Spirituality Strategy Context This strategy is based upon the premise that services should be tailored to the needs of service users and that all staff have a responsibility to be aware of, and sensitive to, the spirituality of each individual in their care. This view is consistent with a range of national strategies, national service frameworks, and nationally agreed policy guidance and recommendations published by the Department of Health and other Government departments. Many of these include details relating to specific services but there is a common theme reflecting the NHS Patient s Charter (1995) which informed patients that: all health services should make provision so that proper personal consideration is shown to you by ensuring that your privacy, dignity and religious and cultural beliefs are respected. In line with this the NHS Constitution (2009) states that patients have the right to be fully involved in their own care with this including a right to make choices based on personal preferences and to be treated with dignity and respect. The NHS 2010-2015 from good to great preventative, people-centred, productive (DH 2009) highlights that:- Effective care is always the product of a relationship and that for delivery of truly high quality care, that relationship must be based on an accurate and sensitive understanding of the context in which people live and work. Equality of outcomes and personalised services will only be delivered by working with communities, recognising difference and tailoring provision. The implementation of this strategy will require and demonstrate that services have tailored processes and provision to enhance their work with the community whilst recognising and respecting the differences between individuals and groups. In addition, the Care Quality Commission (in their role as a regulatory body under The Health and Social Care Act 2008) require services to demonstrate that:- People who use services express their views as to what is important to them. So far as is appropriate and reasonably practicable, personal views and preferences are accommodated. Care and treatment is provided with due regard for an individual s religious persuasion and cultural background. Carers recognise diversity and understand personal choices so that they can express views on behalf of a patient. 1
Appropriate assessments and planning are undertaken to meet individual needs and make required, reasonable adjustments. The CQC require services to provide services that recognise and accommodate each individual s social and cultural values. These are defined (by CQC) as:- Customs: rites, rituals, religion and lifestyle. Values: beliefs, morals. Social norms: patterns of behaviour that are accepted as normal and right (including dress and diet). The term spirituality is used to describe a range of beliefs and/or practices that are important to an individual and their perception of who they are. For some, a system of belief and practice will reflect a religion with related traditions and structures. Others will not identify with any religion or shared belief system but their personal beliefs, practices and preferences are no less important. Spirituality Spirituality is therefore not confined to the followers of a religion, rather it can be considered as reflective of an individual s personality, culture, experience, beliefs and preferences. Viewed in this way it may be reasonable to assume that, whilst we do not all follow a religion, we all have a spirituality, although this may be difficult to define. As a consequence the identification and recognition of an individual s spirituality is an essential part in the process of viewing a person holistically and of ensuring that services are provided to accommodate diversity and respect individuality. Purpose The purpose of the strategy is not to promote a particular religion, belief or manner of spirituality but rather to continue a process that will increase the ability of services to respond to the spirituality issues relevant to each service user, carer or member of staff. This should include those who define themselves as agnostic or of no specific religion. All services within Solent Healthcare have processes in place to identify individual needs (and possibly preferences) as part of the assessment process. To extend this, and the related potential for truly person-centred care that responds to spiritual needs, there must be clarity regarding the minimum expectations, the range of resources available and the means to access these. There will also be a need for some, to have a greater level of awareness, knowledge and competence. As a consequence, standards (to reflect these tiers of competence ) have been developed and these are outlined later in this strategy document. 2
Whilst it is important to recognise the wider, and difficult to define, view of spirituality it is also the case that many people have beliefs and practices which are more readily identifiable as a formal religion with recognised structures and practices. Although it is essential to retain an awareness of each person s individuality it is also important for services to have (or be able to access others with) an understanding of the rites, customs and doctrines of the religions that are likely to be important to some of their service users. The British Social Attitudes Surveys (1996 and 2006) asked participants whether they regarded themselves as belonging to a particular religion. The results are summarised in the table below and serve to indicate the likely prevalence of the religions most commonly followed in Britain. Religion/Faith 1996 (%) 2006 (%) Christian specifically Church