Research Objectives

Walking with me:Exploring how spirituality influences the working practice of frontline mental health professionals using narrative based Discovery InterviewsbyJulie Leonovssubmitted for MSc in Psychological Research Methods (Open University, March 2010)

Research Objectives • The majority of research surrounding spirituality concentrates on the views of service users and carers: staff viewpoints have often been omitted. • Rationale: to explore the alternative perspective of staff about the role of spirituality in their work, in order to identify gaps and strengths in services. • Assist in raising the profile as a means of service improvement in line with the DOH Equality and Diversity Agenda. • Improve communication between service users, carers and staff about the role of spirituality in mental health recovery.

Research Methodology • Interviews conducted at: Tranwell Urgent Care Psychiatric Unit in Gateshead. • Opportunity sample: 2 female, 3 male. All British. • 2 Occupational Therapy workers • 1 Psychiatric secretary • 1 Psychiatric staff nurse • 1 Community Psychiatric Nurse (CPN) • Religious background: 1 Catholic, 1 Methodist the rest were undisclosed.

Research Methodology continued • Qualitative, ethnographic and phenomenological approach. • Discovery Interviews: established by NHS Modernisation Agency (2004) • Holistic, person-centred approach to interviewing capturing the wholeness of personal experience by allowing individuals to tell their narratives freely. • Prompted by a framework of questions called the SPINE which aids a natural discussion of experiences and memories.

Discovery Interview Spine • How would you define your spirituality? • Can you describe how your spirituality has an influence on your daily work? • In what way does your spirituality influence your professional decision-making? • Can you describe when your spirituality may have caused you to experience conflict in your work? • Can you describe how your spirituality influences your relationships with patients, carers and colleagues? • What is it like for you to practice your spiritual beliefs within this unit? • Do you feel that the Trust supports and encourages your spirituality and if so, in what way? (e.g. Improvements etc?) • Tell me about any experiences within this unit surrounding your spirituality?

Data Collection and Analysis • 5 Interviews audio recorded and transcribed. • Thematic Analysis: coding for themes across all 8 questions with sub-themes developed.

Data Collection and Analysis

The Spiritual Indifference and Detachment • Personal spiritual convictions shouldn’t be introduced into the work place – service user and carer needs were paramount in order to aid recovery. “You let them share what they like but you don’t bring any of your religious background into it.” [Rachel] • Why? Staff may be too pressurised to accommodate spirituality into their working role – even if desired. “I think that in modern life we hurtle headlong…constantly bombarded with things…and don’t get a chance to discover that spiritual side of our existence…” [Matthew]

The Spiritual Indifference and Detachment • It wasn’t the NTW Trusts role to support and make provision for any spiritual needs workers had, although it was for service users as this could aid their recovery. • Staff needed to exercise their own autonomy in exploring their spiritual path, mainly from external sources (e.g. Church, community) “I am a strong believer for people taking personal responsibility for many aspects of their lives…so I wouldn’t think an NHS Trust needs to worry about my spirituality” [Matthew]

Physical Grounding here on Earth • Defining and describing spirituality and how it affected them in their work and decision-making was grounded in the physical aspects, rather than the metaphysical. “Not necessarily being a person who believes in another being outside of life, once your dead your dead, you just go back into a pile of dust, back into the earth…When you’re finished that’s it, you’re gone!” [John] “I don’t understand how people can ignore science…I need to have things laid out in front of me in black and white…I need evidence. I guess for that reason I cannot have a faith, as having a faith there is a kind of not having the evidence…[Tom]

Physical Grounding here on Earth • One participant defined his spirituality in metaphysical terms, viewing God as his guiding force. “My spirituality is quite mysterious and hard to pin down, but essentially deals with the unquantifiable mysteries of the unseen about God, about forces in nature and in creation.” [Matthew] • Overall, spirituality was viewed as tangible, with a grounding in life events and experiences, and how coping strategies could be transferred to the work situation. “My decision-making is based on my theory from life, my profession and evidence from my professional background, not from my religion.” [Rachel]

