Journal of Social Work in End-of-Life & Palliative Care, 9:158–179, 2013

Copyright © Taylor & Francis Group, LLC

ISSN: 1552-4256 print/1552-4264 online
DOI: 10.1080/15524256.2013.794051

A Relational Model for Spiritually-Sensitive

Hospice Care

ANN M. CALLAHAN
Department of Social Work, Middle Tennessee State University,
Murfreesboro, Tennessee, USA

When faced with terminal illness, it is natural for hospice patients

to question the meaning of life. Hospice workers need to have the
ability to assist patients in dealing with these questions in case
patients need their assistance. Helping patients deal with questions
about life meaning is associated with spiritual care. The following
article presents a qualitative study on the provision of spiritual care
by hospice workers. The results are used to inform a relational
model for spiritually-sensitive hospice care that demonstrates how
a variety of individual factors have the potential to influence the
delivery of spiritual care.

KEYWORDS hospice care, relational spirituality, spiritual care,

spiritual needs, spiritual sensitivity

It is natural for patients in hospice care to question the meaning of life. They
might ask questions such as “Why me?” and “What is my legacy?” or “Is there
life after death?” to understand their experience. Spiritual care can help
patients cultivate life meaning, purpose, and worth that define spiritual well-
being (Kellehear, 2000; Millison, 1988; Murray, Kendall, Boyd, Worth, &
Benton, 2004). There are a variety of ways to provide spiritual care—including
the conduct of a spiritual history, psychotherapy, and chaplain referral (Callahan,
2010, 2012).
Spiritual care interventions are typically delivered through the caregiv-
ing relationship; however, it is possible that the caregiving relationship itself
may serve as a form of spiritual care (Belcher & Griffiths, 2005; Bullis, 1996;

Received 6 July 2011; accepted 21 December 2012.

Address correspondence to Ann M. Callahan, PhD, MSSW, LCSW, Department of Social
Work, Middle Tennessee State University, P.O. Box 139, Peck Hall 134, Murfreesboro, TN
37132, USA. E-mail: ann.callahan@mtsu.edu

158
 Spiritually-Sensitive Hospice Care 159

Callahan, 2010, 2012; Canda, 1999; Hall, 2004; Hermann, 2001; McGrath &
Newell, 2004; Sandage & Shults, 2007; Stanworth, 2006; Staude, 2005;
Stephenson, Draucker, & Martsolf, 2003; Wright, 2002). This would suggest a
reciprocal relationship between spirituality and caregiving (Sandage & Shults,
2007).
Substantial evidence shows that the quality of the caregiving relation-
ship can significantly influence treatment outcomes across settings (Beresford,
Croft, & Adshead, 2008; Catty, 2004; Cooper, 2005; Hubble, Duncan, & Miller,
1999; Kim, Kim, & Boren, 2008; Lambert & Barley, 2002; Martin, Garske, &
Davis, 2000; Norcross, 2002; Priebe & McCabe, 2008; Reis et al., 2008; Watson,
2006). More specifically, the caregiving relationship can be used as an effec-
tive mode of intervention in hospice care (Canning, Rosenberg, & Yates, 2007;
Emanuel, Alpert, Baldwin, & Emanuel, 2000; Puchalski, 2006) and is central
to the provision of spiritual care (Rogers, 2007; Sandage & Shults, 2007).
Given that the caregiving relationship has therapeutic power, it is
important to consider what relational factors might influence the spiritual
care process. The majority of research only focuses on the delivery of spiri-
tual care interventions, rather than the potential for the caregiving relation-
ship itself to be a spiritual care intervention (Callahan, 2010; Crits-Christoph
& Gibbons, 2003). There are also many interpersonal factors involved in the
caregiving relationship, but little is known about how they may contribute
specifically to the patient’s experience of enhanced life meaning through
spiritual care.