of England specifically Roman Catholic other Christian Islam Hindu Jewish Sikh Buddhist Other non-christian No religion 52.8 29.3 8.9 14.6 1.8 0.6 0.3 0.2 0.5 0.4 42.6 47.5 22.2 9.0 16.3 3.3 1.4 0.5 0.2 0.2 0.4 45.8 N.B. Census figures from 2001 record that approximately 72% of the population are Christian with only 23% having no religion or not answering. Other figures are broadly similar to those from 2006 in the table above. There is a need to ensure that, as a minimum, the customs and doctrines of these most common religions are understood and can be accommodated within Solent Healthcare services. In March 2010, the Portsmouth Community & Mental Health Services and the Adult Mental Health Community Development Workers produced 'A multi-faith guide for healthcare professionals' and this includes a wealth of information in relation to each of the religions listed in the table above. There also needs to be a range of established and effective links with representatives from each of these religions so that service users can be helped to maintain links and access appropriate support in addition to that offered by NHS staff. 3
The aims of the strategy This strategy aims to enable Solent Healthcare services to respond appropriately to the range of spirituality and/or religious needs of service users. To achieve this, the strategy, and the processes described within it, aim to: Raise the level of understanding in relation to spirituality and its importance. Define and describe environmental and ecological features that are required to accommodate those practising the most common religions (as listed above). Define and describe tiers of awareness, knowledge and competence in relation to spirituality Enhance and describe the network of links with religions and cultural leaders or advocates. Promote personalized care in line with each individual s spirituality needs; these being considered as consistent with psychological, social and physical needs. Describe an operational structure to support individuals at each of the three tiers of competence. Clarify the rules and responsibilities of staff at each of the three tiers of competence. Complement developments and ongoing activity in relation to Dignity, Respect and Diversity within Solent Healthcare. To facilitate the above, four levels of 'Awareness and Activity' have been developed. These can be monitored as a discrete area of personal performance/professional practice but it is anticipated that they will be used to enhance the use of the Knowledge and Skills Framework (KSF and e-ksf) to monitor performance, facilitate appraisals and identify development plans. Some elements of the Four Levels of Awareness and Activity may also be (and in some cases, clearly are) a requirement for both the effective use of existing processes and the completion of required duties, such as: the completion of patient/personal profiles the assessment of patients/service-users the processes of care planning and related review Person-Centred Planning (PCP) and the facilitation of related activity engagement in Wellness Recovery Action Plans (WRAP) and the use of the Recovery Star the use, and assessment of, proficiencies in relation to the Standards for Dignity and Compassion in Care progression through the Dimensions of the Knowledge and Skills Framework (KSF and e-ksf) 4
Four Levels of Awareness and Activity The Four Levels of Awareness and Activity represent the roles and responsibilities of staff to ensure that all services can operate with due regard for each individual's spirituality. A separate document provides detail regarding the expectations and responsibilities of staff at each of the four levels alongside space to record comments or examples of practice in relation to each. The expectations at the first level relate to all employees whose duties require them to interact with Service Users, Patients, Families or Carers. As a consequence these primarily relate to an awareness of the issues and resources available. The required level of competence relates to an ability to interact appropriately with Service Users, Patients, Families or Carers and an ability to access the resources/support available. Specifically, each individual at this level will; Recognise that all people will have a spiritual dimension and that for some, but not all, this will include a religious element. Recognise that an awareness of each individual s spirituality will assist the development and delivery of appropriately personalised care. Be aware of the Network of Support in relation to spirituality. Be aware of the Portsmouth Community and Mental Health Services Multi- Faith Guide for Healthcare Professionals. Be aware of personal responsibilities as outlined in the relevant dimensions of the Knowledge and Skills Framework (e.g. Communication, Personal and People Development, Equality and Diversity). Be able to develop a rapport with Service Users and Carers. Be able to understand and use Active Listening Skills. Be able to refer to, or access support from; o o o the Network of Support the Multi-faith Guide colleagues to aid with the above The expectations at the second level relate to all employees whose duties require them to supervise or manage those interacting with Service Users, Patients, Families or Carers. These expectations include all of those within the first level with additional responsibilities that reflect the role as a supervisor of others. In addition there is an expectation of greater personal awareness and skill and a requirement to be able to access support that exists outside of Solent Healthcare services. 5
