Curriculum development, courses, and CPE: Part I: Curriculum development in spirituality and health in the health professions
Curriculum development in Spirituality and Health, which focuses on formal teaching of this topic, is a relatively new field within medicine, nursing and other health professions, in terms of formal courses in this subject area. Inspired by the advances of scientific technology, medical, and nursing schools focuses their training primarily on the scientific and technical aspects of their disciplines. It is important to note that, historically, some aspects of spirituality, which included religion, ethics, and caring presence, were part of medicine and nursing academic settings. However, spirituality was gradually omitted in favour of the technical and biomedical aspects, with the humanities and other non-technical subject matter deemed less important. In this chapter we are focusing primarily on major efforts in the USA, UK, and Australia. We also cover pastoral counselling, spiritual direction, and chaplaincy as these professionals work closely within the health system to provide spiritual care for patients and families.
United States perspectives
In the mid-1980s in United States, a few medical schools, particularly schools associated with a particular religious denomination, developed courses in religious traditions and healthcare, or included religious values as part of ethics courses. In 1993 only three US medical schools provided teaching on religious and spiritual issues as applied to medicine;[1,2] this figure has since risen to over 80% of medical school schools. Now, more than 100 US medical schools have such training. This increase is in part due to a John Templeton Foundation funded programme entitled the GWish Spirituality and Medical Education Program directed by the George Washington Institute for Spirituality and Health at the George Washington University. This was a competitive award programme in which medical schools proposed a curriculum in spirituality and health, and the curricula were rigorously judged by leading academic deans and curriculum faculty. Schools with the highest score were given a small amount of funding to develop their curricula. Interestingly, even schools that were not awarded funding, but who applied to the award programme developed courses in spirituality and health. Anecdotal evidence supports the idea that this was driven by schools’ interest in developing courses that humanized the curriculum.
The first required medical school course in Spirituality and Health, with spirituality broadly defined, was developed at the George Washington University School of Medicine and Health Sciences in Washington, DC.[2,3] A committee of faculty and community clinicians helped develop it as an elective in 1992; four years later, the course was integrated into the four-year medical school curriculum. The strengths of the curriculum and perhaps one reason it was accepted was that the course built on existing goals of the medical school to enhance more holistic, person-centred care through curricular changes. The curriculum in spirituality and health also met the goals of the Medical School Objectives Project, an Association of American Medical Colleges (AAMC) ten-year project to change medical school education with increased focus on humanities, communication skills, and compassion. Thus, when the Awards for Curriculum Development Program was started other medical schools could also build upon other programmatic curricular goals which courses in spiritual could support.
Awards for Curriculum Development for Medical Schools have recognized the best curriculum proposals and brought oversight to the integration process at award recipients’ schools, medical schools have implemented such courses in their own fashion, resulting in a wide variety of topics, pedagogies, and timelines—and different definitions of the knowledge, attitudes, and specific patient-care competencies medical students should attain from these courses. Since the inception of this programme, now known as the GWish Curricular Awards in Spirituality and Health, there has been significant success integrating spiritual care in the healthcare practices taught by US medical schools and building consensus among national organizations regarding the significant role spirituality plays in patient-focused, quality healthcare. Currently 80% of US medical and osteopathic schools offer courses in spirituality and health—a marked increase from the few schools that taught courses about twenty years ago.
A significant factor in the development of curricula in spirituality and health has been the partnership with the Association of American Medical Colleges (AAMC). In response to empirical, ethical and philosophical principles, the Association of American Medical Colleges (AAMC), the World Health Organization (WHO), and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) recommended including spirituality in clinical care and education. In collaboration with the Association of American Medical Colleges (AAMC), the work of GWish has had impact on medical education in this subject area. Learning objectives and criteria for teaching were developed in 1998 with the AAMC, but with the development of courses, the field has developed substantially and has increased the sophistication of teaching as well as content of learning objectives.
The support of the AAMC occurred because the objectives of the course in Spirituality and Health that were beginning to be developed in the early 1990s were aligned with a larger national curricular initiative led by the AAMC. In 1998, the Association of American Medical Colleges (AAMC), responding to concerns by the medical professional community that young doctors lacked humanitarian skills related to patient-centred care, undertook the Medical School Objectives Project (MSOP). The final project report notes, ‘Physicians must be compassionate and empathetic in caring for patients … they must act with integrity, honesty, respect for patients’ privacy, and respect for the dignity of patients as persons. In all of their interactions with patients they must seek to understand the meaning of the patients’ stories in the context of the patients’ and family, and cultural beliefs and values.’