KEY CONCEPTS

Callahan (2010, 2012) theorized that a caregiving relationship must be

spiritually sensitive to be a source of spiritual care. Canda and Furman (1999)
described “spiritual sensitivity” as a “way of being and acting throughout the
entire helping process” (p. 186). The communication of respect for religious
and spiritual diversity was identified as the core component of spiritual sen-
sitivity. Callahan extended this work by exploring what other behaviors
might be involved in “spiritually-sensitive hospice care.”
Based on Buber’s (1923/1970) theory of dialogue, Callahan (2010, 2012)
suggested that spiritual sensitivity was a style of caregiving that validated a
patient’s spiritual essence. Spiritual sensitivity was described as an apprecia-
tion for the patient’s uniqueness, reverence, and Divine love for the patient,
authentic interpersonal engagement, responsiveness to patient needs, and
awareness of the profundity of the caregiving experience. This style of
engagement can be a form of spiritual care insofar that it promotes enhanced
life meaning.
Callahan (2010, 2012) further suggested that spiritually-sensitive hos-
pice care could also contribute to a caregiver’s experience of enhanced life
160 A. M. Callahan

meaning. Faver (2004) conducted research on family caregivers and found

that caregivers experienced enhanced life meaning through selfless engage-
ment in the caregiving process. This style of engagement gave caregivers the
strength to continue caregiving with “joy and vitality” (p. 243). Hence, self-
less caregiving enabled caregivers to experience “relational spirituality.”
Taken together, theory and research suggest that the caregiving relation-
ship may serve as a spiritual care intervention itself depending on the hospice
worker’s style of engagement. Spiritually-sensitive hospice care is a style of
engagement that validates the spiritual essence of the patient. Spiritually-
sensitive hospice care becomes a form of spiritual care insofar that it promotes
the experience of enhanced life meaning known as relational spirituality. In the
process, the caregiver may also experience relational spirituality.

CURRENT STUDY

The purpose of the current study is to inform a relational model of spiritu-

ally-sensitive hospice care based on the work of Callahan (2010, 2012). As
seen in Figure 1, the preliminary model proposes that hospice care must be
spiritually sensitive to serve as a form of spiritual care that evokes enhanced
life meaning or relational spirituality. Spiritual sensitivity thus mediates the
relationship between hospice care and relational spirituality. Information
from hospice workers will be used to broaden this model for future research
(Strauss & Corbin, 1998).
This study focuses on the experience of hospice workers who were
particularly interested in spiritual care. These hospice workers were selected
based on the assumption that they would be more sensitive to patient spiri-
tual needs. It was also assumed that these hospice workers would be more
likely to take specific steps needed to facilitate patient access to spiritual
care. Hence, documentation of this process would allow for examination of
relational factors that might represent spiritually-sensitive hospice care.

FIGURE 1 Relational model of spiritually-sensitive hospice care. A model of the mediating

effect of spiritual sensitivity in the relationship between hospice care and relational
spirituality.
 Spiritually-Sensitive Hospice Care 161

METHODOLOGY

Participants
The researcher obtained funding for this study from the Appalachian College
Association (ACA). After receiving approval by the Institutional Review Board
(IRB) of the researcher’s University, study participants were solicited through
community contacts to comprise a purposive, snowball sample. Despite a
large number of contacts made, the entire process resulted in the inclusion
of six hospice organizations, represented by 16 hospice workers. This low
response rate was likely due to an indirect form of participant recruitment
that was completed in two phases further detailed below.
The first phase of the study was a pilot study that involved the solicita-
tion of study participants in the eastern region of one southern state from
May to August 2009 (n = 6). The researcher contacted the managers of three
of the largest hospice organizations by phone and mail to ask each manager
for assistance in the recruitment of study participants. In one case, this
involved working with a hospice manager to complete the hospice organiza-
tion’s internal review board process before being allowed to participate in
the study. Study participants were also solicited by word of mouth through
community contacts.
The second phase of the study expanded the study sample to include
hospice workers across the same southern state from May to August 2010
(n = 10). The second sample was collected based on membership lists from
the state’s professional home care association and Department of Health.
The researcher contacted the hospice managers of 70 hospices by mail to
solicit hospice worker participation. This involved direct follow up by telephone
and meeting with hospice staff at two hospice organizations per request of
the hospice manager. Again, study participants were also solicited by word
of mouth through community contacts.