In addition to points in Level One, each individual at Level Two can: Recognise unmet spirituality or religious needs and respond to these appropriately (possibly via the points listed below). Facilitate developments to shape care/interventions that are sensitive to an individual s spirituality needs. Develop and implement a plan for care that is based upon, or shared by, an awareness of spirituality or religious needs. Ensure that staff (for whom the individual has supervisory or management responsibilities) are competent in relation to spirituality at the required/appropriate level. Facilitate referrals, and gain access, to a range of religious, community and cultural leaders. Facilitate assessments which include, or focus upon, spirituality and (if relevant) religious needs. (NB: these assessments may be included as part of existing documents and do not need to be specialised spirituality assessments) The expectations at Level Three relate to those who may be considered as 'champions' in relation to spirituality and this strategy. These expectations include all of those within the first and second levels with additional responsibilities that reflect a role within a wider network of support. This 'Spirituality Network of Support' includes those within Solent Healthcare at Levels Three and Four of The Four Levels of Awareness and Activity and a range of external partners from community and faith organizations or groups in the area. This role will therefore require an ability to work effectively with others within the Spirituality Network of Support and an ability to deliver effective support, guidance and training. In addition, these staff will need to have a greater knowledge and understanding of the main world faiths and be prepared to contribute to the ongoing review and development of the Spirituality Strategy and its effectiveness. Specifically, those at Level Three will be required to: Have knowledge and understanding of the main world faiths (as included within the PC & MHS Multi-faith Guide). Have an ability to provide support and guidance to a range of others regarding spirituality and religion. Have effective links and a working relationship with members of the Spirituality Network of Support. Ensure assessments and care plans include and address issues relating to spirituality. 6
Operate as a resource to assist others seeking knowledge or access to others within the Spirituality Network of Support. Facilitate/provide training to raise awareness, knowledge and skills in relation to spirituality. Contribute to the evaluation and further development of the Spirituality Strategy. The fourth level relates to a leadership role for a small number of individuals (possibly one) with responsibility for the implementation, development and review of the strategy. At this level there is a responsibility to ensure that the required arrangements are in place to enable; all services to have access to an appropriate range of Community and Faith leaders/practitioners; i.e. the Spirituality Support Network. the provision of appropriate resources to support the development of awareness, knowledge and skills any required environmental developments; to meet obligations in relation to Spirituality. the implementation, development and review of the Spirituality Strategy and the related use of the Four Levels of Awareness and Activity The diagram overleaf depicts the Four Levels of Awareness & Activity and the relationship with the Spirituality Network of Support. 7
The Spirituality Network of Support and the Four Levels of Awareness and Activity The Diagram below represents the Four Levels of Awareness and Activity and the relationship with the Spirituality Network of Support. The majority of employees will operate at Level One. For most, access to support will be via senior colleagues operating at Level Two. Spirituality Network of Support Level 3 Level 2 Staff at Level Two will generally be working alongside those operating at Level One and be able to provide direct support & guidance. In addition those at Level Two will be able to access additional support from leaders/practitioners within Community and Faith groups. This may be via direct referrals or via the support of colleagues operating at Level Three. Level 1 Those operating at Level Three will have established effective working relationships with a range of Community and Faith leaders/practitioners and be able to facilitate their involvement and support. In addition these staff will have a greater level of knowledge and operate as part of the Spirituality Network of Support. The implementation, development and review of the processes outlined above, will be the responsibility of an individual (or small group) operating at Level Four and as the person responsible for the Spirituality Strategy, the Four Levels of Awareness and Activity and Spirituality Network of Support. 8
The Spirituality Network of Support As noted above, there is a need for staff within the NHS to work with a Spirituality Network of Support. Traditionally the NHS had relied upon chaplains to provide pastoral and spiritual support and in the worst cases this could be seen as a service primarily for those of Christian faith that risked alienating, or even discriminating against, others. Locally, the Christian chaplains have taken a wider role; offering pastoral support to all whilst also facilitating links between service users/patients and representatives of their religion or faith group. More recently, the development of increasingly person-centred services has resulted in a need for all staff to be aware of each service user's individual needs and preferences. As indicated by the expectations within the Core Dimensions of the Knowledge and Skills