In the follow-up MSOP III report, published in 1999, the AAMC further supported the development of courses in spirituality and health in medical schools by identifying seven spirituality-related learning objectives medical students should demonstrate to the satisfaction of faculty prior to graduation. The objectives include the ability to elicit a spiritual history and a cultural history, an understanding that the spiritual dimension of people's lives is an avenue for compassionate care-giving and the ability to apply that understanding to a patient's spirituality, knowledge of research data on the impact of spirituality on health and healthcare outcomes, an understanding of and respect for the role of clergy and other spiritual leaders, and an understanding of their own spirituality and how it can be nurtured as part of professional growth.
One of the recommendations of this report was to encourage schools to develop spirituality content in a vertically integrated required curriculum. Thus, spiritual history was integrated into the part of the curriculum that taught history-taking; spirituality and chronic illness into the problem-based learning case that dealt with chronic illness, and spirituality as a way people understand illness was integrated into a humanities course. Thus, spirituality is a theme that is woven into a curriculum and integrated in such a way as it is part of the whole patient care. It is not just a course that students learn in one year, but not integrate more fully in the understanding of the whole patient. It is also a theme that recurs throughout the four year curriculum and is thus reinforced in the student's learning. A sample curriculum is included in Table 56.1. For other examples see www.gwish.org.
Table 56.1 Spirituality and medicine course at George Washington University School of Medicine and Health Sciences
Taking a spiritual history (integrated with history taking course)
Compassionate presence, attentive listening integrated throughout POM 1 & 2 communication skills
Reflections on gross anatomy
Service of Remembrance for body donors
Humanities courses include spirituality, art and humanities themes integrated
Problem-based learning where spiritual issues are integrated into cases
POM 2: Spirituality and chronic illness: breaking bad news
PBL: problem-based learning cases where spiritual issues are integrated into cases
Spirituality and end-of-life care
Medicine clerkship: GWish-Templeton reflective rounds
POM 4: Palliative care
Spirituality integrated as required domain of palliative care
Additional lectures to physical therapy, physician assistant students, as well as residents
*Practice of Medicine (POM) is a four-year integrated required curriculum in which spirituality is integrated as part of larger courses.
Chaplains play a role as faculty in the United States medical schools, particularly in sessions that involve communication skills, ethics, and compassion. In some primary care residency programmes, and palliative care fellowship programmes, residents and fellows shadow chaplains to get a better understanding of the role of spirituality in the care of the patient, what chaplains do and how the resident or fellow can address spiritual issues with patients and families.
In addition to medical schools the John Templeton Foundation with the National Institutes for Health Research (NIHR), and later GWish also funded primary care and psychiatry residency programs in spirituality and health curricular development. In psychiatry, specific learning objectives were developed which formed the basis of what is now a requirement within the American Psychiatric Association to teach spirituality, religion and mental health.
Canadian medical schools and residency programs also competed for the awards in spirituality and health; several of those programs developed some course material particularly in psychiatry. One of the awardees built her course on data she gathered from clinicians and patients that demonstrated a patient desire to have their clinicians address patient spirituality. A needs assessment survey was done in 2005, which demonstrated an interest by the Deans of several of the medical colleges in exploring spirituality in the context of cultural competency courses or palliative care.
Spirituality-based medical school national competencies
While the number of medical schools addressing the role of spirituality in medicine is impressive, the growing variances in content and approach are of significant concern, as well as a major impediment to gathering outcome data. Medical schools continue to implement spirituality courses in their own fashion, resulting in a wide variety of topics, pedagogies, and timelines—and differing skills, knowledge, and attitudes medical students are to attain from these courses. These variances have contributed to the absence of large-scale, long-term research on the impact of spirituality courses on medical students’ spiritual competency and consequent clinical outcomes.