Procedure
Respondents were briefed on the interview process with a copy of the con-
sent form and questions mailed to them beforehand. Respondents set the
interview time. This time was usually early in the morning or late in the
evening when the respondent was at home. Data were collected through a
semi-structured interview conducted over the telephone. One interview was
conducted in person per respondent request. Overall, this approach helped
offset schedule conflicts and geographic distance that could have prevented
study participation.
Each interview lasted from 45 minutes to 1 hour. The interview ques-
tions were based on a comprehensive literature review (Callahan, 2010),
consultation with two academicians, and additional consultation with one
162 A. M. Callahan

veteran hospice worker. The questions were not changed between the two
phases of study, except for the removal of one question that led to study
participant confusion. This question was “What would you call the type of
response you offer to a patient with a spiritual concern/need?” Study partici-
pants were asked these remaining questions:

1. How do you know when a patient has a spiritual [or religious] concern/
need?
2. How do you respond? If you make a referral, is there anything else you
do?
3. Do you think your response is a source of spiritual support? Why?
4. Do you respond differently when a patient does not have a spiritual con-
cern/need? How?
5. What do you think is the most effective way of responding to a patient
with spiritual concerns/needs?
6. How do you think a patient’s spiritual needs are being addressed by
others in your organization?

Although the interview was not audio recorded, detailed notes were taken
with a word processor to create a transcript. The transcript was reviewed and
edited with missing data inserted and bracketed for clarity. This preliminary
transcript was sent to each respondent to verify the accuracy of the account.
There were no substantive changes. One respondent requested editorial
changes. Another respondent requested a new transcript to compensate for
formatting issues that could not be prevented and did not alter the content.
The data collected from both phases of the study were analyzed
together. It was assumed characteristics of spiritually-sensitive hospice care
would emerge to inform the relational model (Figure 1; Strauss & Corbin,
1998). As per the interview schedule, information about how each respon-
dent assessed patient spiritual needs, provided spiritual care, and measured
effectiveness was examined. Content analysis was used to identify consistent
themes within and across accounts in the following three steps (Boeije, 2002;
Eisenhardt, 2002; Huberman & Miles, 1998).

STEP 1
Transcripts (N = 16) were reviewed to isolate descriptions of the interper-
sonal process involved in spiritual care. Particular attention was paid to
isolating interpersonal exchanges that included a description of how the
respondent and/or patient experienced the caregiving relationship. These
interpersonal exchanges were highlighted in the transcripts with handwritten
notes in the margins to summarize researcher impressions. This process
resulted in 34 accounts of interpersonal exchanges being selected for closer
examination.
 Spiritually-Sensitive Hospice Care 163

STEP 2
Behaviors involved in spiritual care were identified and coded by comparing
the content within and across each account. When several codes seemed to
represent a particular theme or category, these codes became subcategories
of a broader thematic category. The resulting thematic categories used to
organize subcategories of behaviors associated with spiritual care included:
(a) Willingness to Address; (b) Spiritual Assessment; and (c) Spiritual Care,
which will be described further in the Results section.

STEP 3
Respondent and patient reactions to spiritual care were analyzed to explore
their potential for having experienced enhanced life meaning. These obser-
vations were exploratory in nature since respondents were not specifically
asked if providing spiritual care was meaningful. Words used by the respon-
dent to identify patient reactions to spiritual care became codes that were
organized into subcategories. Respondent reactions to providing spiritual
care were more oblique; thus they required additional analysis relative to the
context of the account. Patient and respondent reactions were then com-
pared to each other to assess for shared meaning.

Quality Enhancement
The researcher attempted to enhance the quality of these data by drawing
from colleagues to inform research questions and methodology, emersion in
the data with multiple passes for saturation and validation, and reflexive
examination of researcher interpretation relative to personal experience and
religious affiliation. Notes were also maintained throughout the study and
detailed here to assist others in study replication. Nevertheless, there were
study limitations that will be discussed briefly before and more fully after a
review of the results.
To allow for succinct examples of what appeared to be spiritually-sensitive
hospice care, abbreviated excerpts from the original transcripts will be refer-
enced. This required the use of brackets to either summarize key information
or include missing data. Efforts were made to ensure bracketed data preserved
the intent of the respondent’s account. Respondents originally reviewed the
transcripts and verified the accuracy of missing data included in brackets.
This process, however, may have increased the risk for inaccurate interpreta-
tion of the account.
The results are presented based on the thematic categories of: (a)
Willingness to Address; (b) Spiritual Assessment; (c) Spiritual Care; and (d)
Experience of Meaning. Under each category, there will be a review of
related subcategories that emerged through the process of conducting
164 A. M. Callahan

content analysis. Key examples will be provided to help demonstrate each

category and subsequent definition of spiritually-sensitive hospice care.
These results start with respondent demographics (N = 16).

