Introduction

In 2009, Puchalsky et al. [1] defined “spiritual care” in medicine and differentiated physicians’, nurses’, and social workers’ roles in delivering spiritual care from those of clergy and psychiatrists. The authors recommended that every patient should at least undergo “spiritual triage” to determine whether the patient is experiencing a spiritual crisis and/or negative religious coping that could interfere with the patient’s ability to adjust to a cancer diagnosis. Puchalsky et al. defined spirituality as “the aspect of humanity that refers to the way individuals seek and express meaning and purpose and the way they experience their connectedness to the moment, to self, to others, to nature, and to the significant or sacred.”

Though, for many people, spirituality is primarily expressed through religious beliefs and rituals, spirituality and religiosity are not superimposed. Rather, the notion of spirituality may encompass religiosity but then goes beyond it, extending to anything that comes from the spirit or the “breath of life.” In the present paper, we will use spirituality in its broader meaning, while referring to religiosity when relating to specific data about it, as they appear in the medical literature.

Spiritual well-being and spiritual care are important to individuals with a cancer diagnosis at all stages of their illness and especially at the time of progression and toward the end of their life. In cancer patients, a sense of spiritual well-being has been associated with lower levels of anxiety and depression, a reduced sense of isolation, easier adjustment to the effects of cancer and its treatment, and increased ability to enjoy life during treatment [2–4]. Patients with advanced cancer who received less spiritual care than desired reported having significantly more depressive symptoms and less meaning and peace than patients with advanced cancer who received the spiritual care they desired (p = 0.042) [5]. Further, patients with improved spiritual well-being appear to have improved pain control. By contrast, studies report that negative religious coping has been associated with distress, confusion, depression, and poor quality of life in cancer patients [6, 7].

Despite these empiric data, at least 65 % of clinicians do not take a spiritual history [8, 9]. The reasons why some physicians do not address their patients’ spiritual care have been only minimally explored. For many care givers, reasons for not taking a spiritual history might include a lack of training, a lack of time, unrealistic survival expectations, and/or lack of familiarity with one’s own existential beliefs [8, 10, 11].

While the need to better define spiritual care and its applications worldwide seems intuitive, much of the literature about addressing patients’ spiritual care originates from monotheistic, Judeo–Christian Western populations. Only limited knowledge of the international practice and implementation of spiritual care exists to date [12]. Through our survey of the Multinational Association of Supportive Care in Cancer (MASCC) members and its analysis, we sought to gain a broader more inclusive perspective of physicians’ understanding of patients’ spiritual care needs and improve our approach to providing spiritual care to patients. We will present and discuss the findings of a spiritual care survey developed by the Psychosocial Oncology Study-Work Group of the MASCC, an international, multidisciplinary organization whose members represent more than 60 countries on five continents, to ascertain the spiritual care practices of MASCC members. Because of the unique multicultural character of this organization, we felt we were uniquely positioned to develop a more global definition and understanding of the international practice and implementation of spiritual care.

Methods

This study was approved by the institutional review board at The University of Texas MD Anderson Cancer Center. The Psychosocial Study Group developed a 16-question survey that asked participants about their experience with and perceptions of spiritual care and vetted it over two annual meetings in 2009 and 2010. In order to gather as many respondents as possible, we sent all 635 MASCC members four e-mails between February 2 and 22, 2011, inviting them to complete the survey via SurveyMonkey, an online survey service [13]. The e-mails included an introductory letter assuring the potential participants that their identities and responses to the survey would remain confidential and that their completion of the survey would constitute their consent to be included in the study. They were also reminded not to take the survey more than one time. Demographic information collected during the survey included participants’ age, gender, country of birth, country of practice, discipline, and years of experience. The demographics were tabulated, and summary statistics were used to describe results. Investigators involved in database management and statistical analyses did not have access to the identities of the study participants. Chi-square tests were used to compare group differences for categorical variables. Mann–Whitney and Kruskal–Wallis tests were used to evaluate group differences for continuous variables. Specifically, gender comparisons were done by Mann–Whitney tests, groups of 3+ categories were all done by Kruskal–Wallis test. No adjustments were made for multiple comparisons. Comparisons by age groups were done via Kruskal–Wallis; they were not adjusted for multiple comparisons. Where appropriate, the odds ratio (OR) was calculated by simple logistic regression. P values < .05 were considered statistically significant. SPSS version 17.0 (SPSS, Inc., Chicago) was used to analyze the data. The Appendix contains a list of the survey questions and response categories.