In addition, most curricula in spirituality and health assess student satisfaction or self-reported changes in attitudes or knowledge using institution-based evaluation methodologies. Competency-focused outcome assessments are lacking primarily because no national spirituality-related competencies or widely accepted evaluation model exist. Most curricula in spirituality and health do not assess competency outcomes, focusing instead on assessing student satisfaction or self-reported changes in attitudes or knowledge.[10,1]
Evaluation methodologies and analysis also are institution-based, lacking an outcomes orientation primarily because no national or widely accepted model exists. Recent reviews of resident research, as well as evidence-based health curricula reveal that few programmes utilize sophisticated evaluation methodologies that address competency or patient outcomes.[11,12]
The AAMC summarized the lack of outcomes research and the impact medical education has on patient care, ‘There is a lack of empirical evidence of the relationship between medical preparation (education and training) and the quality of care. While it is presumed that more comprehensive education and training better prepares a physician to provide high quality of care, there have not been studies to confirm this. It is also possible that certain types or elements of education and training may have a greater impact on some physician activities than other activities. Given the national concern with quality and outcomes, additional resources should be invested in research in this area.’
To address these challenges, GWish led a F.I.S.H. Foundation-sponsored 2009 National Initiative to Develop Competencies in Spirituality for Medical Education (NIDCSME) that was based on the courses developed in Spirituality and Health over the past 15 years. The NIDCSME developed competency behaviours in healthcare systems, knowledge, compassionate presence, patient care, personal and professional development, and communications through a consensus process. These competences provide standards for learning objectives, teaching methods and evaluation that can be used to address these challenges. (See Figure 56.1) These competencies are based in the already accepted The Accreditation Council for Graduate Medical Education (ACGME) competencies for residency training and add compassionate presence as its own category given the importance of presence in clinical care.
Twenty-seven representatives from eight medical schools, which were competitively chosen, participated in the National Initiative to Develop Competencies in Spirituality for Medical Education. Using the framework of the ACGME competencies, participants formulated spirituality-related competencies for medical students and the behaviours, teaching methods, and assessment tools required to demonstrate student attainment of those competencies.
GWish-Templeton reflective rounds for medical students
Building upon a clinical interprofessional spiritual care consensus conference (National Consensus Conference, further described in Chapter 29) where spirituality was linked to personal and professional development of clinicians, the GWISH developed a clinical course titled GWish-Templeton Reflective Rounds funded by the John Templeton Foundation. The G-TRR focus on students’ personal and professional formation through the exploration of spirituality in the context of self and patient care. The reflection guide that schools are using is based on the verbatim used in CPE education (see Part II of this Chapter). Medical schools in the USA are currently implementing these rounds and looking at student outcomes, such as burn-out, depression, spiritual wellbeing, and being patient centred. By focusing on a student's inner life or spirituality it is anticipated that these outcomes will improve, with less student burnout and depression, and increased spiritual wellbeing and patient centredness. GWish is also piloting a reflection mentor programme as a part of professionalism in which students will have a group reflection process, based on group spiritual direction led by a trained reflection mentor. The goal of these two programs is to focus on formation of students as future physicians integrating their inner life or spiritual development as part of their professional development.
Most nursing theories are based on a dynamic and holistic view of the human individual as a biological, psychological, social, and spiritual being. Nursing theories include aspects of spirituality in patient care, directly or indirectly, including caring, interpersonal relationship, and spiritual variables. In addition, one of six essential features of professional nursing practice is the establishment of a caring relationship to facilitate health and healing. Spirituality has actually been described as the ‘cornerstone of holistic nursing practice’, and as ‘the integrating aspect of human wholeness …integral to quality care’. In 1978, the first nursing diagnosis related to spirituality, spiritual distress, was established in the North American Nursing Diagnosis Association (NANDA) and remains today. The Code of Ethics for professional nurses in the United States recognizes the importance of spirituality and health, illustrated by Provision 1 of the code, which states, ‘the nurse in all professional relationships practices with compassion and respect for the inherent dignity, worth, and uniqueness of each individual unrestricted by considerations of social and economic status, personal attributes, or the nature of health problems.’ Interpretive statements for this provision of the code further asserts that ‘the measures nurses take to care for the patients enable the patients to live with as much physical, psychological, social and spiritual wellbeing as possible.’ The International Council of Nurses also has a Code for Nurses which states, ‘The nurse promotes an environment in which the human rights, values, customs and spiritual beliefs of the individual, family and community are respected.’
