided, who is providing it and how the contribution of this essential element of care is measured.Spiritual Care Australia 1 released the first National Standards of Practice in 2013 (Spiritual Care Australia 2013), however implementation of these standards is not mandatory and there has been no evaluation of how widely these have been used and/or integrated.A commonwealth grant in 2015 enabled the 1 Spiritual Care Australia is the national professional association for organisations and individual practitioners in spiritual care services.The association seeks to unify, consolidate, support, promote & encourage the development of spiritual care within contemporary multi-faith, multi-cultural Australia.development of National Guidelines for Spiritual Care in Aged Care that were launched in 2016 and provide a well-defined example of a national approach within a specified sector (Meaningful Ageing Australia 2016).In response to the need for a nationally agreed approach for spiritual care provision and governance in acute health, Spiritual Care Australia and Spiritual Health Victoria2 established a working group in 2015 to plan for a national consensus conference.This idea was based on conferences held firstly in the USA and then internationally that sought to develop consensus on definitions, models and future goals for spiritual care in palliative care and health care (Puchalski et al. 2014).The main purpose of the Enhancing Quality and Safety: Spiritual Care in Health National Consensus Conference was to agree a nationally consistent approach and framework to ensure quality and safety in spiritual care services for Australian hospitals.There were three key drivers identified to facilitate the development of a national strategy for spiritual care: 1.
A nationally consistent governance framework to ensure quality and safety in spiritual care services; 2.
Viable and sustainable spiritual care models; and 3.
Quality education and training.

Sequence of Events
Following the release of the outcomes from the international consensus conference held in Geneva in 2013 (Puchalski et al. 2014), the Chief Executive Officer for Spiritual Health Victoria took a proposal to a meeting of the Community of Practice (Health)3 recommending that a national consensus conference be held in Australia.At a subsequent meeting held in November 2015 the Community of Practice agreed to proceed and over ensuing months a working group was established (with representatives from three of the six Australian states and one of the two Australian territories).From November 2016 to January 2017 a national survey was conducted to explore the attitudes of key stakeholders to the provision of spiritual care in hospitals.The results of this survey were used to inform the conference participants and have since been published (Holmes 2018).
Dr Norman Swan4 agreed to facilitate the conference and the conference program was finalized including keynote speakers and presentations of case studies.Two pre-conference papers were prepared and distributed to all participants and included an evidence brief, 'Is there evidence that spiritual care positively affects health outcomes and patient experience?' and a summary of survey results 'Report from a National Survey'.

Participants
The conference was an invitation only event with numbers originally capped at sixty to foster a good environment for a working conference.The working group sought to bring together a diverse range of key health experts, influencers, academics and practitioners and invitations were sent to national and state based peak bodies for health, all Australian Health Ministers and state-based health departments.Invitations were also sent to individuals with relevant interest or expertise identified by the working group.This diversity of participants was important as the working group agreed that, 'by not using a homogeneous group, but rather a wide variety of affected parties, one can identify all the issues and opinions that surround a certain issue, policy or problem' (Manley 2013, p. 757).In the end sixty-eight people gathered in Melbourne from across Australia.Participants represented universities, health practitioners, government health departments, faith representatives, spiritual care practitioners, and national organisations and peak bodies.

Conference Proceedings
The conference took place over two days in June 2017 beginning with a pre-recorded welcome from the Victorian Health Minister.Conference participants were assigned to one of eight table groups with a delegated scribe.The first day of the conference included presentations making the case for the inclusion of spiritual care in health and identifying some of the barriers to inclusion.A number of spiritual care practitioners delivered case studies of their research in the field.There was some opportunity for conversations amongst table groups following presentations and the day concluded with feedback from each table summing up their responses to the day.The second day commenced with a presentation on how to influence policy from Dr Stephen Duckett 5 before the table groups commenced work on developing principles for design and delivery of spiritual care services.Participants then self-selected into new working groups to identify key strategic directions in six agreed areas: 1. Governance 2.
The Uniqueness Principle (what is unique, distinctive about spiritual care?) Following the two-day conference, a preliminary report was prepared based on all of the gathered notes from the working groups and distributed to all participants.The CEO of Spiritual Health Victoria and the National President and the Executive Officer of Spiritual Care Australia undertook further refinement of the identified directions and a follow-up national meeting was held in August 2017.At this meeting sixteen people representing twenty organisations reached consensus on five principles for the design and delivery of spiritual care services and ten policy statements and committed to implementing these in the organisations they represented.

