SPIRITUALITY IN AGED CARE
EDUCATION PACKAGE: PILOT PROJECT FINAL REPORT DECEMBER 2013
Author: Jacqueline Taylor — Manager Aged Care and Community Services
“The relational model of spirituality is one that nearly all staff can understand and work with.” (Pastoral Care Coordinator/Facilitator)
“I really enjoyed it. It was great to see care staff and volunteers being actively involved in discussions." (Participant)
“…..One of the participants made it very clear that she had no belief in any higher power or God. For her, life was life and death was the end of that life and there was nothing that gave her ‘spirituality’. When in truth this RN was a very compassionate, sensitive, highly skilled nurse. This exercise took longer than at the last pilot but it was the turning point and so very valuable. At the end of the exercise we named spirituality “goodness” as that which gave her ultimate meaning, because that is how she saw her contribution to her work and the world, and that is what she expected from others. She was quite emotional at times during the discussion and everyone in the group allowed her to speak and respected all that she had to say. At the end of the day she came and thanked me for allowing her to be ‘who she really is’. Also in the group were people of strong Christian faith and it was so good that this forum allowed everyone to express their own spirituality from their own life’s journey.” (Independent Facilitator
“It taught me that you can engage in a meaningful way with the client whilst still attending to your many duties throughout the day.” (Participant)
“The content of the course is magnificent in my view.” (Pastoral Care Coordinator)
_____________________________________________________________________________ © This document is copyright. Apart from any use permitted under the Copyright Act 1968, no part may be reproduced by any process, nor may any other exclusive right be exercised, without the permission of Spiritual Health Victoria (SHV), PO Box 396, Abbotsford, Victoria 3067 Australia.
TABLE OF CONTENTS
TABLE OF TABLES .................................................................................................................. 3 LIST OF FIGURE ...................................................................................................................... 3 KEY TERMS AND CONCEPTS ................................................................................................... 4 ACKNOWLEDGEMENTS ......................................................................................................... 7 INTRODUCTION .................................................................................................................... 8 EXECUTIVE SUMMARY ........................................................................................................... 9 BACKGROUND & LITERATURE REVIEW ................................................................................. 17 A DESCRIPTION OF THE EDUCATION THAT WAS PILOTED ..................................................... 22 METHOD ............................................................................................................................. 24 SUMMARY OF OUTCOMES .................................................................................................. 27 OVERVIEW ................................................................................................................................................... 27 IMPACT ON PARTICIPANTS ............................................................................................................................... 27 IMPACT ON PILOT HOST ORGANISATIONS ............................................................................................................ 29
DISCUSSION – IMPORTANT THEMES .................................................................................... 30 WHO SHOULD PARTICIPATE? ........................................................................................................................... 30 FACILITATORS ............................................................................................................................................... 30 FORMATS .................................................................................................................................................... 31 ONE LEVEL OF EDUCATION OR TWO? ................................................................................................................. 32 FLEXIBILITY IN THE COURSE CONTENT ................................................................................................................. 33 ALERTING THE FACILITATOR TO SPECIAL CIRCUMSTANCES ....................................................................................... 34 SIZE OF THE GROUP ........................................................................................................................................ 34 VENUE ........................................................................................................................................................ 35 POST EDUCATION FOLLOW-UP ......................................................................................................................... 35 FUTURE EVALUATION ..................................................................................................................................... 35
SPECIALIST LEARNING MODULES FOR THE FUTURE ............................................................... 37 RECOMMENDATIONS .......................................................................................................... 38 RECOMMENDATIONS FOR THE SECTOR ............................................................................................................... 38 RECOMMENDATIONS FOR SHV ........................................................................................................................ 39 FOR AGED CARE PROVIDERS IMPLEMENTING THE EDUCATION .................................................................................. 40
BIBLIOGRAPHY .................................................................................................................... 41 APPENDICES ........................................................................................................................ 43
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TABLE OF TABLES Table 1: Table 2: Table 3: Table 4: Table 5: Table 6: Table 7: Table 8:
Examples of new strategies devised by pilot organisations to improve spiritual care ...12 Description of Education Models involved in previous pilot projects ............................19 Spirituality in Aged Care Package: Learning Modules .....................................................23 Pilot Host Demographics .................................................................................................26 Learning modules to be developed in the future............................................................37 Numbers of evaluation surveys returned .......................................................................44 Key to Evaluation Surveys ...............................................................................................44 Complete table of new organisational strategies applied after undertaking the education package ..........................................................................................................45 Table 9: Participants Roles ...........................................................................................................51 Table 10: Comments from participant’s Level 1 ‘Evaluation of the Day’ survey ...........................53 Table 11: Responses from Post Pilot 3 Month Participant Survey: Participant’s identification with faith groups .....................................................................................................................54 Table 12: Responses from Post Pilot 3 Month Participant Survey: Q1 .........................................54 Table 13: Responses from Post Pilot 3 Month Participant Survey: Q2 .........................................54 Table 14: Responses from Post Pilot 3 Month Participant Survey: Q3 & 4 ..................................55 Table 15: Responses from Post Pilot 3 Month Participant Survey: Q5 .........................................55 Table 16: Responses from Post Pilot 3 Month Participant Survey: Q6 .........................................56 Table 17: Responses from Post Pilot 3 Month Participant Survey: Q7 .........................................57 Table 18: Responses from Post Pilot 3 Month Participant Survey: Q8 .........................................57 Table 19: Responses from Post Pilot 3 Month Participant Survey: Q9 .........................................58 Table 20: Responses from Post Pilot 3 Month Participant Survey: Q10 .......................................58 Table 21: Responses from Post Pilot 3 Month Participant Survey: Q11 .......................................59 Table 22: Participant satisfaction regarding course expectations .................................................61
LIST OF FIGURES Figure 1: Domains of responsibility for providing spiritual care in aged care ...............................22 Figure 2: Attitude Rating Scale .......................................................................................................60
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KEY TERMS AND CONCEPTS * The acronym RACF (Residential Aged Care Facility) is used throughout this document.
The development of the Spirituality in Aged Care Education Package is underpinned by the following key terms and concepts about spirituality and spiritual care. These definitions apply generally in healthcare contexts and are adapted from the Key Terms and Concepts included in the SHV’s Capability Framework for Pastoral Care & Chaplaincy, 2011. This document is available to download in full from SHV’s website www.spiritualhealthvictoria.org.au in the ‘Resources / Standards and Guidelines’ section.
SPIRITUALITY Spirituality is intrinsic to the human person. It is the self-in-relationship with:
self others nature, environment, universe the transcendent
Spirituality may be experienced in a quest for meaning, purpose, connection, belonging, hope. It can deepen with growing reflective capacities and self-awareness, and can become more conscious at major turning points in life. Spirituality is always embedded in the unique experience and story of each person, and so is essentially individual and subjective. Due to this subjectivity, each individual’s story needs to be heard, and the person’s own spirituality discerned case by case, so it is difficult to generalise satisfactorily about what is always a unique reality. Common themes or aspects may, however, be recognised, perhaps in these areas:
Cognitive: A search for meaning, answers to life’s deep questions, hope, a sense of purpose Affective/relational: Connectedness to self, others, nature, the Transcendent Other Ethical: A moral sense of how to live with integrity and in relation to the rights and needs of others.
These common aspects make research into spirituality possible, even granted the uniqueness of each person’s spirituality. More qualitative methods of research may be more appropriate than objective, quantitative methods, in this field. Spirituality can be expressed in many different ways, often unique to the individual. It can also be expressed in ways that are communal, drawing on the accumulated wisdom of a community. When this is the case, the individual’s spirituality can be expressed in religion (see below). However, spirituality is more primordial than religion, so that even the most religious person may at times explore other expressions of their spirituality beyond their particular religious tradition, especially when religion becomes overly theoretical, dry or removed from personal experience.
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RELIGION Religion is understood as those organised, communal expressions of spirituality which use shared points of reference such as charismatic figures, sacred texts, teachings, rituals and practices, and moral precepts, to express and make accessible the cognitive, affective/relational and ethical wisdom of a faith community for its members. Religious traditions and communities can range across a continuum of levels of organisation – some much less systematised and focused on teachings than others. In religion, the relationship with the Transcendent Other (often identified as God or gods), is more explicit and to the fore, whereas in personal spirituality this may be much more implied, or even difficult to discern. The organised, communal aspects of religion are balanced by the individual’s own personal spirituality and faith. It is a mistake to assume that all adherents of a particular religious tradition are the same. Their personal relationships and story will at times mean that their faith or belief system and practice, while it draws from the organised and communal tradition to a greater or lesser extent, can be nuanced considerably. Again, it is important to listen carefully to the individual and their story, and to respond to the unique person with whom one is relating. SPIRITUAL CARE Spiritual care encompasses all ways in which attention is paid to spirituality, and particularly in the healthcare environment, to the spiritual issues that arise in the experience of illness, suffering, life and death. The terms ‘pastoral care’ and ‘spiritual care’ are very closely linked. In this [Key Terms and Concepts] document, the term ‘spiritual care’ is used throughout, with the understanding that ‘pastoral care’ could just as suitably be used. Spiritual care is understood to include the dimensions set out in the ICD 10 – AM1:
Pastoral Assessment, Pastoral Ministry or Conversation, Pastoral Education or Counselling, and Ritual or Worship.
Pastoral care is often provided in a one-to-one relationship, completely centred on the person, because of the essentially individual and unique nature of spirituality noted above, and makes no assumptions about personal convictions or life orientation2. Through attentive and reflective listening to the individual’s experience and story, this care seeks to identify their spiritual resources and needs, and to enable them to work through issues of meaning and connectedness in ways that assist them in this part of their life journey. Pastoral care is part of the responsibility of all healthcare services, because spirituality is intrinsic to the human person. This reflects the World Health Organisation’s understanding of health and healthcare referred to earlier, which includes the spiritual dimension along with the physical, social and psychological. It can be provided by all healthcare staff, by volunteers, carers, family and even fellow patients/residents, when the person is treated with respect, listened to in a meaningful way, and treated as a whole person within the context of their life, values and beliefs. It is provided in a more intentional and focused manner by those specifically formed, trained and 1
World Health Organisation International Classification of Diseases, Version 10, Australian Modification (ICD 10-AM). See NHS Education for Scotland, Spiritual and Religious Care Capabilities and Competences for Healthcare Chaplains. p.3. Available at www.nes.scot.nhs.uk/spiritualcare/resources/PrintersFinalProof.pdf.pdf 2
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employed as professional practitioners in this field. Pastoral care may or may not be explicitly religious, depending on the person’s spiritual identity and journey. A person employed as a professional in pastoral care would usually be employed by the healthcare facility as a member of its staff. CHAPLAINCY Chaplaincy is a form of professional pastoral ministry requiring the skills to provide pastoral, religious and spiritual care in a range of diverse healthcare settings (or in other contexts, such as schools, universities, or prisons). Endorsement from one’s faith community is usually required to minister as a Chaplain. While some Chaplains work mainly with members of their own faith community, increasingly Chaplains are expected to possess the skills to work in an ecumenical or inter-faith manner as appropriate in a pluralistic society. Chaplains may be required to take on other relevant responsibilities related to their ministry location or position description, such as crisis ministry, counselling, worship, appropriate rituals/sacraments, ethical consultation or educational activities. A professionally employed Chaplain would usually be employed by their particular faith tradition or community, and accredited by the healthcare facility. It should be noted, however, that this understanding of Chaplain is not necessarily reflective of usage in many healthcare contexts in Victoria today. In some facilities, for example, a pastoral care professional is employed by the facility as a “Hospital Chaplain”, or “Ward/Unit Chaplain”, with a role description which includes providing pastoral care to all individuals, families and staff, rather than primarily to members of any specific faith community.