Although nursing education teaches spirituality as a basic and essential element of the individual, there is too limited scholarly development of the nursing process in relation to this concept to make it a standard part of nursing education. In other words, there is not widespread acceptance of a standardized method to assess, plan, intervene and evaluate spiritual care in nursing. In 2004, a survey of 132 baccalaureate nursing programs in the US found that few defined spirituality or spiritual nursing care. However, in the most recent iteration of the Essentials of Baccalaureate Education for Professional Nursing Practice, developed and published by American Association of Colleges of Nursing in 2008, spirituality was integrated throughout this document. As a result, current nursing schools are integrating spirituality more fully in their curricula.
The US National Association of Social Workers’ Code of Ethics declares that a social worker must include spirituality when completing an assessment. Recognition of the relevance of spirituality to social work practice has led to recommendations that spirituality and religion be included in the Master of Social Work curriculum. Social work's earliest roots in the US were religious; religions sponsored the first social services programmes. The first Council on Social Work Education Curriculum Policy Statement (1953) used as its standard for accreditation that the ‘physical, mental and emotional growth should be considered with due regard to social, cultural and spiritual influences upon the development of the individual.’ However, in the 1970 and 1984 Curriculum Policy Statements, references to spirituality and religion were not included. As with medical education, resurgence in the interest in spirituality, religion, and social work occurred in the 1990s and continues to the present day. The concepts of spirituality and religion have been reintroduced into the Council on Social Work Education's curriculum guidelines in 1995. The guidelines state that programmes ‘must provide curriculum about difference and similarities in experiences, needs and beliefs of people.’ The standards also state that practice content include approaches and skills for practice with clients from different social religious spiritual backgrounds.
Social work education is also focused on the relationship aspect of care. Social workers are trained to be a compassionate presence—to listen with empathy, assess a person's psychosocial network, and help draw in appropriate resources to help the patient do as well as possible. They are trained to be partners with the patient, open to the patient's agenda, and know how to listen to the patient's fears, hopes, and dreams.
Physician Assistants (PA) programmes, like medical schools in the US, have seen an increase in the number of spirituality and health courses. Paramount in the education of physician assistants is recognition, respect, and non-judgemental attitude for diversity which includes spiritual, cultural and ethnic diversity. Mandated content in curricula for accreditation listed in the Standards of the Accreditation Review Commission include respect for diversity of patients, including beliefs and values.
The American Psychological Association (APA) has funded postdoctoral fellowships for PhD psychologists in which they rotate with all members of an interdisciplinary team, including chaplains. Fellows learn to identify and address spiritual and religious concerns related to chronic illness and death and dying, and how to collaborate with other disciplines. Additionally, APA funded a programme for continuing education focused on end-of-life care, which includes the spiritual and religious issues facing dying patients, and how to conduct a spiritual screening.
Physical therapy and occupational therapy
The physical therapy profession currently does not require the integration of spirituality in patient care in the physical therapy curriculum, and it is unclear how physical therapy faculty and practitioners view its inclusion. There is limited research on the integration of spirituality in the field of physical therapy or within its academic environment. A recent study investigated this further and found that more than half of the respondents indicated that they believed that spirituality concepts should be included in physical therapy education and that every physical therapy programme should include it in its curriculum. Response patterns indicated that respondents felt that spirituality concepts should be integrated into the physical therapy curriculum, rather than having specific courses focused on spirituality. In particular, effects on the older patient were cited as having potential benefit of inclusion of spirituality for the older patient. There are programmes in physical therapy that include some material on spirituality, especially how to do a spiritual screening.
Occupation therapists also include spirituality as an important aspect of care. There has been a large body of research in this area in Canada. The Canadian Association of Occupational Therapists (CAOT) has recognized spirituality as an integral component of occupational performance in client-centred practice. Despite acknowledging the influence of personal crisis, illness, and disability on a client's spirituality, occupational therapists have debated whether spirituality should be addressed within their scope of practice. Utilizing a national sample of occupational therapists to investigate the current role of spirituality in practice, Engquist et al. found that the majority of therapists affirmed that spirituality was a critical dimension of the health and rehabilitation of their clients. Nevertheless, many therapists neglected to address the spiritual dimension with their clients. Kirsh recommended a narrative approach to assessing a patient's spiritual needs in relation to his/her occupational therapy performance.