Framework, and now by Level 1 of the The Four Levels of Awareness and Activity, there is a need for a basic level of awareness and competence. This includes an awareness of, and an ability to access, relevant resources which include a Spirituality Network of Support. The Spirituality Network of Support consists of: NHS Staff operating at Level Three of The Four Levels of Awareness and Activity Individuals from Faith groups/religions that have agreed to offer support Cultural leaders and representatives of community groups that have agreed to offer support As a consequence all staff will have the ability (albeit for some not directly) to offer and to accommodate requests for visits from clergy of particular denominations. The majority of service users/patients are likely to be local and so it may be preferable for them to be visited by someone already known to them rather than to have a generic representative or NHS chaplain visit them. When this is not the case, the Spirituality Network of Support will enable contact with local churches, temples, synagogues etc. and to cultural or community group leaders. It is important to note that, whilst this is relevant to the specific needs/wishes of those following a particular religion, the approach described is also essential in relation to any individual's wider spirituality needs and those without religious views must also be helped to access the spiritual support they request. Single-denomination religious chaplains may not be able to fulfil this role for the full range of people in our increasingly diverse society. Pastoral support services in the NHS therefore need to facilitate access to a wider range of support and perhaps move away from a presumption of religion to build on the philosophy of respect and support for both diversity and the individual. Delivery The delivery of this strategy will require progress from the strategic setting of direction stage through four additional stages. The next of these stages represents development, from the direction set by the strategy (once any required revision has been made), to establish the Structure required. This will require the identification of a Lead (to operate at Level 4 of the Four Levels of Awareness and Activity), the identification of Champions/those at Level 3, the development of the Spirituality Network of Support and related agreements, the production of required resources and the development of training which should include a focus upon why? in addition to the what, when, where and how?. The third stage is, in effect, the Roll Out in which there would be the facilitation of training, the distribution of resources and access to the Spirituality Network of Support. 9
Training at this stage will need to focus upon raising awareness of the issue, the strategy and the related expectations/processes. In addition, training will be required to develop basic skills such as Active Listening. The fourth stage relates to Supporting and Coaching which will be required to develop confidence and competence across services implementing the strategy. This will primarily utilise existing structures of supervision, support and reflective practice. The fifth stage relates to Performing. This is an ongoing stage and not an end point of the process. At this stage the strategy and related processes will be embedded and operating effectively. This stage includes ongoing review and development with this referring to the review/audit of the strategy and its related processes plus the ongoing review of each individual s involvement via appraisal and the Knowledge and Skills Framework (KSF). An outline of this process, as a proposed Action Plan, has been developed and is attached. 10
Implementation of the Spirituality Strategy - Action Plan October 2010 Stage/Aim Action Responsibility and Timescale 1. Setting the Direction 1.1 Complete strategy following initial feedback/review GK 2. Establishing Structure 2.1 Identify the Lead Manager/Practitioner (L4) 2.2 Identify the Champions (to operate at Level 3 of the Four Levels of Awareness and Activity) with at least one in each service. L4 2.3 Establish agreements with those, external to Solent Healthcare, that will operate as part of the spirituality Network of Support (SNOS). L4 and Champions (L3s) 2.4 Produce contact details and role descriptions in relation to the SNOS L4/L3s 2.5 Liaise with SNOS to identify environmental and ecological issues of greatest significance to the main faith groups. L4/L3s 2.6 Liaise with HR, the Dignity & Diversity group and Estates to address issues raised via 2.5 L4/L3s 2.6 Develop Training plans and schedules for use in Stage 3 Roll Out. L4/L3s 11
Stage/Aim Action Responsibility and Timescale 3. Roll Out 3.1 Facilitate training in line with schedules developed as indicated at 2.6 tbc 3.2 Distribute resources, including; contact details and role descriptions of those in the SNOS documentation relating to the Four Levels of Awareness and Activity the PC & MHS Multi-faith Guide 4. Supporting and Coaching 4.1Provide support to ensure: that issues relating to the spirituality of service users are addressed that the implementation of the strategy is reviewed using existing processes (eg. supervision, appraisal via KSF, reflective practice, etc) the effective use of the SNOS the identification of good practice tbc tbc 5. Performing 5.1 Review strategy implementation via audit tbc 5.2 Review, and revise as appropriate, the membership and role of the SNOS tbc 5.3 Review, and revise as appropriate, the training and support available to Solent Healthcare staff tbc 5.4 Review, and revise as appropriate, the resources available to support the strategy tbc 12