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The Spiritual Needs of Diverse Elders in Long-Term Care: Developing Awareness … and Putting It into Practice

Robert L. Weber, Ph.D. (Spring 2009). Aging & Spirituality: Newsletter of the American Society on Aging’s Forum on Religion, Spirituality and Aging.  Special Issue: Meeting the Spiritual Needs of Diverse Elder Populations in Long-Term Care.

Spiritual care for elders living in long-term care facilities is essential, no matter the religious orientation of the facility or the specific religious beliefs of a given resident. Providing for such care is not the exclusive domain of chaplains and other representatives of the clergy. All facility personnel may be called upon not only to recognize a resident’s spiritual needs, but also to respond to them. Training is a vital aspect of helping long-term care staff fulfill this responsibility. Although I focus here on learning to work with diverse spiritualities and faith traditions, the tripartite training model I discuss is applicable across other dimensions such as race, disability, gender and orientation.

A recent experience serving as executor and health care proxy for an older friend showed me that such training is usually spotty or nonexistent. Two years ago, I arranged long-term care for Anna (a pseudonym), a very spiritual Catholic who had lived independently into her early 80s. She first moved to an assisted-living residence founded by a Catholic religious order; the residence required a high degree of independence. When her needs increased due to dementia, Anna moved to a nondenominational facility with a secure unit for cognitively impaired elders. She later left the second residence to move in with a family member.

Spirituality always provided a secure anchor for Anna, and it became even more important as she faced progressive cognitive impairment, decreasing physical function and an end to her independent lifestyle. She also valued spirituality as a support in the face of her mortality.

Comparing Facilities

The religiously affiliated facility met many of Anna’s spiritual needs. Although there was no formal chaplaincy, a dozen retired priests in residence provided daily mass at the in-house chapel, and residents who valued mass, such as Anna, were given daily reminders. A weekly rosary group also met, and Anna had the option of attending an end-of-life spirituality group whose members could bring spirituality to bear on their fears and anxieties surrounding death.

At this first facility, however, I learned that there was no mandated training of staff to develop their competence in responding to a resident’s spiritual needs. The initial staff orientation and subsequent in-service training sessions emphasized the importance of respect for residents’ values. Off-site courses enabled professional staff to meet continuing education requirements for eldercare; some of the courses addressed spiritual care, but they were elective.

At the secure-unit facility, the number of spiritual resources available to Anna diminished. The second facility had no Catholic chaplain and no chapel. A visiting priest distributed Communion once a week, and a regular rosary group met. The facility arranged to take residents to an off-site Sunday mass, but because of safety considerations, only those who were able to arrange for someone to accompany them could go.

The director of the secure unit, who was himself quite spiritual, arranged for new staff to receive an intensive seven-hour training on working with older adults. It inculcated a basic set of attitudes: unconditional positive regard, compassion, right speech and authentic presence. The director also placed emphasis on the importance of attending to a resident’s spiritual well-being.

Teaching Competence

What both facilities clearly needed was a systematic training program to develop staff competence in spiritual care, as competence is conceptualized in the diversity literature. As Larry Minnix, president of the American Association of Homes and Services for the Aging, has written, “Long-term care institutions that support a well-planned program of spiritual care assure the potential for ending life with integrity and meaning. Such a program is an essential component of long-term care. More institutions need to incorporate spirituality as essential to philosophy, mission and program.”

Derald Wing Sue and David Sue define three aspects of cultural competence which also can be readily applied to issues of religious and spiritual diversity in elder populations in long-term care: awareness, knowledge and skills. It may be impossible to train all staff in all three areas. To enable staff to respond respectfully and effectively to residents’ spiritual needs, at minimum, they should be trained in the first aspect. Awareness involves the following:

•    Awareness of and sensitivity to one’s own spirituality.

•    Consciousness of one’s own spiritual values and acknowledgement of one’s inherent attitudes, biases, beliefs and feelings that might affect residents adversely. These biases and beliefs may be specific to a particular religious tradition or to spirituality in general.

•    Development of comfort with and respect for the spiritual differences that exist in the facility.

•    Recognition of when it is appropriate to refer residents to a representative of their spiritual tradition.

Luckily, there are abundant resources for developing awareness training programs Exercises such as spiritual genograms enable staff members to discover the roots of their own spirituality and the remarkable diversity of spirituality that may exist in their families. The staff can also examine their attitudes and biases toward spiritual traditions both their own and others. By doing so, staff can preempt negative interactions and can deepen their commitment to the spiritual care of residents.

What Is Needed

Time, money and priorities are all obstacles to providing adequate spiritual-awareness training. If a facility does not identify spiritual care as a top priority, money and time will not be allocated. As one colleague put it, it is not profitable to take staff away from their normal duties, even for an hour, which means that competence training must be delivered in some new, creative way.

For spiritual-care training to take hold, facilities will require an evidence-based validation of its worth and a broader mandate from regulatory agencies. Gerontologists must provide research to demonstrate the connections between spiritual care, health and well-being and to show spiritual-care training is cost effective. By engaging in constructive activism in the field of aging, members of FORSA and NOMA have the potential to be on the vanguard of cultivating these necessary conditions.

Robert L. Weber is a faculty member at Massachusetts General Hospital and the Harvard Medical School, both in Boston. In addition, he is a member of the Psycho-Spirituality Initiative at the Massachusetts School of Professional Psychology. Click here to contact him.

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