Although spirituality is recognized as important, education in spirituality is minimal. Methods of addressing spirituality varied and were limited to case studies, workshops, and guest speakers without any formal curriculum.
In other countries the situation is similar. Much is written of the importance of spirituality in occupational and physical therapy yet curricula do not exist or are limited to a lecture, case study or workshop.
The American Association of Colleges of Pharmacy has recently held meetings to consider integrating spirituality into their curriculum. At their annual conference, in 2010 there were presentations on the importance of addressing spiritual issues with patients and clients and the need for this material to be covered in the curriculum. There are some courses in several of the Schools of Pharmacy in the United States which are beginning to teach this material. One such programme, in Western School of Osteopathy, developed a course on Spirituality and Health jointly between the Schools of Osteopathy and Pharmacy that was taught by faculty from both schools for students from both schools.
Chaplains, pastoral counsellors, and spiritual directors
Professional chaplains in the United States receive their clinical training in Clinical Pastoral Education (CPE) programmes, and generally have a master's level degree such as a Master of Divinity or clinical masters as indicated in Part II of this section. There are other training programmes that are not CPE, however, the standard in US hospitals and palliative care programmes is for Board Certification which requires a minimum of 1600 hours of CPE.
Pastoral counselling providing psychologically sound therapy that integrates the religious and spiritual dimension. Under the auspices of American Association of Pastoral Counseling, pastoral counselling adheres to rigorous standards of excellence, including education and clinical training, professional certification and licensure. Typical education for the AAPC-certified pastoral counsellor consists of study that leads to:
◆ a bachelor's degree from an accredited college or university
◆ a three-year professional degree from a seminary
◆ a specialized masters or doctoral degree in the mental health field.
Spiritual direction is the process of accompanying people on a spiritual journey and inviting the directee into a deeper relationship with the spiritual aspect of being human. Spiritual direction offers a place to explore spiritual experiences, prayer practices, meditation, and the significant or sacred. Spiritual direction is not counselling or psychotherapy. Spiritual directors training includes one year of academic and practicum in study of theology, spirituality, and psychology. Practicums are supervised by peers and supervisors. At the end of the training the person receives a certificate of completion, but most training programmes do not ‘certify’ a person as a spiritual director.
The ancient tradition of spiritual direction, as shown in the early practices of the Deserts Fathers of Egypt, indicated that spiritual directors were usually the wise men and women of the community. The process of arriving at being a spiritual director is more of listening to a calling than practicing a profession. However, St Teresa of Avila stated that, based on her experiences, she would like a spiritual director that is more holy and learned, but if the two qualities are not present in the person she would rather have a learned director. The learned director will be more able to direct people in any walk of life. Therefore, the programmes that presently train spiritual directors have this same focus in mind: that their studies and their learning will be great assets to any spiritual director the director may undertake. While in the past spiritual directors originated within Christianity, today spiritual directors may come from many of the religious and spiritual traditions of the contemporary world. Within the Christian tradition there are, of course, a spread of spiritualities including those from the Catholic, Orthodox, and Protestant traditions that all shape particular understandings and practices of spiritual direction—e.g. Ignatian, Franciscan, the Quaker practice of spiritual guidance, etc. Other religious traditions have different approaches to spiritual direction, such as in Buddhism where the relationship is more teacher/pupil. Increasingly there are also non-religious spiritual directors such as secular humanist directors. Organizations such as Spiritual Directors International network spiritual direction courses, centres, and directors.
Training healthcare professionals
In the UK the NHS is devolved across the four countries of England, Scotland, Wales, and Northern Ireland and whilst there are country specific features and structures, the training of health professionals broadly follows a similar path of undergraduate training courses, graduate entry into a profession followed by postgraduate and specialist training programmes. Curricula and courses generally combine the interrelated demands of achieving competent clinical practice, academic standards, and the requirements of professional regulation. The content of training is therefore shaped by the workforce demands of the national health services; the knowledge, skills, and behaviours that professional bodies expect students to learn, and the academic criteria of higher education institutions.