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ACKNOWLEDGEMENTS
SHV acknowledges the support of the Victorian Government Our very sincere thanks go to the facilitators and organisations that took part in the pilots and then diligently followed through with a long evaluation schedule. Their dedication to the task and their feedback has been invaluable. They were Facilitators: Pauline Arnold, Debra Saffrey-Collins, Megan Coote, Vince Corbett, Shaun DowlingHorgan, Nigel Stone and Vivien Williams. Pilot Host Organisations: Brotherhood of St Laurence, Bupa Barabool and Bupa Bellarine, Chaffey House Merbein, Echuca Community Aged Care, Echuca Regional Health’s Glanville Village, Manningham Centre, Sea Views Manor Ocean Grove, Sacred Heart Mission, St Vincent’s Health RACF’s (Auburn House, Cambridge House, Prague House and Riverside House), Uniting Aged Care Box Hill. We thank Professor Terry Mills, Honorary Statistician, Bendigo Health, for providing statistical support to the project. Thanks also to Rev’d Dr Lindsay Carey, La Trobe University, for his assistance with the design of the evaluation, and to Lilli Krikheli, research intern, who also worked on this project. Our continued appreciation goes to Irene Nolan, author of the original education package, for her interest and energy throughout. Thanks go to Rev’d Dr Alan Niven, Rev’d Dr Bruce Rumbold, Rosemary Kelleher, Ilsa Hampton, Andrew Taylor and Toni Warren for their assistance with this report. Contributors associated with this document include Jacqueline Taylor (Project Manager), and SHV team: Cheryl Holmes, Trish Fernley, Dan Murphy, Christine Hennequin and Ros Cairns.
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INTRODUCTION In 2010 Spiritual Health Victoria (then known as the Healthcare Chaplaincy Council of Victoria Inc.) acquired funding from the Victorian Department of Health to develop an education package to enable all staff and volunteers working in residential aged care facilities to identify and respond to the spiritual needs of aged care residents. The Spirituality in Aged Care Education Package was subsequently developed by Irene Nolan and piloted at Carshalton House, a residential aged care facility that is part of Bendigo Health in regional Victoria. The feedback received from the original pilot was excellent and encouraged SHV to test the suitability of the education package in a broader range of aged care contexts. As a result of the pilot project, the education has now been piloted a further 13 times. The aims of the Spirituality in Aged Care Education Package Pilot Project were threefold:
To test the effectiveness of the Spirituality in Aged Care Education package for staff and volunteers in aged care settings
To test whether this model of education is appropriate for aged care settings beyond the stand alone residential aged care facilities for which it was originally designed
To explore the practical ramifications of implementing the education package in a wider range of contexts.
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EXECUTIVE SUMMARY Spirituality is intrinsic to the human person. It may be experienced as a quest for meaning, purpose, connection, belonging, or hope. It is manifested through a person’s relationship with themselves, with others, the environment and the transcendent. While many people hold religious beliefs which form the basis of their spiritual expression, spirituality is always embedded in a person’s unique experience and story, and so is essentially individual and subjective (SHV, 2011b). It is important to understand that whilst other dimensions of the human being decline as they age, the spiritual dimension can continue to flourish (Mackinlay, 2012). Spiritual care encompasses all ways in which attention is paid to spirituality. It begins with understanding the person’s spirituality and supporting them in the life practices that are important to them (SHV, 2011b). The World Health Organisation includes “Personal beliefs/spirituality (e.g. Meaning in life)” as one of the six domains of healthcare that contribute to Quality of Life (WHO, 1998), and as such, spiritual care is an essential component of healthcare. Australian studies into the needs of the elderly also create compelling arguments for providing spiritual care (for example: Mackinlay, 2001, 2006, Hall & Sim 2005). This is reflected in the growing list of legislation and healthcare policy documents that state or imply a responsibility from governments and aged care providers to attend to older people’s spiritual needs SHV, 2013). In a contemporary model of spiritual care the provision of care is the domain of all staff and volunteers, and not just the responsibility of specialists such as pastoral care practitioners or faith representatives. To integrate an up-to-date model of spiritual care into the aged care system, all aged care staff and volunteers need to have a basic awareness and understanding of spirituality and spiritual needs, as well as organised and supported strategies for responding to those needs. Figure 1: Domains of responsibility for providing spiritual care in aged care
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In 2010 SHV acquired funding from the Victorian Department of Health to develop an education package to enable all staff and volunteers in residential aged care facilities to identify and respond to the spiritual needs of aged care residents. SHV subsequently developed the Spirituality in Aged Care Education Package consisting of eight hours of education. The education is offered in two levels – Level one (5 hours) is designed for all staff and volunteers. Level two (3 hours) is for a select number of ‘graduates’ who are thus enabled to be appointed as spiritual liaison staff members. The role of the spiritual liaison staff member is to provide a ‘first port of call’ when staff and volunteers who have identified that a care recipient has spiritual needs but are unsure about what to do next. An important facet of the education is that it is not intended to increase the staff’s workload, rather it is designed to enhance how staff and volunteers approach their work by teaching a holistic perspective with a particular focus on spirituality and spiritual needs. The education package was piloted once, in a standalone RACF, during the initial project and the feedback received was excellent. The results encouraged SHV to test the effectiveness of the education in a broader range of aged care settings. This resulted in the current pilot project in which the education package was piloted a further thirteen times. The aims of the Spirituality in Aged Care Education Package Pilot Project were threefold:
To test the effectiveness of the Spirituality in Aged Care Education package for aged care staff and volunteers To test whether this model of education is appropriate for aged care settings beyond the stand alone residential aged care facilities for which it was originally designed To explore the practical ramifications of implementing the education package in a wider range of contexts.
The education was piloted
In a range of residential and community based settings In metropolitan and regional settings In three different formats (whole day, half day and as single sessions) With group sizes ranging from 6-22 participants For participants from individual sites and combined sites For staff and volunteers caring for a wide range of aged care demographics For providers with and without professional pastoral care on site For staff ranging from general managers, clinical practitioners, personal care and lifestyle staff, through to support staff such as administrators and kitchen staff.
The facilitators were professional pastoral care practitioners, some of whom were employed by the providers who were hosting the pilots, and others who were independently recruited by SHV. The pastoral care practitioners underwent two days of training to enable them to act as facilitators for the pilot study. The thirteen pilots went ahead from February-July 2012, with 130 participants. The education was evaluated by participants, the organisations that hosted the pilots, and by the facilitators. Feedback was sought when the education was initially completed and then again three months later.
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117 participants completed the Level one education and returned evaluations demonstrating that the education package was effective in
Increasing participant’s knowledge about spirituality and the spiritual needs of the aged Increasing participant’s confidence in talking to aged care recipients about their spiritual needs Increasing participant’s knowledge about resources relating to spiritual care Changing individual and organisational attitudes and work practices in relation to the spiritual care of aged care recipients.
However, while the evaluations demonstrated that the education was effective at participant level across the board, there were variations at the organisational level. Ten of the hosting organisations (n=13) returned surveys after three months. Eight of those organisations continued to have strategies in place to enhance the practice of spiritual care as a result of the education. The evaluations showed that the level of management input into each pilot was the strongest predictor of whether an organisation would develop new workplace strategies to enhance spiritual care practice as a result of the education. This was consistent whether the organisations had pastoral care on staff or not (3/8 had pastoral care staff, 5/8 did not). The three organisations that did not return surveys after three months, and the two that did but had not devised strategies for enhanced pastoral care had lower levels of management involvement in their pilots. Management involvement occurred on a number of levels:
Endorsement and ‘ownership’ of the pilot project within their organisation ‘Hands on’ responsibility for implementing the pilot Supportive participation in pilot groups Responsiveness to staff suggestions for new strategies.
The best outcomes occurred in organisations where management had a high level of positive involvement in at least three of these areas, and where there was a high level of cohesion between managers where more than one was involved.
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Table 1: Examples of new strategies devised by pilot organisations to improve spiritual care Include spirituality on staff meeting agendas, at team leader meetings Staff have got together a whole folder of resources which is on the kitchen table [We will] define spirituality for all staff Explore with all staff the value of listening/being listened to as a way of enhancing all relationships [We will] be a positive and supportive work environment [We will] continue to find creative ways to reminisce, communally, according to capacity (valuing story; perhaps choosing a theme; facilitating letting go; building relationships) We have a spiritual assessment form in draft Spirituality Care Plans… A resident was asked to speak about the importance of spirituality at a meeting with staff [We will] enhance skills about communicating about holistic care at handover Create a spiritual care checklist for handover Have an accessible resource folder for spiritual referral and issues All participants (spiritual liaison staff members) are to form a steering committee and set clear objectives for the next year. The educator is to assist Review current clients holistically – ensuring attention is being given to their spiritual needs Run the Spiritual Care in Aged Care Education Package for relatives and friends Include spirituality in all orientation literature. Explore the possibility of someone talking with each new staff member at orientation Send a staff memo, and put a notice in staff room advising of the spiritual liaison role, with the names of spiritual liaison staff The senior management and board have committed to the part time engagement of a pastoral care practitioner….to assist with the implementation of a greater focus on spiritual care Talk about the spiritual liaison role at handovers The spiritual liaison staff member is to find time to be a good listener when other staff have an issue about a resident The Lifestyle Coordinator will investigate better ways for reminiscence sessions and life reviews [ We will] consider a pastoral care volunteer program Request spiritual care be included in Education Planning, In-Service days, Clinical Skill Days, Volunteer Training Days
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Lifestyle coordinator will compile an “action plan” of suggestions and discuss with Manager of Aged Care Services….Manager to delegate tasks to steer liaison group to follow through and implement plan Ask if spirituality liaison group can schedule regular case conferences to include other care staff Talk about ways to improve an integrated approach to care/raise profile of leisure and lifestyle Implement 6 monthly memorial services and invite families Ask management to support spiritual care in group meetings [Introduce] policy changes We would like regular visits from the education facilitator to keep us on track Add spirituality & staff competence to the quality system Add spiritual care to Best Practice Group. Part of Accreditation Standards 2.9,3.4,3.5,3.7,3.8 I believe a mini version of the training should be part of mandatory training as part of person-centred care for all levels of staff [We will] use the handouts Integrating this course in the yearly training schedule would be very important The Chaplain’s team is receiving more referrals A strong effort was made by staff to keep a resident in touch with her church community. They wouldn’t have done that before Four aged care staff have been added to the pastoral care team as spiritual liaison representatives. Chaplains support their role Changes have been made to material that is available for residents’ families in palliative care
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RECOMMENDATIONS FOR THE SECTOR 1. The pilot project has demonstrated that the Spirituality in Aged Care Education Package is effective in enabling all staff and volunteers from a range of aged care settings to identify and respond to the spiritual needs of aged care recipients. It has also demonstrated that the education is effective in providing a context in which staff can explore and implement strategies to enhance the provision of spiritual care and a person-centred approach. This project was undertaken on behalf of the Victorian aged care sector. As such it is recommended that the following organisations endorse the Spirituality in Aged Care Education Package and work with the Victorian aged care sector to implement this education.
Victorian Department of Health Aged & Community Services Australia (ACSA) Alzheimer’s Australia Victoria Council of the Ageing (COTA) Carers Victoria Leading Aged Services Australia – Vic (LASA Vic) Palliative Care Victoria Centre for Cultural Diversity in Ageing Victorian Aboriginal Community Controlled Health Organisation (VACCHO)
This education package will assist aged care providers to meet the national standards and guidelines that require them to provide spiritual care. While the constituency of SHV’s work is Victorian, it is recognised that the outcomes of this project have national implications. As such, it is recommended that the following organisations also endorse the Spirituality in Aged Care Education Package and work with the national aged care sector to implement this education.
Commonwealth Department of Social Services PASCOP (Pastoral and Spiritual Care of Older People) Leading Aged Services Australia Aged & Community Services Australia Alzheimer’s Australia Palliative Care Australia Partners in the Culturally Appropriate Care (PICAC) Program Aboriginal Community Controlled Health Organisations COTA Australia Carers Australia
2. It is recommended that the Commonwealth Department of Social Services make additional funding available for staff administrating the Home Care Packages Program to implement this education. 3. It is recommended that the Victorian Department of Health makes additional funding available to Victorian public sector RACFs and HACC providers to implement this education. 4. Data from the surveys undertaken on behalf of individual participants and organisations identified a desire in the sector for additional learning units for all staff and volunteers as they relate to the following areas
Spiritual Assessment in Aged Care Contexts Spirituality in Palliative Care in Aged Care Contexts
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Spirituality and Sexuality in Aged Care Contexts Spirituality and Dementia Care Spirituality, Death and Dying in Aged Care Contexts Spirituality, Loss and Grief in Aged Care Contexts Spirituality and Advanced Care Planning in Aged Care Contexts Spirituality and Aged Mental Health Spirituality and Intellectual Disability in Aged Care Contexts
It is recommended that the Commonwealth Department of Social Services and the Victorian Department of Health resource appropriate agencies to develop specialist learning units to address this gap in the comprehensive provision of education for all staff and volunteers in aged care contexts. RECOMMENDATIONS FOR SHV 5. It is recommended that SHV further revise and adapt the Spirituality in Aged Care Education to create two versions: Version 1: i. Maintains the current model of the education package which is comprised of two levels of education, and incorporates instruction about the ‘spiritual liaison role’ ii. Is a revision of the current education package in line with the outcomes of the pilot project iii. Is aimed at discrete residential or community based sites. Version 2: i. Adapts and combines learning modules from the two levels of education but omits the ‘spiritual liaison role’ ii. Offers the equivalent of one whole day of education iii. Is appropriate for a combination of staff and volunteers from multiple residential or community based sites. 6. It is recommended SHV appoint a suitable agency to train future facilitators of the education package. 7. It is recommended that the education package is facilitated by professional pastoral care practitioners who
Meet the standards for Certified Membership (Entry Level or Advanced Level) of Spiritual Care Australia (see www.spiritualcareaustralia.org.au) And/or have the capabilities, experience and qualifications described at Level 3 of SHV’s Capabilities Framework for Chaplaincy and Pastoral Care 2011 Have experience working in aged care contexts Have undertaken specialist training enabling them to become accredited facilitators for the Spirituality in Aged Care Education Package.