Results

Of the 635 MASCC members we invited to participate in the study, 271 members (42.7 %) from 41 countries completed the survey. The demographic characteristics of the respondents are shown in Table 1. Over half of the respondents were women. The age groups with the highest proportion of respondents were the 50–60-year-old (36.2 %) and 40–50-year-old (26.9 %) groups. The years of practice experience was well distributed, with those having 20–25 years of experience comprising the largest group (17.3 %). The majority of respondents practiced in North America (42.4 %), followed by Europe (35.4 %) but also included respondents from Asia, Africa, and the Middle East. Physicians comprised 46.9 % of the study respondents, followed by nurses, allied health professionals, and dentists. The Appendix shows key survey questions and responses.

Table 1 Demographic characteristics of respondents (N = 271)
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Definition and importance of spiritual care

The first two questions in the Appendix asked respondents to define spiritual care in their professional practice and to rate the role of spiritual care in the overall care of cancer patients on a 10-point scale, from 0 (“not at all”) to 10 (“most important”). Respondents most commonly defined spiritual care as “offering emotional support as part of addressing psychosocial needs” (49.8 %) and “alleviating spiritual/existential pain/suffering” (42.4 %). The median overall rating for all respondents for the role of spiritual care was 7 (range, 1–10). Ratings did not differ by gender (median = 7 for both men and women, p = .68). Although not statistically significant, palliative care nurses and palliative care physicians rated the role of spiritual care as more important than other disciplines (median scores = 8 vs 7, p = .10). When scores were examined by age group, there was a trend for younger respondent groups to give ratings that reflected a greater importance of the role of spiritual care (p = .08). The two youngest groups (20–30 years and 30–40 years) rated spiritual care as an 8, the 40–50-year-old and 50–60-year-old group rated the importance as a 7, while the oldest respondents (60+ years old) rated the importance of spiritual care at a 6. Respondents who considered themselves spiritual felt that the role of spiritual care was more important than respondents who did not consider themselves spiritual (median = 6 vs 7.5, p < 0.001). The third question pertained to spiritual practices. The most common spiritual practices included music therapy (42.4 %), art therapy (29.5 %), dignity therapy (27.7 %), and yoga (26.9 %), and healing touch (24.4 %).

We then asked survey takers if they thought their role was to explore the spiritual concerns of patients, almost half of the respondents answered “sometimes” (49 %), over one third answered “yes” (39 %), while the remainder answered “no.” Of those who answered “sometimes,” 41 % were non-palliative care physicians, 22 % were nurses, 17 % were allied health professionals, 11 % were palliative care physicians, and 8 % were dentists. Of those who answered “yes,” 24 % were non-palliative care physicians, 36 % were nurses, 10 % were allied health professionals, 21 % were palliative care physicians, and 9 % were dentists. Of the palliative care physicians, 59 % answered “yes” and 41 % answered “sometimes.” The majority of non-palliative care physicians answered “no” (43 %) or “sometimes” (41 %), while only 27 % answered “yes.” While all palliative care physicians and nurses indicated they accepted the role of providing spiritual care, only 15 % of medical oncologists and 9 % of oncology nurses indicated their acceptance. The role of exploring patients’ spiritual concerns was not associated with age or gender. Similarly, belief that it was one’s role to do this was not associated with whether if one referred patients for spiritual care assessment, whether respondents had spiritual training or education, years of practice, or whether respondents felt they could adequately provide spiritual care. When respondents who indicated they do not conduct their own spiritual assessment were asked whether they refer patients to someone else for spiritual care assessment, 9.2 % indicated “always,” 18.5 % said “usually,” 45.8 % said “sometimes,” 14.9 % said “seldom,” and 11.6 % stated “ never.”