The countries of the UK are also within the European Higher Education Area that provides a common frame of reference for higher education and comparable qualifications to support student mobility and employability. Member states of the European Union are also subject to antidiscrimination laws that include eliminating discrimination on the grounds of religion and belief (Article 19 of the Treaty of Lisbon). In the UK, the NHS is therefore required to respect the human rights of individuals, ensure it understands the particular needs of patient groups and achieve equal outcomes. This is an important basis for spirituality and spiritual care, but training about diversity in beliefs and religious practice is inadequate in itself. For example, the standards of proficiency required to register as an occupation therapist in the UK include the knowledge, understanding and skill to ‘recognize the value of the diversity and complexity of human behaviour through the exploration of different physical, psychological, environmental, social, emotional and spiritual perspectives.’ No other competences are specified despite the relevance of religion and spirituality to the occupational behaviour of an individual and the holistic philosophy of occupational therapy.
A common expectation of health professionals is that they will provide high quality person-centred care that is responsive to individual needs. This means that students should be capable of understanding and responding to the comprehensive needs of patients. For example, graduate medical doctors are required to, ‘Interpret findings from the history, physical examination and mental-state examination, appreciating the importance of clinical, psychological, spiritual, religious, social and cultural factors.’ Similarly to meet the requirement for registration all nurses must acquire the competence ‘to carry out comprehensive, systematic nursing assessments that take account of relevant physical, social, cultural, psychological, spiritual, genetic and environmental factors, in partnership with service users and others through interaction, observation and measurement.’ At the higher specialist level of training the content of the syllabus may be more specific, for example to be registered on the Specialist Register in Palliative Medicine a doctor must ‘have the knowledge and skills to elicit spiritual concerns, recognize and respond to spiritual distress and demonstrate respect for differing religious beliefs and practice and accommodation of these in patient care.’
The extent to which courses within the UK reflect the aspirations of curricula is variable and inconsistent. A survey of members of the Royal College of Nursing (UK) found that nearly four out of five of the nurses surveyed (n = 4054) agreed that they received insufficient training in this area and that it should be addressed within programmes of education. In UK medical schools it has been estimated that between 31 and 59% are likely to provide teaching on the subject, which could be as little as a single tutorial, much of it optional, and with ‘little uniformity between medical schools with regards to the content, form, amount or type of person delivering teaching on spirituality.’ In 2008, Neely and Minford investigated the current status of teaching on spirituality in medicine in United Kingdom medical schools. They e-mailed contacts within the medical education unit (deans and associate deans of medical education and senior lecturers in medical education) of each medical school. As a result, 59% of respondents stated that there are at least some topics on spirituality in their curricula. A person trained in spirituality, or a medical practitioner with a special interest in spirituality, were the professionals most likely to teach this issue. Of the respondents that teach spirituality, 50% included compulsory teaching on spirituality in medicine, 80% included as optional components. Teaching about different faiths and cultures and about the link between spirituality and health is delivered in 70 and 80%, respectively, of the medical schools that deliver teaching on spirituality. However, only 40% of these schools include spiritual history taking and only 30% include spiritual counselling.
Variability arises from the discretion that training providers have in how they achieve learning outcomes, course designs and resources, and the personal and professional interests of faculty members. An evidence-based UK consensus statement on clinical communication illustrates some of the problem: it states that communication teaching should include issues related to spirituality, but purposively avoids describing competency levels because these are ‘school-specific’ and the approach allows the inclusion of areas that ‘resist easy measurement, such as integrity and respect.’ Consequently, statements and curricula guidelines about spirituality and spiritual care remain recommendations that generally lack specificity, and add little to how teaching, learning, and assessment on this subject can be inter-related.
Spirituality and spiritual care provide subjects for a wide range of learning opportunities in the UK that include special study modules available as options within training programmes, inter-professional modules and short courses, conferences and knowledge sharing through specialist discussion and interest groups. A prominent example of the latter is the Spirituality and Psychiatry Special Interest Group (SPSIG), which is a forum for psychiatrists to discuss spirituality in relation to mental healthcare.
Eligibility for a training post as a healthcare chaplain in the UK usually depends upon candidates demonstrating a level of prior pastoral formation, knowledge, and skills through a period of general training and supervised practice. For Christian candidates this is typically attained through a ministerial degree programme (ordination training) and completion of first training post with mentorship (post-ordination training phase). Candidates from other faith communities may have analogous learning and there are some opportunities provided by institutes of higher education for certificate-level and foundation degrees in chaplaincy subjects.