8. It is recommended that SHV regularly evaluate and revise the Spirituality in Aged Care Education Package. 9. It is recommended that SHV further pilot the education package for health professionals and volunteers in palliative care and acute care settings. 15 | P a g e
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FOR AGED CARE PROVIDERS IMPLEMENTING THE EDUCATION 10. The research showed that the education was most effective in changing attitudes and workplace practices, in terms of individual and systemic change, when there was a high level of management involvement. It is recommended that senior management take the key role in promoting, planning, participating in, and supporting staff to implement new strategies for enhancing spiritual care that emerge as a result of the education. 11. It is recommended that aged care organisations conduct the Spirituality in Aged Care Education Package at regular intervals, particularly for new staff, including managers. 12. It is recommended that consumer organisations obtain funding to backfill positions to enable staff to attend the education during paid work time. 13. The recommended format for the revised and adapted education package is the ‘whole day format’ until further piloting of the education clarifies the impact of the half-day and singlesession formats. 14. The recommend group size is 8-14 participants. A co-facilitator is required for larger groups. 15. The chosen venue needs to enable participants to focus solely and comfortably on the education. It is recommended that catering be provided as an example of the hosting organisation’s pastoral care of their staff and volunteers. 16. It is recommended that consumer organisations communicate with their facilitator prior to the commencement of the education about participants’ circumstances or workplace issues that may impact on the running of the education. 17. It is recommended that organisations revise the evaluation templates for their own use according to the discussion contained in this report, and that organisations who undertake and evaluate this education in future willingly share this information with SHV. 18. Organisations who participated in the pilot project identified a need to have ongoing specialist support after completion of the education, to assist them in implementing work place changes to spiritual care delivery. It is recommended that Victorian organisations contact SHV to discuss strategies to address this need.
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BACKGROUND & LITERATURE REVIEW Spiritual needs arise for everyone regardless of race, culture, beliefs, education or age, and in recent decades there has been an increased awareness of the importance of the spiritual dimension in later life. This is reflected in the growing list of policy, legislation, standards and guidelines underpinning the aged care sector that state or imply a responsibility from governments and aged care providers to attend to older people’s spiritual needs (SHV, 2013). The most well known of these is Expected Outcome 3.8 of the Aged Care Accreditation Standards, entitled, “Cultural and Spiritual Life”. The requirement for this standard is that residents’ “Individual interests, customs, beliefs and cultural and ethnical backgrounds are valued and fostered”. Simultaneously there is gathering momentum in the healthcare sector for a person-centred approach to care. A person-centred approach is interested in the whole person, including their spiritual needs. It is particularly appropriate for vulnerable groups such as the aged. As a consequence, all staff and volunteers engaging in person-centred care need to be sensitive to the non-medical and spiritual dimensions of care. However not all organisations whose focus is aged care have staff who feel confident in understanding and providing spiritual care, nor do many have ready access to pastoral care practitioners or faith representatives. There is an identified need in the aged care sector for basic educational programs that teach all staff and volunteers about contemporary spirituality and spiritual care (Mackinlay, 2006; Hall & Sim, 2005). In response to this need, in 2010-2011 SHV developed the Spirituality in Aged Care Education Package with funding from the Victorian Department of Health’s Count Us In! Initiative. A full report on the development of the education package, entitled Spirituality in Aged Care Project Final Evaluation Report April 2011, including an extensive literature review, is available from SHV. The Spirituality in Aged Care Education Package was piloted once during its initial development, at Carshalton House RACF in Bendigo. Carhshalton House is a stand-alone public sector residential aged care facility that is part of Bendigo Health. The pilot was successful and engendered a great deal of enthusiasm, encouraging SHV to plan a more comprehensive pilot project. Within the course of the current pilot project the education package has now been piloted a further 13 times
In a range of residential and community based settings In metropolitan and regional settings In three different formats (whole day, half day and as single sessions) With group sizes ranging from 6-22 participants For participants from individual sites and combined sites For staff and volunteers caring for a wide range of aged care demographics For providers with and without professional pastoral care on site For staff ranging from general managers, clinical practitioners, personal care and lifestyle staff, through to support staff such as administrators and kitchen staff.
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Overview of spiritual care education for all staff and volunteers in aged care There is little available in the way of units of education about spirituality and spiritual care for all staff and volunteers. The single unit that was identified is the Aged Care Channel’s ‘Spirituality and Practice’ unit. The Aged Care Channel is an online provider of aged care education programs available by subscription. There are a number of other education units that are related to spiritual care and that promote themselves as directed at a cross section of the aged care workforce: 1. The ‘HCCVI Basic Training for Volunteers Program’ (HCCVI, 2011a). This was a basic training package for use by health care providers for people beginning to work as volunteers across the health sector, including aged care. The training has been updated and expanded. The ‘Spiritual Care Volunteer Training Package’ (SHV, 2015) will be available from September 2015. 2. Holy Family Services have developed an accredited Certificate IV and Diploma of Pastoral Care and Ageing (NTIS 91561NSW) which is advertised as “suitable for people interested in pastoral care and ageing, pastoral carers from any faith background, those working or volunteering in faith communities, in communities and in aged care”. This is currently delivered in NSW and Victoria. 3. The Centre for Ageing and Pastoral Studies in Canberra has developed a range of courses from certificate to Masters Level for “healthcare professionals, pastoral care workers and clergy.” 4. For the past three years Stirling Theological College in Melbourne (a College of the University of Divinity) has run a week long intensive entitled Pastoral & Theological Issues of Ageing which has attracted a range of aged care staff and volunteers as well as professional pastoral practitioners. While some aged care providers and palliative care agencies are using ‘in-house’ units of training with a focus on spiritual care for staff and volunteers, these are not in the public domain they have not been included in this brief overview.
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Related Pilot Projects The literature search revealed three educational pilot studies whose parameters had substantial overlap with the current project, and which provide a meaningful context: Table 2: Description of Education Models involved in previous pilot projects Pilot Study
Germany (Wasner, 2006)
Australia (Bloemhard, 2008)
United Kingdom (Johnson, 2010)
Description of the models of education involved in previous pilots A single pilot was conducted in Munich in 2002, in which a cross section of 63 palliative care professionals and volunteers undertook training to enable the participants to recognise the different facets of suffering of the dying person and their relatives enabling them to respond effectively. Training format: 3.5 days over consecutive days. The education was named ‘Wisdom and Compassion in Care for the dying’. It was based on a Buddhist model with “non-denominational scope”. In 2006, the Mid North Coast Division of General Practice (MNCDGP) in NSW received a grant from the Department of Health & Ageing to increase local health care providers’ levels of understanding and skills in relation to the spiritual care need of palliative care clients. 96 workshops about spirituality and spiritual care were delivered to a range of multidisciplinary health professionals and volunteers from various healthcare settings including aged care. Training format: 45 minutes to 4 hours, with an occasional seminar format. Facilitator’s description: Over time the focus of the education shifted from giving spiritual care to others to exploring the role of spirituality in an individual’s own life”(p1)… “The main preparation involved picking a topic and collating a series of hand-outs. Sometimes I would utilise a special article or download relevant information to give to participants.”(p4) The facilitator’s role was to support “groups to explore what the role, function and attributes of spirituality could possibly involve in a healthcare setting”. (p4) In 2006, 106 Anchor Care Homes took part in training that consisted of 3x whole days that took place 4-6 weeks apart. Education covered information about death and dying including spirituality, reflection on the home’s current approach, exploration of personal feelings, how to be a non-judgmental listener, and sessions on palliative care and practice.
The strongest parallel between the earlier pilots and the current project is that all four projects have at least part of their focus on teaching spirituality and spiritual care to multidisciplinary staff in healthcare settings.
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Similarly, all four projects employ units of experiential learning, including interactive, inclusive, reflective and practical exercises. Johnson (2010, p56) argues that “due to the generally low level of prior education and lack of practice in learning situations, it was essential that our training [at Anchor Homes UK] was based on interactive and experientially based learning methods”. He also states that “what made the process an effective learning and practice changing experience, was the way it invited participants to share their own life experiences, stories and personal caring practices as part of a mutual exchange”. Bloemhard (2008, p5) commented on the need for the education to be experiential stating that “after all, spirituality is not a thing, it is an experiential process”. Broadly speaking, one difference between the earlier pilots and the current project is their stronger focus on education related to death and dying. However, the significance of this difference is difficult to measure, because the literature presents a strong case for an awareness of imminent death being integral to effective aged care. Johnson (2010, p47) states that “everyone who enters an aged care home is ‘at the end of life’ and that “death and dying are a constant presence in the life and work of care homes”. A recent Australian systematic review also noted that death is a strong theme in residential aged care: “…impending death is considered a powerful stimulus for reflection on the significance of life and destiny for residents in RACFs” (Edith Cowan Uni, 2005. p81). The earlier studies employed various methods of evaluation including:
All three sought qualitative feedback from participants. The NSW pilot study is presented as a ‘case study’ consisting of the personal reflections of the pilot facilitator informed by feedback from participants (Bloemhard, 2008). Bloemhard’s insights resonate with the invaluable feedback gained from the pilot facilitators throughout the current SHV project. The German pilot sought qualitative and quantitative feedback from participants using numeric rating scales and a range of validated instruments (Wasner, 2006).
Pilot findings about changes of attitudes and competencies of participants: The German and UK pilots found significant changes to the attitudes/competencies of their participants. The German pilot was able to establish that the spiritual care training had a positive influence on the participating palliative care professionals which was sustained over a six month period. The outcomes of the UK pilot included significantly altered attitudes to death and dying which in turn resulted in major changes to policy and practice within the Anchor Homes organisation. The NSW pilot did not measure changes to participants’ attitudes but noted as an outcome the importance of caregivers being at ease with their own spiritual beliefs, need and practices if they are to feel confident and gain competence in being engaged in spiritual care giving. (Bloemhard, 2008. p6). Johnson (2010) listed a range of new strategies employed by the Anchor Care Homes that emerged as a result of the education. An important finding of the UK pilot that resonated with the SHV project was the pivotal bearing of management participation on positive outcomes of the training. The Anchor Homes pilot concluded that If the manager is not part of the trained group, the likelihood of the new ideas taking root is low. With her or him directly involved and taking responsibility for the subsequent ‘cascade’ training and full implementation, the translation into standard practice is very high – 20 | P a g e
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especially…when there was strong commitment from senior management (Johnson, 2007. p8). This theme is also highlighted in an earlier Australian study (Hall and Sim, 2005. p37) which asserted that the “development of any model for spiritual care would require management support and encouragement, particularly at facility level, to enable the integration of a new and shared understanding”. Some other aspects of the previous pilots that resonated with the SHV pilot project:
The demonstrated need to revise and adapt the education models as a result of holding the pilots. This happened in both the UK and Australian pilots while the German pilot identified a need for further research to “improve the existing courses” (Wasner 2006. p103). The use of handouts to sustain the education: the UK pilot provided handouts, leaflets, key policy statements and templates that could be easily identified and used as a resource. Bloemhard also developed a resource package. Bloemhard (2008. p4) notes the “great demand” in her local area for spiritual care educational events which was made evident by the number of training events that she facilitated. The need for post training follow up - “Some of the participants commented that it would be quite helpful to have regular meetings close by or a refresher training every six months” (Wasner. 2008 p103).