Morals and Values recognised as being Human • Humanistic principles of love, compassion and forgiveness etc were seen as being human, or a good professional and compatible with nursing skills but not associated with spirituality. “There’s a lot there you know, you’re empathetic approach, your sympathy, showing an understanding, being friendly and accepting people for who they are. I think those are the basic things you learn as a nurse really…I wouldn’t have associated those with spirituality” [Tom] • Although it was recognised that fundamentally being a good person would be linked to most faiths as would the reciprocal tenet: “Treat others as you would like to be treated yourself”

Morals and Values recognised as being human • One participant did feel his spiritual beliefs guided him in his work and relationships. “My spirituality place a very high value on a human being…ill, deformed or whatever, they are still human and are still in the image of God, therefore they are deserving of the utmost respect and care and that’s a strong motivator for me” [Matthew] • Overall, values of compassion, empathy etc were recognised as being human, irrespective of healthcare training or spiritual beliefs. But such values were acknowledged as important in their working role and when building relationships with people.

Hesitation and Caution Leading to Avoidance • Significant Finding. Whilst some participants were willing to discuss spirituality with colleagues, all expressed caution and even fear when approaching service users or carers. This may explain the presence of spiritual indifference? • Spirituality was viewed as a taboo subject. It was mainly avoided for fear of offending people, causing conflict or imposing their beliefs on to others. • Due to their lack of training around spirituality and faith participants didn’t feel confident or qualified in discussing this subject. But the pressures of daily work also meant spirituality often got sidelined. • It was felt spirituality could potentially divide people and jeopardise working relationships. Alternatively, Mindfulness was seen as an encompassing channel to unite service users and aid their recovery because it wasn’t necessarily associated with any specific religion.

Hesitation and Caution Leading to Avoidance “If you are working with a family and you overstep the mark and ask about their spirituality and their faith and you upset that family because of your lack of understanding, your lack of awareness and your lack of knowledge…then that could come back on you.” [Gary] “Again it’s that fear, is this going to build a bridge between us or is this going to be separating us…In my ignorance I don’t feel that this is a particularly good relationship tool. But I do with colleagues.” [Rachel] “Mindfulness is what helped me bring spirituality to work, but I think that because it’s professionally accepted and not connected to religion, it feels safe, it feels like you’re not having to put religious beliefs onto anyone else when you’re doing it.” [Rachel] “…talking to people about what they see as their destiny and who they really feel they are is quite high up in their needs and we’re running around putting out little fires and trying to keep some stability quite low down on that pyramid…it’s frustrating, yes, but sometimes you have to put those bigger questions on hold…” [Matthew]

Professional Dilemmas – negotiation and compromise • Conflict was experienced at work not with personal spirituality but when working with service users and carers of a strong faith. Often sensitive compromises had to be reached so that a person’s recovery could continue. “The Dad would come in and say you should be doing this or that and this would have a knock-on effect with his daughter as this then would re-trigger her epilepsy and paranoid psychosis…it was a case of sitting down with the family and saying, “well not to knock your religion but because you are following this way, strictly, this is the effect it is having on your daughter.”” [Gary] • Often it is a discovery process with staff and clients working in a reciprocal way. Clients very often educated the workers about their faith and cultural practices, which aids their healing. • Professional dilemmas can arise if workers are spiritual and feel there could be an alternative to the medical model. It was felt that scientific objectivity shouldn’t always over-shadow subjective discretion.

Professional Dilemmas – negotiation and compromise “Overall I do feel we are too ‘medical’ in our approach. Like you have an illness and it can be cured by drugs…I definitely have a sense of it being so much wider than that, in terms of spirituality…” [Matthew] • The hierarchical structure within medicine often meant that a worker’s spiritual beliefs had to be sidelined to maintain the political status quo. There appeared to be underlying power-based struggles between medical opinion and spiritual followings. “ A Doctor might look at someone and go, “right, it’s just psychosis, they’re mad, they need medicating, and this is the way we will solve the problem.” I would be sitting there thinking there’s more to it than that and maybe there is something spiritual that could be explored or approached in a different way.” [Matthew] “There’s an unwritten code of ‘don’t contradict the doctor, especially in front of the patient’…I know colleagues have been rebuked for having a different opinion. You have the medical system, evidence base…whereas for the spiritual system, there isn’t much of an evidence base.” [Matthew]