The UK Board of Healthcare Chaplaincy has set standards for training, education, and continuing professional development. In particular, it has published a framework of capabilities and competences that extend beyond knowledge and skills of professional practice to include core values and personal spiritual development. Chaplains can access CPD programmes for healthcare professionals and there are a small number of chaplaincy-specific postgraduate programmes. A distinctive feature of training in the UK is that Clinical Pastoral Education (CPE) has not become an established model, instead academic and professional training combined with methods of reflective practice and pastoral supervision have emerged that draw upon practices including theological reflection, clinical supervision and professional development.
Education of healthcare professionals in Australia is predominantly based in public universities. Some healthcare support disciplines are trained through the Technical and Further Education (TAFE) system at Certificate IV and Diploma level. TAFE qualifications have some limited articulation with the university system. Professional awards are developed by the universities in consultation with professional peak bodies and are approved by those bodies, which in turn have direct accountability to the commonwealth (federal) government.
Religion is taught as an academic discipline in many of Australia's 39 public universities, but the secular charters of these universities mean that religious vocational training is provided through theological schools, many sponsored by a specific Christian denomination. Most of these schools now cooperate to provide degree programmes accredited by various state governments. These awards in theology articulate with university programmes, but are administered separately.
Curricula in spirituality and health
Unlike the UK and USA, there are no published studies of spiritual care content in the awards offered by Australian public universities. A survey of university websites undertaken for the purposes of this chapter found that a clear majority of universities offer spirituality subjects, and that these are taught in a range of faculties, mainly arts, education and health. Where spiritual care subjects are listed in health sciences courses they are usually part of a nursing programme and/or with a particular focus in ageing, indigenous health or palliative care. Of Australia's 19 medical schools which listed a full subject in spiritual care, only one has a full subject on Spirituality and Health. In 2007 at the medical school in Sydney, Spirituality and Health was accepted as one of the learning areas; 2008 a steering committee was formed for this subject, and in 2009 Spirituality was integrated into the curriculum. The process was based, in part, on the curriculum development in this subject in the USA. Mandatory sessions include an introduction to chaplaincy, meaning in medicine, definition of spirituality, and a review of the research. Methodologies include case discussion, didactics, use of film and literature, group discussion and individual projects (K. Curry, 2011, personal communication).
This does not mean that spiritual care is not taught as part of the healthcare qualifications in the universities that do not provide any spiritual care listing, but it does imply that such teaching is incidental—a lecture or a small module, embedded in general instruction about patient care. It also reflects that teaching spiritual care is not mandated by any profession's accrediting body. For example, although a number of subjects in spiritual care are offered in Schools of Nursing, there is no mention of spiritual care in the national framework for accreditation of nursing and midwifery courses, while in the standards and criteria for accrediting courses leading to registration the only mention of spiritual care occurs in the context of cultural safety. It is difficult to escape the conclusion that, where spiritual care is taught, this is more due to the initiative of particular university staff members, or perhaps departments, than to the professions themselves. However, spirituality interest groups are affiliated with many professional associations.
It is worth noting that competencies identified by a report of the Australia and New Zealand Deans of Medical Schools for the commonwealth government includes the need for spiritual and religious care of practitioners and patients. How this might translate into curriculum is not as yet indicated. In the health sciences more broadly, La Trobe University currently is considering a proposal to establish a Grad Cert Spiritual Care that would be embedded in a spiritual care stream of the Master of Health Sciences degree.
In the UK and USA, medical humanities programmes offer a learning environment open to considering spiritual need and spiritual care. The focus of such programmes is upon creating settings conducive to human development.[57,58] An Australian Association for Medical Humanities has been formed, although the only specific awards to date are offered by the University of Sydney's Centre for Medical Humanities. This Centre, which has links with the Centre for Medical Humanities, University of Durham, UK, offers a Grad Cert Med Hum and Master of Medical Humanities, including this year a subject ‘Spirituality, Consumerism and Healthcare’. The University of Newcastle's Artshealth Centre for Research and Practice, offers a medical humanities subject (albeit infrequently) in addition to developing interdisciplinary research in arts and medicine. The University of Melbourne Medical School, through the Medical Humanities Unit in conjunction with the Centre for Health and Society, offers an elective programme in medical humanities/ethics research.