So, despite the previous absence of discrete models of education about spirituality in aged care education available in the public domain, and the paucity of literature focused on education about spirituality and spiritual care in aged care, the three related pilot studies conducted during the previous decade did suggest that short units of education could be an effective method of changing staff attitudes and competencies in the areas of spirituality and spiritual care, and that changes could also be sustainable over time.
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A DESCRIPTION OF THE EDUCATION THAT WAS PILOTED As mentioned previously, the education package that was piloted in the current project was initially developed under the Victorian Department of Health’s Count Us In! Initiative in 20102011. A report on the original project entitled Spirituality in Aged Care Project Final Evaluation Report April 2011 is available from SHV. The SHV Spiritual Care in Aged Care Education Package is based on a ‘whole-of-staff’ model. That is, the domain of providing spiritual care is viewed as a responsibility of all staff and volunteers engaged in aged care. Figure 1: Domains of Responsibility for Providing Spiritual Care in Aged Care
The aim of the education is to imbue an understanding of relational spirituality, and to explore strategies for identifying and responding to the spiritual needs of aged care recipients. An important facet of the education is that it is not intended to increase the workload; rather it is designed to enhance how staff and volunteers approach their work. The education package was originally developed with all staff and volunteers working in standalone RACFs in mind. The education package is designed to be reflective and experiential rather than didactic, and is facilitated using principles of adult learning. The individual learning modules are listed in Table 3 (p23). As the learning modules are designed to build on each other, the education is suited to closed groups where no new participants are admitted to the group after the commencement of the education. The learning modules are spread across two levels of education. The Level one education is for all staff and volunteers. The length of the five learning modules can vary depending on the size of the group and level of interaction, but they are designed to be comfortably delivered over the course of a day. However, as the learning modules are discrete and take approximately 1.5-2 hours each, the pilot project also sought to test the Level education using two other formats – 22 | P a g e
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Delivered as two half day sessions: three learning modules facilitated in the first session followed by two in a second session. Two of the pilots used this format. In one, the sessions were a day apart, and one in the other, the sessions were a week apart. Delivered as individual sessions at weekly intervals. Two pilots used this format. The Level two education is designed to be undertaken by appropriate ‘graduates’ from Level one, enabling them to take up the spiritual liaison role within their organisation. Spiritual liaison staff members provide support to other staff and volunteers by being available to have conversations regarding residents’ spiritual needs, and by helping other staff members and volunteers to decide what to do next. This might mean taking some direct action, consulting with senior staff, or making a referral to a spiritual/pastoral care practitioner, or faith representative. The success of the spiritual liaison role is reliant on all staff and volunteers having gained an understanding of the concepts of spirituality and spiritual care contained in the Level one education. As an example; a cleaner notices while cleaning a resident’s room, that the resident is distressed. He approaches the resident and has a conversation. Afterwards he is left with some concerns about the resident’s peace of mind, and wonders whether she may need following up. He is unsure what to do, so he approaches a spiritual liaison staff member to discuss his concerns. Together, they decide that the spiritual liaison staff member will make other staff aware of his concerns at handover, so that the resident’s need can be monitored. In every pilot (n=13), the Level two education was facilitated as a half-day session, within a week of when the Level one education was completed. Table 3: Spirituality in Aged Care Package: Learning Modules Spirituality in Aged Care Education Package - Overview Level one education Learning Module 1: Qualities and Values Learning Module 2: Presence and Listening Skills Learning Module 3: Understanding Spirituality and Religion Learning Module 4: Relational Spirituality – A Model of Spirituality Learning Module 5: Working with Relational Spirituality and Potential Responses Part A: Referrals – When and Where? Part B: Seeking Advice and the Spiritual Liaison Role Level two education Learning Module 1: Spiritual Liaison Role, Consultation and Facilitation Skills Learning Module 2: Spiritual Tasks and Pastoral Care Learning Module 3: Practice Session Learning Module 4: Spiritual Care of the Person with Dementia Learning Module 5: Working As a Team
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METHOD The pilot project was developed in line with the principles of an exploratory action learning model. Using this model, the researcher repeats a process, reflecting on what has happened and using this information to plan the next action (Dick, 1999). For this project the Spiritual Care in Aged Care Education Package was piloted thirteen times in a range of settings (refer Table 4, p26). Ethics: Full details of the conduct of the initial project to develop the education package were submitted to the Bendigo Human Research Ethics Committee by way of the national ethics application form in June 2010. Approval to commence the project was granted by HREC on 7th July 2010. After holding later conversations with La Trobe University, it was established that the current pilot project did not require ethics approval. Evaluations: There was an extensive formal evaluation schedule for the pilot project (see Table 6: Numbers of Evaluation Surveys Returned, p44). Written and verbal feedback was sought from facilitators, hosting organisations and group participants. Participants were surveyed at the completion of the education and also after three months. Organisations were surveyed before the education began and after three months. Participants and organisations were also surveyed after twelve months. At time of writing, the twelve month evaluations are still being collected so that feedback is not included in this report. Facilitators supplied written feedback after each pilot, and attended a forum after the completion of all the pilots to talk about their pilot experiences. At the organisational level, each pilot host was asked to nominate a single contact person at management level with whom SHV could liaise with about all aspects of the pilot and subsequent evaluation. A statistical analysis was applied to a set of participant surveys, paired by number, collected before and after the completion of the Level one education. The evaluation surveys and forum transcripts were uploaded onto NVivo10 and grouped according to themes. Costs: Costs associated with hosting the pilots were shared between the participating organisations and SHV. Host organisations were required to cover the cost of staff attending the education, as well as staffing backfill if required. They were also required to provide a venue, and catering if they chose to include it. SHV covered the costs associated with independent facilitators, including travel and accommodation, as well as supplying education manuals and other resources.
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Pilot Chronology: April 2011 SHV completed the initial development of the education package which was piloted once at Carshalton House RACF in Bendigo as part of the initial project. December 2011 54 invitations to take part in the pilot project were emailed to Victorian aged care providers and one Western Australian provider who had expressed interest. Information also went out to key stakeholders such as Commonwealth and Victorian governments, the Aged Care Standards and Accreditation Agency and relevant peak bodies. The mail out was limited to the range of providers on the SHV database. In order to ensure the participation of a range of aged care provider demographics, a number of organisations were approached directly. The aim was to pilot the education across 14 organisations with approximately 140 participants. The response was very positive and the project was initially oversubscribed. Eventually 13 pilots went ahead. Participating organisations were invited to nominate an ‘in-house’ pastoral care practitioner (if available) to undertake training to become a facilitator. Otherwise, SHV recruited suitable candidates to train as independent facilitators. February 2012 The SHV ran a two-day ‘Preparation for Facilitators Workshop’. During the workshop, potential facilitators undertook the education themselves, discussed strategies for promoting the pilots, and were given information about the evaluation schedule. February-July 2012 130 participants consented to take part in 13 pilots. See Table 4: Pilot Host Demographics, p27 for details. Variations in each of the pilots included geographic and demographic differences. See Table 9: Group Participant’s Roles, p52 to see the range of people that took part. The education package was tested in three formats o Whole-day format as previously recommended (n=9) o Half-day sessions (n=2) o Single Sessions (individual weekly sessions) (n=2) Group sizes for Level one education ranged from 6-22 participants. Group sizes for Level two education ranged from 3-20 participants. August 2012 Facilitators took part in forum where they were asked to share their experiences and ‘brainstorm’ solutions to issues that had arisen during the pilots. October 2012 Collection of three month post-pilot evaluations completed. July 2013 Twelve month post-pilot evaluations completed. These outcomes are not included in this report.
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Table 4: Pilot Host Demographics Pilot identity Location
Pilot Host’s Client Focus
Format selected for education Single Sessions Whole day
Pilot host has Pastoral Care on staff: Yes
Pilot 1
Metro
Pilot 2
Metro
Psychogeriatric Nursing Home Financially & socially disadvantaged, RACF & community based care
Pilot 3 Pilot 4 Pilot 5 Pilot 6 Pilot 7 Pilot 8 Pilot 9
Regional Metro Regional Regional Regional Metro Metro
General RACF Predominantly CALD General RACF General RACF General RACF General RACF Financially & socially disadvantaged, RACF & community based care
Pilot 10
Metro
Pilot 11 Pilot 12
Pilot 13
Group size; Level one education
Group size, Level two education
7,7,6,7,7
4
Yes
22
20
Whole day Half day Whole day Whole day Whole day Whole day Half day
No Yes No No No No Yes
10 6,4 8 13 9 11 8, 7
8 3 7 5 6 11 3
Single Sessions Whole day Whole day
Yes
8,8,7,8,4
3
Regional Metro
Psychogeriatric Nursing Home General RACF Financially & socially disadvantaged, RACF & community based care
No Yes
8 10
8 7
Metro
General RACF
Whole day
Yes
10
4
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SUMMARY OF OUTCOMES OVERVIEW 130 individual participants took part in 13 pilots hosted by ten aged care provider organisations. One organisation hosted four pilots for their individual RACFs. Of the 130 participants involved, 117 participants (90%) completed the Level one education. The education was presented in ‘Whole-day’ format at nine pilots, in ‘Half-day’ format at two pilots, and in ‘Single-Session’ format at two pilots. When the Level one education was presented in ‘Whole day’ format, the completion rate was 98% (n=101). The completion rate for ‘Half Day’ format was 43% (n=14), and for the ‘Single Session’ format was 66% (n=15). 100 participants went on to complete the Level two education which introduced the ‘spiritual liaison role’. Participant feedback was very positive and three pilot organisations reported having incorporated the ‘spiritual liaison role’ three months after the completion of the education. However, a number of issues were identified with implementing the Level two education indicating that the model needs further development. See discussion under heading “One level of education or two?” p32. Demographic information about the 13 host organisations is set out in Table 4, p26. Seven pilots took place for staff and volunteers of stand-alone RACFs, six pilots took part for staff and volunteers from combined sites. Of these, four pilots were for staff from a combination of RACFs, and 2 pilots were for staff and volunteers from combined RACFs and community care providers. The participants themselves were drawn from the whole spectrum of the aged care workforce, from general managers to admin and kitchen staff. They included six volunteers (see Table 9, p52). Three-month evaluations: Individual participants and the organisations hosting the pilots were surveyed again after three months to test whether the education had made a lasting impact on work practices. 10/13 organisational surveys were returned (77%). 76 individual surveys from those ten organisations were returned (65% of participants who completed the Level one education n=117). IMPACT ON PARTICIPANTS Statistical Outcomes Participants were asked to complete surveys paired by number at the conclusion of the Level one education. The survey was designed for the original pilot held at Carshalton House. The outcomes were consistent with the findings from the original pilot. The surveys produced strong evidence to show that the Spirituality in Aged Care Education Package was effective in
increasing participants’ knowledge about the spiritual needs of the aged increasing participants’ confidence about talking to aged care residents about their spiritual needs increasing participants’ knowledge about resources relating to spiritual care.
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88% of participants indicated that they were reasonably or highly satisfied that the education package met their expectations. The Statistical Analysis of Participants’ Paired Surveys is included in full in Appendix B, p60. Qualitative Feedback from participants The qualitative feedback from all pilot groups was overwhelmingly positive. This was the case even when circumstances, such as a poor level of management involvement, or facilitators having reported challenging aspects to the pilots, predicted otherwise. Recurring themes from participants’ evaluation:
Heightened awareness of residents/clients’ spiritual needs Enhanced understanding of listening skills Heightened awareness of the importance of a person’s story A particular appreciation for Learning Module 3: “Understanding Spirituality and Religion” An appreciation for the opportunity to spend time with colleagues reflecting on work practices A realisation by some that they were already doing a good job in the area of spiritual care, and were able to pick up on clients/residents’ spiritual needs.
What the three month evaluations showed: Participants were asked to respond to a further survey three months after they completed the education. These surveys could only be identified in terms of their host organisations. 76/117 (69 Female, 7 Male) participants responded (65%). Nine surveys only returned the front page of two pages so that questions 6-12 were not answered. To a large extent, these responses, along with the three month organisational surveys provide the most insight into the effectiveness of the Spirituality in Aged Care Education Package. They demonstrate that for the 76 (65%) respondents
The education was effective with aged care staff and volunteers, not only from Christian backgrounds, but from a broad range of faith identities including Hindu, Baha'i, atheist and agnostic spiritualities, as well as those who cited having an ‘individual belief system’ (see Table 11, p54). 91% considered that knowledge gained from the education influenced their everyday interactions with residents/clients (see Table 14, p55).