Results
A final report of the outcomes from the conference was published in October 2017 (Holmes 2017).The final report outlined the five Principles for Design and Delivery of Spiritual Care Services and the ten Policy Statements as outlined in Tables 1 and 2 respectively.These principles and statements represent the culmination of input and discussions that focused on the key drivers: governance, spiritual care models and education and training.

1.
Spiritual care is integrated and coordinated across all levels of the health system in Australia.2.
Spiritual care is available for all people.3.
Spiritual care is provided by a credentialled and accountable workforce.4.
Spiritual care is a shared responsibility.

5.
Research is conducted on the contribution, value and effectiveness of spiritual care.
5 Dr Stephen Duckett is an economist and health services manager who has occupied leadership roles in health services in both Australia and Canada.He is currently program director of Health at the Grattan Institute (an Australian public policy think tank).

1.
There is a paid professional spiritual/pastoral care workforce in hospitals.

2.
All health professionals receive training about spiritual care.

3.
All patients are offered the opportunity to have a discussion of their religious/spiritual concerns.4.
All patients have an assessment of their spiritual needs.5.
Patient's values and beliefs are integrated into care plans.6.
Information gathered from assessments of spiritual needs is included in the patient's overall care plan.7.
Families are given the opportunity to discuss spiritual issues with health professionals.8.
Faith communities are recognised as partners in the provision of spiritual care.9.
Spiritual care quality measures are included as part of the hospital's quality of care reporting.10.
Hospitals provide a dedicated space for meditation, prayer, ritual or reflection.
The final report was distributed electronically to all conference participants, and other initial conference invitees, and a hard copy was also sent to every Health Minister and Shadow Health Minister in Australia.The Commonwealth of Australian Governments' Health Council Secretariat distributed an electronic version of the report to all Government jurisdictions.