RESULTS

Demographics
The mean age of the respondents was 44 (SD = 15) with 17 years of profes-
sional experience (SD = 13) and 6 years of hospice experience (SD = 5). As
found on Table 1, 13 (80%) respondents were female and 12 (75%) were
Christian. Eight (50%) respondents had an undergraduate degree and seven
(44%) had a graduate degree. There were eight (50%) social workers, six
(38%) nurses, and two (12%) in other positions. Fourteen (88%) respondents
worked full-time.
As found on Table 2, there were representative(s) from six hospices
included in the study. Four (67%) hospices were nonresidential and two
(33%) were residential. Three (50%) hospices had a nonprofit hospital affili-
ation and three (50%) had a corporate affiliation. Five hospices (83%) had a
nonsectarian affiliation. Three (50%) hospices were based in a rural setting
and three (50%) in an urban setting.

TABLE 1 Respondent Demographics (N = 16)

Variables n %

Gender
Female 13 80
Male 3 20
Religion
Christian 12 75
No affiliation 1 6
Unknown 3 19
Education level
High School diploma 1 6
Associate’s degree 3 19
Bachelor’s degree 4 25
Master’s degree 6 38
Doctoral degree 1 6
Unknown 1 6
Position
Social work 8 50
Nurse 6 38
Other 2 12
Employment status
Full-time 14 88
Part-time 2 12
 Spiritually-Sensitive Hospice Care 165

TABLE 2 Organization Demographics (N = 6)

Variables n %

Residential
No 4 67
Yes 2 33
Hospital affiliation
No 3 50
Yes 3 50
Sectarian affiliation
No 5 83
Yes 1 17
Geographic base
Rural 3 50
Urban 3 59

Willingness to Address
The first thematic category assigned upon data analysis was respondent
willingness to address spiritual needs. This thematic category included how
respondents engaged in self-preparation to provide spiritual care and
assessed patient readiness to receive spiritual care. Both of these conditions
were important for the respondent to consider for appropriate timing to initiate
spiritual assessment.

RESPONDENT PREPARATION
Spiritual care began when respondents took time to prepare themselves
before seeing their patients. The use of private prayer was identified as the
primary means of preparing oneself to provide spiritual care. Respondents
asked God for guidance as demonstrated in the following account:

… [I] was in the parking lot [before seeing a patient and said] … I just
wish I knew where he stood with the Lord. If he had any spiritual con-
cerns. [I had] asked before, [but did not get much response]. I went in
and did my usual. [I] did my blood pressure … [and] talked [to him] about
medicine. [The patient said] I just have one question for you today “Why
did Jesus stay on the cross? He could have come off. He didn’t.” [His
question] blew me away … [by] how open his question was. [We] hadn’t
discussed anything that spiritual before. When we … [as hospice work-
ers] are open and ready for [patients to express their] spiritual needs
many times those discussions will come to us without even asking … .
[When I am] mentally saying, I will be ready to help them, it is amazing
how many times that door opened and I never touched the door knob.

The respondent summarized this process of self-preparation by saying, “I

asked the Lord to be my voice, give me the words and help me discern what
166 A. M. Callahan

my patient needs.” Therefore, as part of self-preparation, it seemed the

respondent’s use of prayer facilitated respondent awareness of and willing-
ness to address patient spiritual needs.

PATIENT READINESS
Spiritual care further involved respondent awareness of patient desire and
readiness to address spiritual needs. One respondent described a patient’s
reaction to spiritual care that had been delivered prematurely. The patient
said angrily “I don’t want to hear anything about that God stuff. Don’t bring
that God stuff in my residence again.” The patient “continued to be irate”
despite the respondent’s apology. Another respondent said patients would
“shut down” upon efforts to discuss their spiritual needs. In turn, the respon-
dent said, “I try not to intrude or overstep those boundaries.” The respondent
would invite patients to talk about spiritual needs when they felt comfortable
and would “go where they take me.”