Participants listed many ways in which the education had impacted on their interactions with both aged care recipients and other staff (see Table 15, p56). Repeated themes included
Increased awareness of clients’ feelings, holistic needs, spirituality Increased capacity for listening A greater emphasis on the older person’s life story.
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32 respondents (n=68, 47%) had a perception that residents/clients had responded to the changes which is a highly significant indicator that training is reaching the workplace. Participants’ reported noticing
Aged care recipients being happier to engage, more open, less agitated Three participants commented that they noticed residents being more cooperative.
29 participants (n=68, 43%) indicated that they had perceived changes in workplace practices at their organisation since the education which further strengthens the indicator above. Changes noticed by participants included
The introduction of a spirituality focus group The introduction of meetings to enable networking for staff about spiritual care A new pastoral care practitioner role in a non church-based RACF The introduction of the spiritual liaison role Improved care planning, especially around palliative care Greater attention to residents’ needs Improved referral pathways for spiritual care.
IMPACT ON PILOT HOST ORGANISATIONS A nominated liaison person at management level was asked to complete surveys about their organisation before the pilot, and again three months after the pilot. The feedback from the pilot facilitators was also a useful source of information. Thirteen organisations (n=13, 100%) completed the pre-pilot surveys. Ten organisations returned surveys after three months (77%). In line with the participant feedback, the organisational response was positive. Eight organisations continued to have new strategies for spiritual care in place after three months. Strategies devised to enhance spiritual care are listed in Table 1, p12. Evaluations showed that the level of management input into each pilot was the strongest predictor of whether an organisation would develop new workplace strategies to enhance spiritual care practice as a result of the education. This was consistent whether the organisations had pastoral care on staff or not (3/8 had pastoral care staff, 5/8 did not). The three organisations that did not return surveys after three months, and the two that did but had not devised strategies for enhanced pastoral care, had lower levels of management involvement in their pilots. Management involvement occurred on a number of levels:
Endorsement and ‘ownership’ of the pilot project within the organisation ‘Hands on’ responsibility for implementing the pilot Supportive participation in pilot groups Responsiveness to staff suggestions for new strategies.
The best outcomes occurred in organisations where management, as well as other staff, had a high level of positive involvement in at least three of these areas, and where there was a high level of cohesion between managers where more than one was involved.
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DISCUSSION – IMPORTANT THEMES WHO SHOULD PARTICIPATE? The makeup of the participant groups had an impact on the outcomes of the education. The most positive outcomes occurred when there was a high level of management participation as well as group participation from other staff members. The degree of management participation in each pilot was the strongest predictor of how effective the education was in changing workplace practice. This was the case whether the organisation had pastoral care on staff or not. SHV strongly encouraged management participation in the pilot project; however the degree to which managers participated varied. Management involvement occurred on a number of levels:
Endorsement and ‘ownership’ of the pilot project within the organisation ‘Hands on’ responsibility for implementing the pilot Participation in pilot groups Responsiveness to suggestions for change that emerged as an outcome of the education.
The best outcomes occurred in organisations where management had successful involvement in at least three of these areas, and where there was a high level of cohesion between managers where more than one was involved. Volunteers took part in four pilots. Their inclusion was generally straightforward, however, their inclusion highlighted the need for organisations to assess the appropriateness of including participants other than staff members. The education sessions presented opportunities to reflect on the workplace, and on the needs of particular residents/clients. Many participants appreciated being able to work as a team in this way, often for the first time, which sometimes led to sensitive issues being aired. In one pilot, the presence of a volunteer whose mother was also a resident led to other staff reporting that they did not feel it would have been appropriate to discuss their most pressing issues. With that in mind, it was also the case that some organisations expressed a desire to extend the education to residents/clients, as well as their carers and families, to enable everyone who was involved in providing love and care to be able to identify and respond to a person’s spiritual needs. FACILITATORS Discussions with stakeholders, including the pilot facilitators, emphasised the need for future facilitators to be competent spiritual carers themselves. The facilitators who engaged in the pilot project felt that it was essential for facilitators to not only have a thorough working knowledge of spiritual concepts, but to be able to engage easily in discussions about spirituality and spiritual care. Anna Bloemhard (2008, p5), who piloted education about spirituality in healthcare settings in 2006 also noted that “it is of the utmost importance that the facilitator of interactive process, is familiar, at ease and able to share from their personal spiritual experiences”.
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While it is acknowledged that professionals from other disciplines may have a strong interest and well developed competencies in these areas, the consensus amongst stakeholders in the pilot project was that until the language and concepts of spirituality and spiritual care are more thoroughly embedded into the aged care sector, facilitators should be developed from the pool of professional pastoral/spiritual carers who have experience in aged care settings. During the Facilitators’ Forum held after the completion of the pilots, the facilitators also commented on some of the complexities that they were faced with in delivering the education:
Varying levels of readiness and responsiveness from pilot organisations Varying degrees of receptiveness and resistance from participants Participants with special needs Participants who needed added support Morale and workplace issues A participant who considered making a complaint
Future training for facilitators will need to equip them with strategies for negotiating with aged care workplaces that may be experiencing issues such as those listed, and with strategies for accommodating participants who have special requirements or need added support. FORMATS The report from the original project to develop the Spirituality in Aged Care Education Package (Nolan, Mills, 2011) recommended that the Level one education be facilitated in ‘whole day’ format. That report raised the concern that changing the format of the education might impact on types of discussions that occurred, the energy and impetus of the group, and on the shared sense of achievement that occurred after the Level one education was completed. It also argued that changing the format might discourage the sense of impetus that organisations need to enable a culture shift with regard to spiritual care. To test these concerns, organisations were invited to host their pilot in one of three different formats;
Whole Day (n=9) Half Day (n=2) Single Session (n=2)
In all instances, the Level two education was completed in a single half day within a week of the completion of the Level one education. All pilots ran with closed groups, meaning that no new participants could join in after the commencement of the first session. It is noteworthy that attendances at every session fluctuated when the Level one education was presented in the ‘half day’ format, and in most sessions when the education was presented in ‘single session’ format. For both pilots using the ‘single session’ format, the numbers of participants decreased and then increased again, suggesting that the drop-out rate was due to circumstances other than dissatisfaction with the course. The evaluations show that the pilots using ‘whole day’ format were the most successful in effecting change for their organisation. However a number of challenges for the whole day format were noted:
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Difficulty in taking large numbers of people off the floor at one time Difficulty in finding replacement staff and paying the costs associated with backfill In three instances, the scheduling of a full day’s education in light of upcoming accreditation was a challenge. The pressure of upcoming accreditation was cited by a pilot organisation that withdrew from the project as the reason why they did not go ahead.
The difficulty in taking large numbers of staff off the floor for training is also reflected in the reasons given for choosing the shorter formats: “We chose the half-day format as this way more staff could attend. It is not easy to free up staff for a full day when you only have about 30 staff….As [our organisation] tends to be very busy in the mornings half days were manageable and I believe we would do the same format if we ran the education again” “So, structurally, [the staff] don’t have a history of having training time, apart from these two hours after handover. They could not have made staff available any other time…” Only two of the four pilots using the shorter formats returned surveys after three months. While the twelve participants who responded indicated that their attitudes and work practices had changed in a positive way, there were no changes to organisational practice recorded. It is relevant to note that the cohort of pilots using the shorter formats was not only small, but also had poor levels of management participation in each case. As noted earlier, this was the greatest predictor of the education’s overall effectiveness, therefore it is difficult to assess the impact using the shorter formats. More testing needs to be done to clarify whether the shorter formats are an effective alternative to the ‘whole day’ format. ONE LEVEL OF EDUCATION OR TWO? The ‘spiritual liaison role’ is introduced in the education as a built-in strategy for sustainability. This is especially relevant for sites where there is no professional spiritual/pastoral care on staff. Staff who undertake the Level two education are thereby enabled to become spiritual liaison staff members. As such, they act as ‘first port of call’ for other staff and volunteers who have a concern about the spiritual needs of an aged care recipient, and they can assist a staff member or volunteer in deciding ‘where to next’. The two tiered model was originally developed for single site RACFs. It requires that at least a majority of staff from a given site have undertaken the Level one education so that they understand the spiritual liaison role. While two of the pilots included participants from community based care, participants were drawn from multiple sites so the spiritual liaison role’ could not be properly tested in the community setting. 3/7 of the ‘single-site’ RACFs who hosted pilots reported having effectively incorporated the spiritual liaison role three months after the education. However, issues were identified with the Level two education that may have hindered the takeup rate. 100 ‘graduates’ of the Level one education participated in the Level two education, and the evaluation response rate was 79%. There was a high level of satisfaction with the education content but it became clear that there were issues around recruiting appropriate candidates. 32 | P a g e
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Appropriate candidates were those deemed to be of a sufficient level of maturity, with some leadership skills and enough aged care experience to enable them to successfully take up the ‘spiritual liaison role’. The processes for recruiting Level 2 participants during the pilots were ad hoc and it wasn’t clear to the pilot groups who should be involved. There is a need, for instance, to ensure that lifestyle coordinators and community case managers participate, as they play a key role in creating holistic care plans, but this didn’t always happen. In two of the pilots all of the Level one participants did the Level two education. While this may increase the effectiveness of the model, it puts an added burden on the resources of the hosting organisation. This aspect of the education package needs further development. One suggestion that warrants further exploration is that the Level two education be facilitated at set intervals by an independent agency, whereby organisations who have hosted the Level one education would be invited to nominate participants. Another important finding however, was that the pilot project also demonstrated that the education package was effective in creating positive changes for individuals and for the pilot organisations that did not take implement the ‘spiritual liaison role’. This outcome suggests that the sector would benefit from a second version of the education that teaches the same principles of spirituality and spiritual care, but that omits the ‘spiritual liaison role’. This version could then be directed to groups drawn from multiple sites where participants can expect to return to work with colleagues who may not have undertaken the spirituality education. Therefore, one of the recommendations of this report is that further development be undertaken to provide a second version of the Spirituality in Aged Care Education Package: Version 1: i. Maintains the current model of the education package which is comprised of two levels of education, and incorporates instruction about the ‘spiritual liaison role’ ii. Is a revision of the current education package in line with the outcomes of the pilot project iii. Is aimed at discrete residential or community based sites. Version 2: i. Adapts and combines learning modules from the two levels of education but omits the ‘spiritual liaison role’ ii. Offers the equivalent of one whole day of education iii. Is appropriate for a combination of staff and volunteers from multiple residential or community based sites. FLEXIBILITY IN THE COURSE CONTENT An important aspect of the learning modules that will be taken into account in revising the education is the need for some built in flexibility. The needs of the pilot groups differed in a number of ways and feedback from the facilitators indicated that they adapted the education package in at least six of the pilots.
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Facilitator 1: “… all the stuff on dementia, they are huge experts, so I didn’t deal with that. I felt there wasn’t anything I could add …so I just looked at it and said I encourage you to take it home and read it…” Facilitator 2: “We spent quite a lot of time on the dementia, because we have quite a lot of dementia residents. The staff struggle a bit with how they work out what their needs are, then how to meet them”. Facilitator 3: “I absolutely scrubbed one of the exercises – the listening exercise – because they all said “we have done all this before”. So we moved on. The lesson was that I didn’t need to follow it ‘religiously’ “. The positive outcomes from the pilots where the education was spontaneously adapted to suit the particular needs of the group suggests that it would be helpful to include some flexibility in the education model. ALERTING THE FACILITATOR TO SPECIAL CIRCUMSTANCES It is important that the facilitator is alerted to special circumstances within the group or to participants who have special needs. There were difficulties in two of the pilots when the facilitator was not informed about circumstances impacting on participants. In the first instance the facilitator learned during the lunch break that the group was trying to come to terms with the sudden resignation of a much loved colleague earlier that morning. In her words “When the others found out they “just all collapsed” “. In a second group, the facilitator was not aware that there were two people in the group with hearing difficulties. In both instances this impacted on the education and on outcomes for the participants. These examples have raised awareness of the need for facilitators to gather information about special needs or special circumstances that might impact on the education. SIZE OF THE GROUP The recommended group size was 8-14 participants. Numbers in the actual pilot groups varied from 6-22. The fluctuations in the group sizes for the pilots that undertook the education in Half day or Single session format meant that one session went ahead with as few as 4 participants. The size of the group prompted little comment from pilot organisers or management. However having enough support within the group to manage larger numbers was an important factor. One pilot went ahead with 22 participants drawn from 8 sites. Participants were from RACFs and community based care. This pilot was successful both in terms of participant outcomes and organisational outcomes. It is notable that this pilot had a very high level of management involvement. Despite the success of this very large group, experience and common sense suggests that for most organisations, groups of more than 14 participants make it difficult to provide sufficient support and encouragement for everyone to participate effectively. This is particularly relevant given that the reflective and experiential nature of the education requires a high level of participation. If it is necessary to have more than 14 participants, a co-facilitator should be appointed.