Discussion
Outcomes from the conference provide a clear direction for a nationally consistent approach to spiritual care.The principles and policy statements specify key parameters and measurable benchmarks for spiritual care, with the policy statements aligned with internationally defined quality indicators (Healthcare Chaplaincy Network 2015).In the twelve months since the conference the outcomes have been widely distributed but there has not been a recognized and authorized lead to take this agenda forward in health care.This means that implementation remains ad hoc and subject to different interpretation across states and territories, organisations and health services.Spiritual Health Victoria has initiated preliminary conversations with the Australian Council for Healthcare Standards and the Australian Commission for Safety and Quality in Health Care in response to the risk for health services in providing spiritual care that is not appropriately benchmarked against best practice.However, gaining traction in these conversations remains difficult in the absence of a clear national mandate.There are existing models of care that could inform a national approach.Spiritual Health Victoria and Meaningful Ageing Australia, two leading organisations for spiritual care in Australia, agree on a model of spiritual care (Figure 1) that is supported by the conference outcomes and by other stepped models of care (Fitch;Rumbold 2012).The model at Figure 1 first appeared in a Spiritual Health Victoria consultation document to develop a framework for spiritual care in Victoria in 2011.It has subsequently been reproduced (with sector specific amendments) in the National Guidelines for Spiritual Care in Aged Care (Meaningful Ageing Australia 2016).
A number of Catholic health care providers were represented at the conference and at the follow-up meeting and committed to implementing the principles and policy statements.Spiritual care is already firmly embedded in the provision of health care within Catholic hospitals through their health service employed pastoral care teams.This provides another working model of spiritual care.Evaluation of current models against the nationally agreed (and internationally aligned) policy statements would be a significant step for working towards a nationally consistent approach.The public system throughout Australia continues to provide spiritual care through models that include: spiritual care practitioners employed directly by health services; chaplains employed by faith communities in receipt of government funds; and/or services provided by volunteers.The responsibility for spiritual care provision and accreditation needs to be recognised by organisations such as the Australian Commission for Safety and Quality in Health Care and the Australian Council for Healthcare Standards, by state and federal health departments, and by individual health services.Responsiveness to spiritual needs is recognised as a component of providing quality and safety in health care.In 2018 Spiritual Health Victoria defined spiritual care as "the provision of assessment, counselling, support and ritual in matters of a person's beliefs, traditions, values and practices enabling the person to access their own spiritual resources".This definition is based on the ICD-10AM ACHI/ACS Spiritual Care Intervention Codes (The Independent Hospital Pricing Authority 2017) and the definition of 'spirituality' from the international consensus conference (Puchalski et al. 2014).The current variation in understanding and models of spiritual care that exist in Australian hospitals poses an unnecessary risk to both quality and safety.A nationally agreed approach to spiritual care in the health sector will mitigate against the risks of the current variations in service provision.While the outcomes from the national consensus conference provide a vision for a nationally agreed approach to spiritual care in Australian hospitals, there are emerging questions that will need to be addressed: 1.
How will we demonstrate the contribution spiritual care makes to quality of care? 2.
How can we co-design models for spiritual care to ensure spiritual care is provided in response to people's identified needs? 3.
What is the role of the faith communities as partners in the provision of spiritual care? 4.
What is the pathway for formation of a competent spiritual care practitioner? 5.
How will we ensure a credentialled and accountable workforce?
The final report was distributed electronically to all conference participants, and other initial conference invitees, and a hard copy was also sent to every Health Minister and Shadow Health Minister in Australia.The Commonwealth of Australian Governments' Health Council Secretariat distributed an electronic version of the report to all Government jurisdictions.

Discussion
Outcomes from the conference provide a clear direction for a nationally consistent approach to spiritual care.The principles and policy statements specify key parameters and measurable benchmarks for spiritual care, with the policy statements aligned with internationally defined quality indicators (Healthcare Chaplaincy Network 2015).In the twelve months since the conference the outcomes have been widely distributed but there has not been a recognized and authorized lead to take this agenda forward in health care.This means that implementation remains ad hoc and subject to different interpretation across states and territories, organisations and health services.Spiritual Health Victoria has initiated preliminary conversations with the Australian Council for Healthcare Standards and the Australian Commission for Safety and Quality in Health Care in response to the risk for health services in providing spiritual care that is not appropriately benchmarked against best practice.However, gaining traction in these conversations remains difficult in the absence of a clear national mandate.There are existing models of care that could inform a national approach.Spiritual Health Victoria and Meaningful Ageing Australia, two leading organisations for spiritual care in Australia, agree on a model of spiritual care (Figure 1) that is supported by the conference outcomes and by other stepped models of care (Fitch 2000;Rumbold 2012).The model at Figure 1 first appeared in a Spiritual Health Victoria consultation document to develop a framework for spiritual care in Victoria in 2011.It has subsequently been reproduced (with sector specific amendments) in the National Guidelines for Spiritual Care in Aged Care (Meaningful Ageing Australia 2016).As we contemplate the long road that still lies ahead for the full integration of spiritual care in health, it is important that our focus always remains on what really matters-the person at the center of care and the relationships at the heart of it all.
Funding: Funding for the conference was received from the following sponsors: The State Government of Victoria, St Vincent's Health Australia and Spiritual Health Victoria.

Table 1 .
Principles for design and delivery of spiritual care services.