Healthcare chaplaincy training
Chaplaincy training is largely carried out in Clinical Pastoral Education (CPE) programmes based, for the most part, in acute care institutions. CPE is independent and self-accredited through the Association for Supervised Pastoral Education in Australia or cognate bodies. Credit may be given into academic awards at the discretion of course coordinators at theological schools or university.
Some of those training as chaplains have prior theological qualifications, while others may commence theological studies during their CPE training. Chaplains also undertake studies at postgraduate level in various education and health sciences programmes. Spiritual Care Australia is moving to position itself as a national accrediting body in conjunction with the recently-established Australian Health Practitioner Regulation Agency.
Pastoral counsellors and spiritual directors
There is some limited intersection between healthcare practice at the community level and accredited pastoral counsellors or spiritual directors. These practitioners are trained through theological schools for the most part, and accredited by professional bodies such as Australian Association of Spiritual Care and Pastoral Counselling and Christian Counsellors Association are affiliated with the Psychotherapy and Counselling Federation of Australia, while the Australian Ecumenical Council of Spiritual Directors networks spiritual direction courses, centres and directors across the country.
Medical education in spirituality in other parts of the world
A literature review was undertaken to look at published articles in spirituality and health education globally. The studies in this review indicate a predominance of studies related to health/ medicine and spirituality in USA and Canadian medical schools. Few studies were found in Europe, Latin America, and Asia, and none in Africa and Australia. New studies and curriculum development in spirituality and health outside North America are needed to further investigate the role of spirituality and health globally, and how best to address this important issue in global medical education.
In a number of countries ‘spirituality’ is incorporated through Traditional Complementary and Alternative Medicine (TCAM) that is taught in parallel with western medical programmes or in integrated form. In analogous fashion, spirituality is an integral component of medical training developed for indigenous or First Nation practitioners. The International Council of Nurses called for spiritual assessment of patients to be seen as a professional standard for nurses. To address this requirement in Korea, Yong develeoped a spiritual training programme for middle manager nurses to understand and develop their own spirituality in order to be able to care for their patients. This programme had a significant influence in terms of their own spiritual and emotional wellbeing.
Continuing education for healthcare professionals in spirituality and health
There has been, in response to growing community interest in spirituality and health, a proliferation of workshops and training modules for in-service education of healthcare professionals, staff and volunteers. In some clinical setting, volunteers and staff are trained together, to essentially the same level, in screening skills. Often, although by no means always, these short courses are offered by educators who also teach spiritual care in the tertiary sector. There are numerous conferences, and presentations integrated into professional association annual conferences such as the American Psychiatric Association, the Association of American Medical Colleges, American Academy of Hospice and Palliative Medicine, the International Congress on Palliative Care, International Asian Conference of Palliative Care, the Asian Pacific Organization for Cancer Prevention's Middle East Cancer Consortium (MECC) Workshop on Cancer Pain, Suffering and Spirituality in Turkey, and the Australian Conference on Spirituality and Health to name a few.
Clearly, there are differences in the level of teaching in spirituality and health in the different health professions, as well as different countries. Some of the barriers that have been cited in the literature include diverse definitions of spirituality, disparity of rigor of research used as an evidence base and lack of practical models and tools. As can been seen from other chapters in this book, these models and tools are now being developed and the body of research is more rigorous and continually expanding. However, most clinicians and healthcare providers note that spirituality is important in the lives of patients. Thus, we anticipate the area of curriculum development to grow over the next few years.
How spirituality is taught is another challenge for some programmes. More successful models include taking advantage of major trends in health education, for example, humanizing healthcare with the increase in humanities courses, and integrate spirituality into those subject areas. Courses that are vertically integrated and required have a greater likelihood of impact. Integrating board certified chaplains as faculty, as well as pastoral counsellors and spiritual directors is key to excellence in education in this topic area.
It is also critical to teach spirituality in the clinical years and to include a focus on the spirituality of the health profession students’ lives. Formats that include personal reflection may be a powerful way to convene and experience the fuller dimension of spirituality as it pertains to the students’ lives so that they in turn can have a greater appreciation for spirituality in their patients’ lives. Translating theory into practice requires more than the assimilation of knowledge and skills and needs supporting with formation through reflective practice and learning from the wisdom and tacit knowledge of a community of practice.
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