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VENUE While there was relatively little comment on the practical elements of the pilots from participants overall, multiple participants as well as facilitators from three different pilots provided feedback about less than ideal venue spaces. Amongst the issues cited were
The size of the room Temperature of the room Distance to travel from home The need to be far enough from the work environment to focus on the education
All pilot hosts were encouraged to supply catering for participants as an example of the organisation offering spiritual care to the staff. The nine pilots that went ahead in the ‘whole day’ format all provided catering. The chosen venue needs to be of a standard, and situated far enough away from the workplace to enable the facilitator and participants to fully focus on the education without the risk of participants being called away. “I lost two participants to other facilities because they were onsite…two nurses… it is just so easy for them to be called away.” (Pilot facilitator) POST EDUCATION FOLLOW-UP An issue that was identified in the wake of the pilots was the felt need for continued support from external sources once the education was completed. This was expressed by participants who were integrating new knowledge, and by organisations introducing new processes. There are two strategies for ongoing support built into the education package at present. The ‘spiritual liaison role’ built into the second level of education, and a resource booklet given to participants. Victorian organisations that would like to further discuss strategies for post education support are invited to consult with SHV. FUTURE EVALUATION The evaluations from pilot project demonstrated that, on the whole, the evaluation templates were effective in gathering the data that was required. However, future users may wish to consider the following suggestions before they undertake evaluating a similar pilot: 1. At the end of the Level one education, participants were required to complete two evaluation forms. Participants were asked to complete a statistically paired survey and an ‘Evaluation of the Day’ form. While the ‘Evaluation of the Day’ provided some useful data after half-day and single sessions, on the day that the Level one education was completed, it was often sparsely populated. It is likely that the data collection would have been as effective if the participants were only asked to complete the paired survey on that day. 2. The bulk of the participants’ demographic details were collected on the surveys completed three months after the education. It may be advantageous to collect this information earlier, as it may enlighten as to why some participants start but do not complete the Level one education. The demographic questions could be added to the Participants’ Pre-Education Survey. 35 | P a g e
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3. Suggestions for additional demographical questions to be added to the Participants’ PreEducation Survey: a. What is your country of birth? b. What is your first language? c. How long have you been working in aged care? 4. Future users of the education package may want to consider collecting additional feedback from organisations (and not just from participants and facilitators) immediately after the completion of the education package. 5. The surveys given to participants and organisations three months after the completion of the education contained some repetitive questions that could be deleted or combined.
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Follow up Evaluation for Staff & Volunteers (3 Months): Delete questions 10 & 11 as the answers are revealed in earlier questions. Survey of Host Organisation: 3 Month Follow-Up Survey: Questions 2 & 4 could be combined.
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SPECIALIST LEARNING MODULES FOR THE FUTURE The ten organisations who returned three month surveys all affirmed their interest in running the Spirituality in Aged Care Education regularly as part of staff training. Two organisations added spontaneous comments
“Strong yes” “Think it would be good to run it for relatives and residents”
Participants and organisations were also asked to indicate which of the following areas they would find valuable for future education programs: Table 5: Learning modules to be developed in the future: Spirituality and Palliative Care Spirituality, Sexuality and Aged Care Spirituality and Dementia Care Spirituality, Death and Dying Spirituality, Loss & Grief Spirituality and Advance Care Planning Spirituality and Mental Health
There was a strong positive response to all areas from participants and organisations, and two further topics were suggested: “Spirituality and Culture”, and “Spirituality, Disability and Ageing”.
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RECOMMENDATIONS RECOMMENDATIONS FOR THE SECTOR 1.
The pilot project has demonstrated that the Spirituality in Aged Care Education Package is effective in enabling all staff and volunteers from a range of aged care settings to identify and respond to the spiritual needs of aged care recipients. It has also demonstrated that the education is effective in providing a context in which staff can explore and implement strategies to enhance the provision of spiritual care and a person-centred approach.
This project was undertaken on behalf of the Victorian aged care sector. As such it is recommended that the following organisations endorse the Spirituality in Aged Care Education Package and work with the Victorian aged care sector to implement this education.
Victorian Department of Health Aged & Community Services Australia (ACSA) Alzheimer’s Australia Victoria Council of the Ageing (COTA) Carers Victoria Leading Aged Services Australia – Vic (LASA Vic) Palliative Care Victoria Centre for Cultural Diversity in Ageing Victorian Aboriginal Community Controlled Health Organisation (VACCHO)
This education package will assist aged care providers to meet the national standards and guidelines that require them to provide spiritual care. While the constituency of SHV’s work is Victorian, it is recognised that the outcomes of this project have national implications. As such, it is recommended that the following organisations endorse the Spirituality in Aged Care Education Package and work with the national aged care sector to implement this education.
Commonwealth Department of Social Services PASCOP (Pastoral and Spiritual Care of Older People) Leading Aged Services Australia Aged & Community Services Australia Alzheimer’s Australia Palliative Care Australia Partners in the Culturally Appropriate Care (PICAC) Program Aboriginal Community Controlled Health Organisations COTA Australia Carers Australia
2. It is recommended that the Commonwealth Department of Social Services make additional funding available for staff administrating the Home Care Packages Program to implement this education. 3. It is recommended that the Victorian Department of Health makes additional funding available to Victorian public sector RACFs and HACC providers to implement this education.
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4. Data from the surveys undertaken on behalf of individual participants and organisations identified a desire in the sector for additional learning units for all staff and volunteers as they relate to the following areas
Spiritual Assessment in Aged Care Contexts Spirituality in Palliative Care in Aged Care Contexts Spirituality and Sexuality in Aged Care Contexts Spirituality and Dementia Care Spirituality, Death and Dying in Aged Care Contexts Spirituality, Loss and Grief in Aged Care Contexts Spirituality and Advanced Care Planning in Aged Care Contexts Spirituality and Aged Mental Health Spirituality and Intellectual Disability in Aged Care Contexts
It is recommended that the Commonwealth Department of Social Services and the Victorian Department of Health resource appropriate agencies to develop specialist learning units to address this gap in the comprehensive provision of education for all staff and volunteers in aged care contexts.
RECOMMENDATIONS FOR SHV 5. It is recommended that SHV further revise and adapt the Spirituality in Aged Care Education to create two versions: Version 1: i. Maintains the current model of the education package which is comprised of two levels of education, and incorporates instruction about the ‘spiritual liaison role’ ii. Is a revision of the current education package in line with the outcomes of the pilot project iii. Is aimed at discrete residential or community based sites. Version 2: i. Adapts and combines learning modules from the two levels of education but omits the ‘spiritual liaison role’ ii. Offers the equivalent of one whole day of education iii. Is appropriate for a combination of staff and volunteers from multiple residential or community based sites. 6. It is recommended SHV appoint a suitable agency to train future facilitators of the education package. 7. It is recommended that the education package is facilitated by professional pastoral care practitioners who: Meet the standards for Certified Membership (Entry Level or Advanced Level) of Spiritual Care Australia (see www.spiritualcareaustralia.org.au) And/or have the capabilities, experience and qualifications described at Level 3 of SHV’s Capabilities Framework for Chaplaincy and Pastoral Care 2011 Have experience working in aged care contexts
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Have undertaken specialist training enabling them to become accredited facilitators for the Spirituality in Aged Care Education Package. 8. It is recommended that SHV regularly evaluate and revise the Spirituality in Aged Care Education Package. 9. It is recommended that SHV further pilot the education package for health professionals and volunteers in palliative care and acute care settings.
FOR AGED CARE PROVIDERS IMPLEMENTING THE EDUCATION 10. The research showed that the education was most effective in changing attitudes and workplace practices, in terms of individual and systemic change, when there was a high level of management involvement. It is recommended that senior management take the key role in promoting, planning, participating in, and supporting staff to implement new strategies for enhancing spiritual care that emerge as a result of the education. 11. It is recommended that aged care organisations conduct the Spirituality in Aged Care Education Package at regular intervals, particularly for new staff, including managers. 12. It is recommended that consumer organisations obtain funding to backfill positions to enable staff to attend the education during paid work time. 13. The recommended format for the revised and adapted education package is the ‘whole day format’ until further piloting of the education clarifies the impact of the half-day and singlesession formats. 14. The recommend group size is 8-14 participants. A co-facilitator is required for larger groups. 15. The chosen venue needs to enable participants to focus solely and comfortably on the education. It is recommended that catering be provided as an example of the hosting organisation’s pastoral care of their staff and volunteers. 16. It is recommended that consumer organisations communicate with their facilitator prior to the commencement of the education about participants’ circumstances or workplace issues that may impact on the running of the education. 17. It is recommended that organisations revise the evaluation templates for their own use according to the discussion contained in this report, and that organisations who undertake and evaluate this education in future willingly share this information with SHV. 18. Organisations who participated in the pilot project identified a need to have ongoing specialist support after completion of the education, to assist them in implementing work place changes to spiritual care delivery. It is recommended that Victorian organisations contact SHV to discuss strategies to address this need.
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BIBLIOGRAPHY ACSQHC (Australian Commission on Safety and Quality in Health Care) (2011), Patient-centred care: Improving quality and safety through partnerships with patients and consumers. Sydney. Retrieved from www.safetyandquality.gov.au Aged Care Accreditation Standards as detailed in the Quality of Care Principles (1997) from the Aged Care Act (CthAustl.) 1997. Bloemhard, A. (2008). Practical Implications of Teaching Spiritual Care to Health Care Professionals. Australian Journal of Pastoral Care and Health, 2 (2), 2-8. Cobb M., Puchalski, C. & Rumbold, B. (Eds). (2012). Oxford Textbook of Spirituality in Healthcare. Oxford: Oxford University Press Dick, B. (1999). Sources of rigour in action research: addressing the issues of trustworthiness and credibility. A paper presented at the Association for Qualitative Research Conference "Issues of rigour in qualitative research" at the Duxton Hotel, Melbourne, Victoria, 6-10 July 1999. Retrieved from http://www.uq.net.au/~zzbdick Edith Cowan University. (2005). Guidelines for a palliative approach to residential aged care: A systematic review of the literature. Churchlands. Hall, J. & Sim, P. (2005). Spiritual care and spiritual poverty in aged care – An investigation into current models of spiritual care in high and low care residential aged care facilities and implications. Fitzroy: Brotherhood of St Laurence. HCCVI (Healthcare Chaplaincy Council of Victoria Incorporated). (2011a). HCCVI Basic Training for Volunteers. Melbourne. Retrieved from www.hccvi.org.au Holy Family Services. (2008). Diploma of Pastoral Care and Ageing (NTIS 91561NSW). Sydney. Johnson, M.L. (2010). Learning and Unlearning for End of life Care in Care Homes. International Journal of Education and Ageing. 1 (1), 45-58. Johnson, M.L. (2007). End of Life Care – Report of the Implementation of an Innovative Training Programme in all of Anchor Care Homes. Unpublished report. Mackinlay, E. (2001). The Spiritual Dimension of Ageing. London: Jessica Kingsley. Mackinlay, E. (2006). Spiritual Growth and Care in the Fourth Age of Life. London: Jessica Kingsley. Mackinlay, E. (2012). Care of elderly people. In Cobb M, Puchalski C, Rumbold B (Eds). Oxford Textbook of Spirituality in Healthcare. (pp. 251-256). Oxford: Oxford University Press. NHS Education for Scotland: Spiritual and Religious Care Capabilities and Competences for Healthcare Chaplains. P3. 41 | P a g e
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Retrieved from www.nes.scot.nhs.uk/media/7220/printersfinalproof.pdf.pdf Nolan, I. & Mills, T. (2011). Spirituality in Aged Care Project Final Evaluation Report, April 2011. Melbourne: Spiritual Health Victoria (SHV) SHV (Spiritual Health Victoria (2011b). Key Terms and Concepts. In SHV Capabilities Framework for Pastoral Care & Chaplaincy 2011. (pp 49-52) Melbourne. SHV (Spiritual Health Victoria) (2013). Australian Aged Care Recipient’s Right to Spiritual Care: A Reference Index. Melbourne. Universities of Hull, Staffordshire and Aberdeen. (2010). Spiritual Care at the End of Life: a systematic review of the literature. UK: Department of Health Retrieved from http://www.endoflifeareforadults.nhs.uk Wasner, M., Longaker, C., Fegg, M.J. & Borasio, G.D. (2005). Effects of spiritual care training for palliative care professionals. Palliative Medicine. 2005 Mar; 19 (2): 99-104. World Health Organisation (1998). Health Promotion Glossary.