Personal spiritual inquiry

Forty percent of respondents reported that they are not actively pursuing spiritual inquiry; the majority of those respondents (80 %) reported that they had not pursued spiritual training to help provide spiritual care for cancer patients in the past 2 years. Of the 50 respondents who pursued training to help patients, 38 (76 %) read books and 29 (58 %) attended seminars on spirituality. “Nonspiritual” respondents were significantly less likely than “spiritual” respondents to perform personal spiritual inquiry in the form of spiritual practice or contemplation (p ≤ 0.001). The “spiritual” are pursuing their own spirituality by way of books (p = 0.004), contemplation (p = 0.03), and seminars in spirituality (p = 0.049). Although not statistically significant, the group with the highest proportion of respondents who had undergone spiritual training in the past 2 years was the group with those who had been in practice for 5 to 10 years (p = 0.09).

Over one third of the respondents reported they seldom provide adequate spiritual care, and more than one quarter do not feel they can provide adequate spiritual care (Table 2). One third of the respondents stated that they adequately provided spiritual care most of the time. The majority of respondents who reported that they seldom provide adequate spiritual care or do not feel that they could adequately provide spiritual care were women (55.3 %). Of the respondents who reported that they either seldom provided or could not adequately provide spiritual care, 100 (62 %) were age 40–60 years, 39 (24 %) were age <40, and 22 (13 %) were age >60 years; 64 of these respondents (40 %) practiced in Europe, and 63 (39 %) practiced in North America. The majority (75 %) had been in practice >10 years.

Table 2 Disciplines of respondents who answered “seldom” or “no” to Question 13 (In your your opinion, can you adequately provide spiritual care?”)
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Method, timing, barriers of spiritual assessment

Sixty-nine percent of the respondents reported performing spiritual assessments repeatedly throughout the illness trajectory, and 24 % reported that they believe that spirituality should be assessed soon after diagnosis. The overwhelming majority of respondents reported that they do not use a standardized questionnaire to assess their patients’ spiritual needs (90 %). Those who did used the FICA; others reported using the SPIRIT, HOPE, SBI, and/or FACIT-Sp.

In reply to the question “[What do] you feel keeps you and others from providing spiritual care?,” 55 % reported that they believed they needed more training, 23 % indicated the need to refer their patients to a specialist, 31 % stated that they preferred referring their patients to chaplaincy, 111 (41.0 %) reported that they did not have enough time, and 23 % stated that they did not feel it was appropriate to do so.

Self-categorization, spiritual care training, and self-discovery

One third of the respondents indicated they had some form of training or education regarding spiritual care. The proportion of women who received training or education was higher than that of men who received training or education (37 % vs 26 %, respectively), but this difference was not statistically significant. In fact, the majority of the respondents had not had any spiritual care training, and most indicated that basic knowledge and skills in recognizing spiritual issues were necessary in order to provide spiritual care to patients. There was no significant difference between the proportions of “spiritual” and “nonspiritual” respondents who reported that they needed more training, needed to use referrals, or did not have enough time to fulfill the spiritual care needs of their patients. Respondents who considered themselves “spiritual” were more likely to agree that the need to have basic knowledge and skills (OR = 2.07; (95 % confidence interval (CI), 1.1, 3.9), p = .025) and consulting with a trained chaplain were necessary to provide spiritual care (OR = 2.37, 95 % CI (1.24, 4.54), p = .009). (Question 15 analyzed by responses to Question 19) Half (50.6 %) of the respondents indicated that lack of training and one third of respondents said lack of time (37.3 %) prevented them and colleagues from providing spiritual care.