Openness and Acceptance • Making aspects of spirituality more open an accessible could give staff more confidence in approaching this ‘taboo’ subject. It was agreed all faiths needed to be incorporated into this new openness. • The majority opinion was that the image of the Chaplaincy needed to change as it viewed as quite exclusive and mainly there to support service users not staff. There appeared to be some naivety and negativity as to how they perceived the chaplaincy and so, prevented them from seeking help if needed. Seeking help was also deemed as a failure in not being able to do their job properly. “I think when the Chaplaincy appears on the ward then it’s, ‘here comes the God Squad’…maybe the image needs to be improved…”[Matthew] “Sometimes I think that spirituality makes you sound a bit ‘soft’…I think if you start talking about spirituality, you think of long skirts…[Sue]

Openness and Acceptance • In trying to raise the profile of spirituality, it was felt this should be included into initial patient assessments, as ironically suicide is. This may then empower workers to raise this subject matter with service users and assist them in becoming more pro-active when addressing the diverse needs of others. • It was felt that for the benefits of spirituality to be recognised and publicised in this unit, changes needed to be initially instigated by NHS managers. “I don’t know how they would get around making staff more comfortable talking about it to service users, maybe more evidence that service users want it, maybe we could start incorporating it into initial assessments…It would have to go to managers to be supported in this.” [Rachel]

Information Seeking and Knowledge Base • Including spirituality in mental healthcare was described as a “a minefield”. Participants didn’t feel competent or confident in approaching this alone with service users and carers, especially if they felt it would open up a Pandora’s box and offend people. • When experiencing self-doubt around spirituality, participants became pro-active in using their initiative to seek out external information. This was felt to be a positive move towards empowering them and building their self-confidence. “I would see it as good practice that a nurse should chase up that sort of information…if I am going out to see this family then I am going to chase up stuff on the Muslim background or the Hindu background or the Buddhist background…and seek that information from a book or religious leader.” [Gary] • Participants found working within a multi-faith environment challenging, as they lacked the knowledge they needed to work with these clients. They often had to do their own research or gather this information from the client themselves.

Information Seeking and Knowledge Base • Specific training and education were proposed in order to do their work effectively, as initial nursing education often overlooked the spiritual aspect. However it’s debateable if there would be enough time and resources to cover such a large and diverse area, or even if staff would be willing to undertake this training? “Our training is relatively small and we have so much theory…I don’t think there would be the time or resources to be able to do that. Even now I don’t know if I would feel comfortable doing that.” [Tom] • It was felt if the benefits of spirituality and alternatives to the medical model could be shown to have value around treatment and recovery, then staff may show willing to approach these areas. But overall a large cultural shift needed to occur. “…as we identified earlier you’ve got Maslow’s triangle and most nurses perceive a gap…look we have bigger fish to fry, this person needs help in this area, why are we starting to talk about spirituality…and actually that cultural needs to be shifted…”[Matthew]

Conclusions • Allocate more time for spiritual reflection and consideration. Assist staff to understand the relevance of spirituality in mental healthcare, including recognition and consideration of their own spiritual needs as well as their clients. • Break the taboos surrounding spirituality by creating greater transparency and acceptance of this in the workplace. This could involve Trust managers, employees and inter-disciplinary teams working together in order to raise awareness of spirituality and would make employees feel more supported in their daily work. • Consider changing the image of the chaplaincy and perception of spirituality. Faith leaders need to show they can be there to support staff as well as clients. • Consideration and understanding of the underlying power-base struggles in mental healthcare which may account for participants spiritual indifference, hesitation and reluctance in approaching spirituality.

Conclusions • Greater encouragement, guidance and support by Trust managers generally so that employees feel comfortable discussing spirituality with colleagues and clients. • Provide staff with the relevant resources (e.g. books, leaflets, websites, access to faith leaders etc) so they are able to do their job more efficiently and effectively Also permit workers to seek out their own information in order to build confidence around this subject and therefore banish myths and misconceptions. • The inclusion of spirituality into undergraduate programmes from inception is vital if this aspect is to become the norm, rather than an addition. Opportunities for employees to access CPD and PG training courses if desired in order to build their knowledge and confidence around all aspects of faith and cultural diversity. • Greater awareness raising as to the benefits of alternative approaches to the medical model and reductionism in mental healthcare. A more holistic direction taking into account individuality, spiritual beliefs and cultural diversity.

Any Questions? Thank you for your time and attention Julie Leonovs

Research Objectives