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APPENDICES
Appendix A
Tables……………………………………………………………………............................…
44
Appendix B
Statistical Analysis of Participant’s Paired Surveys……………………...........
60
Appendix C
Invitation to organisations to take part in the SHV ‘Spirituality in Aged Care’ Education Package Pilot Proposal........................................
62
Appendix D
Participant Information and Consent Form (PICF)…………………….............
66
Appendix E
Participant’s evaluation templates………………………………………................
69
Appendix F
Organisations’ evaluation templates…………………………………..............…..
74
Appendix G
Facilitators’ evaluation templates……………………………………….................. 78
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Appendix A – Tables Table 6: Numbers of evaluation surveys returned
Table 7: Key to Evaluation Surveys
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Table 8: Complete table of new organisational strategies applied after undertaking the education package Pilot No.
Strategies reported immediately post pilot
1.
None reported.
2.
Quote: “Others say it has made us more comfortable and confident to talk about the big issues that we didn’t know how to talk about”. [Some staff] have gone off running – they are signing themselves up for workshops all over the place. They have got together a whole folder of resources, which is on the kitchen table. So it is happening at all sorts of really different levels. It is really exciting”.
Pastoral care on staff? Yes
Strategies reported 3 months after the completion of the education Not returned Issue noted by organisation as impacting on new strategies= staff turnover Strategies to enhance spiritual care: 1. Staff report setting up workspaces differently and actively seeking ways to incorporate ‘wholeness’ into their work. 2. Spirituality is included on staff meeting agendas 3. Staff report embracing ideas for change. Manager’s comment: none.
3.
1. Define spirituality for all staff, dispelling preconceptions. How: education process; ongoing circles of learning; using the mantra: relationship through tasks 2. Explore with all staff the value of listening/being listened to as a way of enhancing all relationships 3. Be a positive and supportive work environment. (the workshop had raised the issue of the impact of any staff tension upon the residents)
No
Issue noted by organisation as impacting on new strategies=staff turnover & staff concerns re resident confidentiality. Strategies to enhance spiritual care: 1. 1. We have a basic spiritual assessment form in draft. 2. 2. Several ‘spirituality care plans’ made up (in draft). 3. More training for staff is planned. 4. A resident was asked to speak about the importance of [her] spirituality at a meeting with staff
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3. cont
5. Continue to find creative ways to reminisce communally, according to capacity (valuing story; perhaps choosing a theme; facilitating letting go; building relationships)
Manager’s Comment:
6. Enhance skills at handover – communicating about holistic care
There has been a ‘realisation’ by the spirituality team that we have a long way to go. Spirituality had [been seen as] church services and although we were aware that people are spiritual beings it was largely up to the resident to take responsibility for this side of their lives. [We have a] much more whole and complete approach to care now. I think it would be good to run it for relatives and residents.
7. SHV could provide a checklist for handover, ensuring that spiritual needs are attended. 8. Have an accessible resource folder for spiritual referral and issues 9. All participants (Spiritual Liaison Officers) to form a steering committee and set clear objectives for the next year. 10. The educator is to assist in effecting the objectives 11. Review current clients holistically – ensuring attention is being given to their spiritual needs. E.g. Managers encouraging staff to bring matters about holistic care to handover. 4.
None reported
Yes
Evaluation not returned
5.
None reported
No
Evaluation not returned
6.
1. Inclusion of spirituality in all Orientation literature. Possibility of someone talking with each new staff member at Orientation.
No
Issue noted by organisation as impacting on new strategies: None Strategies to enhance spiritual care: “The discussion as begun about pastoral care… the senior management and
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2. A Staff Memo and Notice in staff room advising of the Spiritual liaison role and the names of the liaison staff 3. Agenda item for staff meetings at the various levels
board have committed to the part time engagement of a pastoral care worker as a trial* in the upcoming financial year …to assist with the implementation of a greater focus on spiritual care.”
4. Talking about the liaison role at handovers
Manager’s comment: none
5. Talking with staff at handover about “being a mindful presence” and listening carefully to the resident
*Author’s comment: Pastoral care practitioner is now employed in this Organisation.
6. Change of attitude towards residents and the things they say and to remember that what they say is valuable. 7. For the spiritual liaison person to find the time to be a good listener when other staff have an issue about a resident 8. In response to the discussion about the resident issue of concern Lifestyle Coordinator will investigate better ways for reminiscing sessions and Life Reviews 9. They asked how could they use volunteers in the spiritual care of residents and I told them about the Pastoral Care Volunteers [at a different organisation] who are carefully chosen and are expected to undertake extensive training of eight days over eight weeks followed by regular ongoing training. I am responsible for the volunteers and because of my passion for spiritual care the training is focused towards this. 10. They would also like to present to the board the idea of specially trained volunteers and/or a spiritual care person role. Not sure how this will be accepted but 47 | P a g e
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no harm in trying. [The RACF manager] will be included in their deliberations 7.
1. Agenda item at staff meeting
No
2. Agenda item at team leaders meeting
Issue noted by organisation as impacting on new strategies: None Strategies for enhancing spiritual care:
3. Memo to staff via hard copy & email notice on boards
1. Spiritual Advisor Role incorporated
4. Request that spiritual liaison role be included in Education Planning, In-Service days, clinical skill days (monthly), Volunteer Training Days
2. Policy changes. 3. Education has been introduced at Skills Days for all clinical staff. Manager’s comment: none
5. Lifestyle coordinator will compile an “Action Plan” of suggestions and discuss with Manager of Aged Care Services. With his permission will delegate tasks to steer liaison group members to follow through & implement. 6. Will also ask if spirituality Liaison group can schedule regular case conferences to include other care staff 7. Talk about ways to improve an integrated approach to care/raise profile of leisure and lifestyle. 8. Implement 6 monthly memorial services and invite families 8.
1. Address management to support [spiritual care] in group meetings 2. Staff suggestion: Spirituality to be introduced throughout the workplace 3.
No
Issues noted by organisation as impacting on new strategies: None. Strategies for enhancing pastoral care: 1. Staff [are] questioning how they do things – there has also been promotion of a person-centred approach
“Would like regular visits [from facilitator] to keep us
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on track
2. Educational resources about a person-centred approach have been acquired.
4. Add spirituality & staff competence to the quality system
3. More organisational focus on residents’ holistic needs Manager’s comment: none
5. Add spiritual care to Best Practice Group. Part of Accreditation Standards 2.9, 3.4, 3.5, 3.7, 3.8 6. I believe a mini version of the training should be part of mandatory training as part of person-centred care for all levels of staff 9.
None reported.
Yes
Survey not returned.
10.
None reported.
Yes
Issue noted by organisation as impacting on new strategies: “There is currently some conflict over some issues and staff have lost sight of spirituality.”
11.
Facilitator: “They all seemed keen to establish more formal ways of enabling spirituality to be more consciously presented to the wider staff. We spoke of the importance of both educating staff about relational spirituality and about identifying spiritual liaison personnel. For some it would mean calling a meeting, or enabling a meeting to be more inclusive. They would like to use some of the handouts, and most of them felt comfortable enough doing this” Issue noted by facilitator before education: There was little or no awareness of a pastoral practitioner role. They were able to identify the need for a counselor, and a religious practitioner, but not a person in pastoral care”.
No
Issue noted by organisation as impacting on new strategies: None.
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Strategies for enhancing spiritual care: 1. All staff who attended are spiritual liaison staff now. Manager’s Comments: The education enhanced the understanding of the staff who participated and also offered interventions to use.
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12.
Pastoral Care Coordinator/facilitator: “Integrating this course in the yearly training schedule would be very important”.
Yes
Issue noted by organisation as impacting on outcomes: none. 1. The referrals that the Chaplain’s Team receives, the approach of staff (especially the Clinical Care Coordinators and the Lifestyle Team) indicates a greater awareness of the relational model of spirituality. 2. Staff’s new focus on spiritual care: A strong effort was made to keep a resident in touch with her church community. “That wouldn’t have been done before”. 3. Four aged care staff have been added to the pastoral care team (spiritual liaison reps). Chaplains support their role. 4. Other staff have been made aware of colleagues who did the training Manager’s comment: none
13.
Areas of need identified: 1. Need to communicate with staff that pilot program is finished and add a few paragraphs about spiritual needs and the spiritual liaison people staff can go to when stuck! 2. Staff would like to know more about cultural issues around death. We have a very multicultural staff. 3. Issues of resources: e.g. Palliative Care
Yes
Issues noted by organisation as impacting on new strategies= changes to management. Strategies: 1. Changes have been made to material that is available for residents’ families in palliative care. Manager’s comment: Some staff are making more & better on-the-spot decisions about meeting spiritual needs.
4. Issues around referrals. Some staff can take responsibility for phoning a priest.
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Table 9: Participants Roles Pilot Participant’s Aged Care Roles
RACFs General Manager RACF Manager Regional Director of Nursing Care Manager Personal Care Attendant Registered Nurse Enrolled Nurse Nurse Unit Manager Lifestyle/Activities Coordinator/Manager Activities/Lifestyle Worker Admin Person Housekeeper Student placement Care Coordinator Cook Diversional Therapist Programs Director "Grade 5" (not clear) Volunteer
Pilot 1
Pilot 2
Pilot 3
Pilot 4
Pilot 5
Pilot 6
Pilot 7
Pilot 8
Pilot 9
2 1
2
Pilot 10
Pilot 11
Pilot 12
Pilot 13
1 1 1
2 1
3 1
4 4
2 2
4 1
4 1 3
2
2 1
4 1 1
1
1
2
1
3
2
1
2
2 1
3 1 2
1
1
2 1 1
1
3
1
1
2
1
4
1 2
1 1
1 1
1
1 1 1 2
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1
2
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Totals 3 4 1 2 24 17 9 2 12 15 3 3 1 3 1 1 1 1 5
Table 9: Participants Roles (continued) Pilot Identifier:
Pilot 1
RN/Quality Officer/Educator RN/Educator Community Based Aged Care Respite Worker Respite Facilitator Day Centre Program Coordinator Personal Care Attendant, Day Centre Community Inclusion Support Worker Community Development Worker Community Care Manager Dementia Care Consultant Community Dementia Coordinator Social Inclusion Program Coordinator Social Inclusion Facilitator Clinical Care Consultant Manager, Community Care Packages Parish Priest Pastoral Associate Volunteer Community Visitor Support Worker Totals
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Pilot 2
Pilot 3
Pilot 4
Pilot 5
Pilot 6
Pilot 7
Pilot 8
Pilot 9
Pilot 10
Pilot 11
Pilot 12
Pilot 13
1 1
7
1 1
1 1 1 2 1
1 1 1 2 1
1 3 1 1 1
1 3 1 1 1
1 1
1 1 1 1 1 1 1 130
22
10
6
8
13
9
11
8
8
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8
1 1 1 1 1 10
10
Table 10: Comments from participant’s Level 1 ‘Evaluation of the Day’ survey Q. What did you find most helpful about the day? What has stood out, along with awareness of residents’ needs spiritually is the time we have shared together as colleagues, with reflection, mindfulness and dialogue together. Q. What did you find most helpful about the day? I found having the time to reflect on a case study with real life implications, was something I could learn a lot from. Knowing that as a group we can all gather over information and stories and work as a team. Q. What did you find most helpful about the day? The connection between spirituality and ADL’s [Activities of Daily Living] in aged care…. Q. What did you find most helpful about the day? - Exploring different aspect of spirituality - Connecting with other staff/programs - Refreshing [my] listening skills - Reflection on personal practice Q. What did you find most helpful about the day? Understanding what spirituality is and how it interacts with all aspects of our lives.” Q. What have you learned that you can use in your role in residential aged care? … [I am] reminded that we cannot always “fix or resolve” issues for clients, but we can be supportive & validate feelings by being present & listening & reflecting. Q. What have you learned that you can use in your role in residential aged care? …Look at the “person”, listen with your heart. Q. What have you learned that you can use in your role in residential aged care? - That spirituality is part of everyday work & actions - That all aspects are connected. Q. What have you learnt that you can use in your role in Residential Aged Care? We all (nurses, cleaners, cooks, maintenance staff) provide spiritual care. Q. What have you learnt that you can use in your role in Residential Aged Care? …Realising what members [residents] say may have an underlying meaning.” Q. What have you learnt that you can use in your role in Residential Aged Care? “Looking at individuals holistically, not as residents I’ve met at work. That they have their histories and they’re someone’s loved one and a family member. Q. What have you learned that you can use in your role in residential aged care? All this was something out of the ordinary. I realized that all the residents [&] carers wanted/needed was first to be listened to with empathy and respect.