Participants who are “spiritual” vs “nonspiritual”

The majority of respondents (76 %) considered themselves to be “spiritual.” Sixty-eight percent of the respondents from Europe, 85 % of the respondents from North America, 43 % of the respondents from Australia, and 79 % of the respondents from Asia considered themselves to be spiritual. The proportion of “spiritual” respondents who claimed a religious category was significantly higher than that of “nonspiritual” respondents (78 % vs 46 %, respectively; p < 0.001). The respondents were relatively evenly split between men (45.9 %) and women (54.1 %), and distributed across the age groups. Individuals who considered themselves to be spiritual were much more inclined to claim a religious category (OR = 4.36, 95 % CI (2.36, 8.05), p < .001). Interestingly, 55 % of people who did not claim a religious category consider themselves to be spiritual. Although professional discipline was not associated with whether respondents thought they were spiritual, the majority of individuals across disciplines indicated they were spiritual (77 % of physicians other than palliative care, 84 % of palliative care physicians, 79 % of nurses, 66 % of allied health professionals, and 68 % of dentists).

Of the 71 respondents who did not claim a religious category, 45 (63.4 %) reported that they seldom or could not provide adequate spiritual care, but this was not statistically significant. Of the 61 respondents who reported that they were not spiritual, 50 (82 %) claimed that they seldom or could not provide adequate spiritual care (p = 0.001).

One hundred ninety-two respondents (71 %) claimed a religious affiliation. Of these respondents, 70 % claimed Christianity (Catholic or Protestant); other religious categories claimed included Buddhism, Hinduism, Islam, and Judaism. Age, years of practice, and gender was not associated with religious category.

Role in exploring spiritual concerns with patients was associated with whether respondents viewed themselves as spiritual (p < .001, chi-square analysis). The majority of patients who did not consider themselves spiritual said they sometimes viewed their role was to explore the spiritual concerns of patients (64 %), while 16 % of these individuals did feel it was their role, 20 % did not. In comparison, 46 % of individuals who said they were spiritual also felt it was their role, while 10 % did not, and 44 % said “sometimes.” Referral of patients to someone for spiritual assessment was associated with whether individuals viewed themselves as spiritual (p = .034, chi-square analysis). Almost one third (31 %) of individuals who did not consider themselves spiritual stated they “seldom” or “never” referred patients to someone else for spiritual assessment, 54 % said “sometimes” while only 15 % said “always” or “most of the time.” In contrast, 32 % of spiritual respondents referred patients to others, compared with 25 % who said they never referred patients. Of note, the majority of those who indicated they never referred patients conducted the spiritual care assessment actually conducted the assessments themselves.

There were other factors associated with whether respondents viewed themselves as spiritual. A larger proportion of respondents who did not consider themselves spiritual chose “none” when asked which spiritual practices they would choose for their patients (p = .01) and specifically not choosing healing touch as spiritual practice (p = 0.002). The proportion of “nonspiritual” respondents who reported that they could not provide adequate spiritual care (82 %) was significantly higher than that of “spiritual” respondents (59 %; p = 0.001).

Not surprisingly, the median ranking respondents who were not spiritual gave for the role of spiritual care in the total care of the cancer patient was 6.0 compared to a rating of 7.5 from respondents who considered themselves spiritual, p < .001 (analyzed by Mann–Whitney test).

Discussion

Our findings from this international survey indicate that a considerable number of oncology professionals, even when involved in a cancer organization designed solely to advance the science of supportive care, are hesitant to include spiritual care as an aspect of one’s role as a caregiver. Before undertaking the present study, we believed that we would obtain ample information to help us develop recommendations regarding an international approach to spiritual care for all oncology professionals involved in supportive care in cancer. Instead, our survey results indicate that although MASCC members feel that spiritual care is important, few have the training or desire to address their patients’ spiritual care needs. Notably, respondents who did not view themselves as spiritual were less likely to perform this important aspect of oncologic care.

Studies have shown that spiritual discussions are a part of clinical care in less than 20 % of visits and patients feel clinicians lack exploratory efforts in this area 30–50 % of the time [14, 15]. Perhaps as Kafka suggested in 1919 “To write prescriptions is easy, but to come to an understanding with people is hard” [16]. However, patients want discussions of spirituality to influence the physician–patient relationship and 40-–94 % of patients are interested in having physician consider their spiritual needs [15]. Assessing patients’ spiritual needs can increase physicians’ awareness of their patients’ beliefs that potentially have clinical relevance, strengthen the doctor–patient relationship, and/or improve communication and satisfaction [17, 18].