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Table 11: Responses from Post Pilot 3 Month Participant Survey: Participant’s identification with faith groups Respondent’s identification with faith groups Christian 46 New Age Spiritualist 2 Baha'i
1
Hindi Anglican-Muslim
2 1
Not indicated Atheistic
7 3
Agnostic Individual belief system
2 6
Not sure
6 Total 76
Table 12: Responses from Post Pilot 3 Month Participant Survey: Q1 Q1. In overall terms, how would you rate the Spirituality in Aged Care Education Package? VG 44 58% Good 28 37% Other 4 5% Total 76 100%
Table 13: Responses from Post Pilot 3 Month Participant Survey: Q2 Q2. Would you consider that the knowledge you have gained from the Spirituality in Aged Care Education has influenced your every day interactions with residents/clients? Yes 69 91% Not sure 6 8% Other (personal statement) 1 1% Total 76 100%
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Table 14: Responses from Post Pilot 3 Month Participant Survey: Q3 Q3. In what ways has the Spirituality in Aged Care Education influenced your every day interactions with residents/clients? More aware of clients feelings, needs, spirituality More compassion empathy respect eye contact tolerance understanding Spiritual needs are met & documented. EOL discussions. Increasing awareness of the needs of people with different cultural backgrounds. Careful not to offend and try to assist with their spiritual needs. Importance of listening Not needing to problem solve Reconfirmed my understanding of spirituality, and contemplation of how to implement this with residents/clients Support other staff, needs of staff Prompt for more activity during activities & interactions More consideration for residents priorities, fear and anxieties Practice silence We don’t have to have all the answers, no need to problem solve Religion is only part of spirituality. Everyone has their own spirituality I realize that residents can have quiet time on their own to meditate, without thinking that they may be a little depressed Understanding that faith is different to religion I think about where they come from and what their lives might have been like It taught me that you can engage in a meaningful way with the client whilst still attending to your many duties thought the day I hear their individual stories Encouraged me to think about each person as an individual More aware of holistic needs (& person-centeredness) of residents Respect for others beliefs/non beliefs. Enabled me to be with [residents] in their time of need Enabled me to be more open with residents Gave me a positive understanding of ageing and improved my attitude to work & home Being more ‘in the now’ Relational Spirituality Model was helpful Looking for non-verbal indications of spiritual need Note: Responses from Post Pilot 3 Month Participant Survey: Q4 – no responses (Q4.If the education has not influenced your everyday interactions with staff, why not?
Table 15: Responses from Post Pilot 3 Month Participant Survey: Q5 Q5. Following your involvement in the spirituality education project, what, if anything, do you find yourself doing differently? Listening. Examples given: “listening carefully for clues about what gives the client joy, fulfilment…meaning in life”. “Listening for when residents want to tell you stories of their experiences and life stories” Reflecting Allowing time in visits, contact with carers & clients for more listening and prompting more questions Not really doing anything differently, but more conscious of holistic practice 55 | P a g e
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Listening and hopefully understanding more. Debriefing with my co-worker, rather than mulling over a situation on my own I am actively encouraging people to tell their stories more Sharing information amongst the team, spirituality folder, team meetings, handover, resident of the day Not rushing and stressing about things I can’t control I will read the map of life of residents, check out their ‘life’ board, speak to relatives and friends where possible and take time to speak to the resident in private…to learn what is important to them in their lives at the moment Look more at their past life and make sure that it is still represented in some way in their present Not a lot has changed really More open to others etc….”Personally I find myself more relaxed and with a better understanding of my own needs and how to achieve them” Initiating conversations pertaining to spirituality Thinking more about End-of-Life wishes Spending more time talking to residents on a deeper level Explaining things to residents Ensuring we ask questions on intake around their specific needs & reviewing current residents It was so valuable having time together to reflect for teamwork with my colleagues Enjoying the moment Good to be supported [in knowing] that I am on the right track Being aware of my own spiritual dimension as a part of the service I give I am able to identify unmet needs for residents and family members and refer them to either consultant/pastoral care/manager or ANUM depending on need Identify spiritual needs My confusion is resolved about spirituality and religion Improved interactions with families Talking to staff openly about spiritual experiences, sharing the spiritual journey with residents & family. Looking at each experience
Table 16: Responses from Post Pilot 3 Month Participant Survey: Q6 Q6. If you are doing things differently as a result of your involvement in the Spirituality in Aged care education, have the residents responded to these changes? N=67 from here on. Yes 32 No 5 Not sure 21 Blank (and one personal comment) 10 Not returned 8 Total 76
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Table 17: Responses from Post Pilot 3 Month Participant Survey: Q7 Q7: In what ways have the residents/clients responded? [Clients are] happy to discuss spirituality, without using the term ‘spirituality’ [Residents/clients are] more open and will discuss necessary wishes with me. I received a complaint that was serious in nature and distressing to the client….After a long conversation about his history with [the organisation] I questioned whether the client was interested in talking with the pastoral care practitioner. He agreed for me to contact him. It is of course only part of our response to his complaint but may help him talking through some of his issues and distress Life at the hostel seems more harmonious and calm. Residents and staff [are] happier [Residents/clients are] more settled, appear happier They [residents] are happy to answer questions that I might ask because I seem interested in them They will communicate with me better as I can follow their spirituality. They have a higher self esteem in my programs They have been happy to engage in conversations pertaining to their belief systems Positively. I now have a relationship with one resident where we can discuss our spirituality – how it differs and how it’s the same [Residents and clients] asked me to spend time with them, to listen to them and sometimes pray with them [Residents and clients are] more open and responsive when talking about things When you say you will be back, they believe you and trust that you will come back Less agitation. Openness to discussing and sharing experiences ….all very hard to pin point, but the calmness is good for everybody For those residents who are able, [they] have been more co-operative in behaviour and easily engage in conversation [I] do not know, but I feel better They open up and express their thought and feelings Residents respond well to kindness and spiritual care Responses from clients’ representatives are good and encouraging. Some families are responding by giving us thank you cards, chocolate and phone calls. Also some are giving donations in kind [They are] able to take their time to state their needs [They] found relief, peace and understanding There have been a few incidents of residents wanting to ‘talk’ about their life, and about concerns of life after death, or dying
Table 18: Responses from Post Pilot 3 Month Participant Survey: Q8 Q8. Have any changes been made in practice at your organisation since the completion of the Spirituality in Aged Care Education? Yes 29 No 4 Not sure 32 Blank 2 Total 67 Table 19: Responses from Post Pilot 3 Month Participant Survey: Q9 57 | P a g e
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Q9. Please provide details to changes in practice at your organisation We have a spirituality focus group [The thing that has changed is] focus in terms of client goals [We are] more toward holistic care Staff [are] more aware of spirituality, the expression of spirituality & members’ spiritual needs Actively practicing beliefs within a holistic framework. Discussions on the benefits of this. Meetings to enable networking It feels as though there have been changes, but I am not sure whether it’s a direct result [of the education] or if I am noticing the spiritual aspects of the organisation more [We] provide residents with equipment or activities that relate to past life They are going to trial having a pastoral care role We now have team leaders that we can speak to We are in the process of implementing a spiritual team and spirituality is now discussed at our clinical skills days Palliative ‘care plans’ have improved and [are] more individualised Staff nominated to be available to assist other staff with residents’ needs Policy changes. e.g. Spiritual Advisors I think we are speaking with more openness, trusting each other as colleagues who shared the [education] experience, but not limited to those who took part [The organisation is] attending to residents’ needs more comprehensively when there is a death [There is] an awareness that everyone who works here is involved in the spiritual dimension of residents and other staff Some staff awareness has been raised but it is still to be embedded As a team, homecare staff have been able to relate more to many clients’ needs [We are] spending time with each individual resident, giving attention to being a quiet presence Referral processes for the chaplain have changed. There is now a direct referral process from care staff Communication between chaplain and staff, effective communication, raised awareness
Table 20: Responses from Post Pilot 3 Month Participant Survey: Q10 Q10. Would you say that the Spirituality in Aged Care Package has had an impact on you? Yes 59 No 0 Not sure 8 Not returned 9 Total 76
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Table 21: Responses from Post Pilot 3 Month Participant Survey: Q11 Q11. If so, which particular aspects of the Spirituality in Aged Care Education had the most impact on you? [I was] made more aware of others’ personal needs Allocating time in a busy schedule to reflect…. Mindfulness [I am ] more open to individuals’ spiritual needs Recognising that spiritual needs are just as important as physical needs That spirituality means different things to different people [The education was a] reminder of the basics. The clear distinction between religious beliefs and spirituality…and the two do not need to be separate [It] has made me more mindful of how simple things in life can be so important to the self ….Increased confidence in identifying opportunities where spirituality can be explored with a client without fear of offending Really want to develop it and move it into the spotlight to help shift old perceptions and limited views of spirituality Being more aware of [the] needs of others, and respect for different cultures …How to use someone’s spirituality to provide quality of life If the residents declines to come to an activity then that is fine. They may just need “time out” Being able to communicate on a different level and being spiritually happy in myself. [It] reflects on my work The idea and practice of being present to the moment, and listening to the client Spirituality is about the whole person It's about listening to a person’s story and their individual needs [It] encouraged me to learn about other beliefs/religions [It] increased my awareness of the importance of spirituality in everyday life If the opportunity arises – talk more with the residents The balance between duty on a daily basis, and the needs of individuals Being able to share feelings, listening, caring, giving time. That spirituality is not a specific religion The time to be together [with colleagues] in reflection It added value to my philosophy of spirituality in aged care To understand that spirituality is a person-centred belief and not necessarily one of religion The importance of ‘being with’ rather than doing or saying something It supports the work I already do The awareness of the importance of ‘relationship’ The ‘Picture yourself going into a nursing home’ exercise The realisation that spirituality can offer people the opportunity to find peace, joy and fulfilment My work attitude has improved because I can communicate more with residents It has made me look at the individuals as more of a whole, rather than just medical needs The vision of spirituality A deeper understanding of spirituality and its many layers The day was well presented. It brought staff together and was very interactive. It made staff aware of how important their interactions with residents are Spirituality, loss and grief [I am] happy with increased knowledge and confirmation of what I have already been doing A feeling of peace and awareness of my own spirituality Highlighting the importance of this project for high care and low care including dementia care. The way in which we approach our residents paves the way open for communication Involvement. Awareness
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Appendix B – Statistical Analysis STATISTICAL ANALYSIS OF PARTICIPANTS’ PAIRED SURVEYS Participants were asked to complete surveys paired by number at the conclusion of the Level one education. The survey was designed for the original pilot held at Carshalton House. The outcomes were consistent with the findings from that original pilot. The surveys produced strong evidence to show that the Spirituality in Aged Care Education Package was effective in increasing participant’s knowledge about the spiritual needs of the aged increasing participant’s confidence about talking to aged care residents about their spiritual needs increasing participant’s knowledge about resources relating to spiritual care. 90% of participants (N=117) returned pre and post education surveys in which participants were asked to rate themselves using the following scale: Figure 2: Attitude Rating Scale
Rating Indication
0
1
2
None
Very little
Some
3 Reasonable Amount
4 High
Questions on the survey: Question 1. How would rate your current level of knowledge about the spiritual needs of the aged? Outcome: A matched pair’s t-test was conducted to test the null hypothesis that, on average, the rating by the participant of his or her level of knowledge about the spiritual needs of the aged did not increase, against the alternative that the rating did increase. The results of the test were significant (t (116) = 10.9, p