Taking a spiritual history, even briefly, can identify patients who have spiritual distress or negative religious coping thoughts, including feelings of being punished or abandoned by God or feelings of fatalism [19–21]. These forms of negative religious coping have been associated with distress, confusion, depression, and decreased quality of life [6, 7]. One study found that most patients believe that sharing information about their spiritual beliefs might enhance their physicians' ability to encourage realistic hope (67 %), give medical advice (66 %), and individualize medical treatment (62 %) [22]. Further, patients whose doctors spend a few minutes asking about their spirituality or what gives meaning to their lives, are more satisfied with their care [20, 23]. Patients' religious and spiritual beliefs can significantly affect their treatment choices, especially as those choices relate to having a living will, making decisions regarding cardiopulmonary resuscitation, or desiring life-sustaining measures in a near-death scenario [17, 18]. One study found that patients who reported that their religious/spiritual needs were inadequately supported by clinic staff were less likely to receive a week or more of hospice care (54 % vs 72.8 %; p = 0.01) and more likely to die in an intensive care unit (5.1 % vs 1.0 %, p = 0.03) than patients who reported that their spiritual/religious needs had been adequately supported. Among high “religious copers,” these differences resulted in higher end-of-life costs (US$6,533 vs US$2,276; p = 0.005) [24].

The outcome of the MASCC survey was not intended to pursue a unidirectional opinion, but rather a wide range of responses for the possibility of integrating a "spiritual history dialogue" into daily medical practice. Altering life and chronic stress situations lead to questions that individuals might try to answer according to their own appraisal of the illness situation. The survey presented only a limited approximation of the complexity of "spirituality" among a diversity cohort of medical professionals.

Embracing and exploring one’s spiritual side may be important in protecting care givers and physicians from burnout and compassion fatigue [25]. Additional training and guidance to help physicians introspect and self-reflect (similar to the meaning-based therapy [26] or dignity therapy [27] prescribed to patients) may be helpful on this quest.

Other researchers have suggested that a “clinical intervention that would increase [an oncologist’s] level of spiritual awareness and his or her level of comfort associated with a personal perspective on death could help decrease the patients level of psychosocial distress” [28, 29]. The key may be that “Those who are more aware of their own spirituality will be better at recognizing, understanding and attending to their patients’ needs” [30]. As one oncologist stated, “Knowing what is important to our patients, what they treasure and think is worth fighting for, and how they wish to be remembered helps guide the dialogue when we run out of treatment options” [31]. If physicians do not use spiritual, existential inquiry when asking patients about their history, it is improbable that they could expect to know their most deeply held beliefs.

Our study was not without potential limitations. One concern with the type of survey that we conduct is the potential selection bias of respondents, who tend to be those most interested in a positive or negative sense. Selection bias and language barriers can confound responses to questions of an emotional nature and thus affect responses and response rate. Lastly, because this was an international survey of MASCC of different countries and cultures, it is possible that some respondents assumed “spiritual” to mean “religious” and answered accordingly.

We developed this survey to better understand the practice and meaning of spiritual care for MASCC members. Ultimately, we hoped to provide a rationale for the need to develop culturally sensitive recommendations to provide guidance to supportive care professionals on how to start approaching spiritual care as part of their clinical practice. The results of our survey study indicate that although MASCC members feel that spiritual care is important, few have the training (or possibly desire) to assess and attend to their patients’ spiritual needs. Although definitions of spirituality trend towards wide non-rigid concepts such as that formulated in 2009 by Puchalsky et al. (1) and the Canadian Palliative Care Association definition: "An existential construct inclusive of all the ways in which a person makes meaning and organizes his/her sense of self around a personal set of beliefs, values and relationships" [32], for some physicians, the concept may remain too ambiguous, obscure, and uncomfortable to discuss with patients.

Surprisingly, we learned that more time and effort must be invested to help MASCC members recognize the importance of their role in providing spiritual care and overcome barriers to assessing spiritual needs and providing spiritual care before guidelines for international spiritual care approaches can be developed.