Spiritual Assessment
Spiritual assessment was important to consider for the information gathered
through this assessment influenced the direction of spiritual care. Interview
style, identification of spiritual needs, and disposition were all identified as
key components of spiritual assessment.

INTERVIEW STYLE
Respondents engaged in spiritual assessment to determine patient resources
and potential need for spiritual care. Spiritual assessment questions were
often integrated into the admissions process as reflected here:
I ask [patients] what their religious affiliation is when I first admit them.
We always write down what church they go to and who their religious
leader is. If they say that don’t go to a church, but [have a particular reli-
gious affiliation then] I ask “Do you have a relationship with a pastor or
priest?” Then I bring up [that we have a] grief and bereavement coun-
selor. [I explain that he is] not here to preach to you. He gives you ways
to deal with what you are going through. Sometimes I will ask them
“Where do you draw your strength from?”

The use of understandable language to conduct a spiritual assessment was

emphasized. This style of interviewing was likened to a “back porch conver-
sation” where you “ask the right questions to get the patients more comfort-
able … until they begin to open up.”

IDENTIFICATION OF SPIRITUAL NEEDS

As patients shared more information about themselves, respondents were
able to identify what factors contributed to their spiritual needs and how
 Spiritually-Sensitive Hospice Care 167

unmet spiritual needs led to the experience of spiritual pain. In the next
account, one respondent explained what some hospice patients reported:

When people are told they are going to die [they] work towards [accept-
ing] that … so when the dying is prolonged … [it gives patients a] longer
time [to] think about what they have done in life … . [A lot of times they
begin to think] I must have done something wrong. God must be punish-
ing me. Why is it taking so long [to die]? What have I done? There must
be something wrong with my faith because now I am scared [to die.] … .
[W]hen people have died, we close [the] doors … to prevent people from
seeing the mortuary [workers] … come [in to remove the body. The
patients realize why those doors get shut … . [O]ne lady told me … [“If I
leave and go home,] … maybe I will not die.” [Others have said] … “I
know the lady across the hall died because I don’t hear her [any-
more].” … [They] become aware … [that the other residents are dying]
and have to sit with [the anticipation of their own death]. … It is a very
trying thing to sit … with that.

Another respondent said that some patients had the spiritual need to be
active church members “engaged [with] the body of believers weekly.” When
church members stopped visiting patients who were no longer able to attend
church, their spiritual need for church community remained unmet leaving
them feeling “completely abandoned.”
When patients were semi-conscious and unresponsive, the respondents
admitted that it was more difficult to determine if these patients had spiritual
needs. In one instance, though, the respondent was mindful that unmet spiri-
tual needs could possibly be linked to the patient’s difficulty with terminal
agitation:

[O]ur chaplain has gone in to pray for patients at the families’ request
[and] then the terminally agitated patient [would] become more peaceful.
[I] don’t know what caused … [the patient to calm down. We] addressed
all those things [that could have made the patient agitated] and the prayer
relieved it. [Based on this reaction,] then [I believe] spiritual distress
caused … [the patient’s agitation].

This respondent solicited additional information from patient family mem-

bers and tried a variety of interventions to determine what caused the
patient’s agitation. Sensitivity to patient potential spiritual needs provided
one more direction for caregivers to reduce patient distress, which likewise
gave the respondent and family members satisfaction in being able to assist.

DISPOSITION
The process of spiritual assessment resulted in the collection of informa-
tion about patient spiritual needs. If the patient required spiritual care
168 A. M. Callahan

beyond the expertise of the respondent, then the assessment resulted in

a referral to the hospice chaplain or other resource as found in this
account:

If they say I don’t have a religious affiliation [or] … if they say “Oh, I
believe in God.” I usually … back off … especially [if they say this] upon
admission. I just don’t get into that seriously … I … leave that to [our
chaplain] because that is their specialty. I report back to them “This is
what [the patient] said to me” [and] they know how to approach people
[with spiritual needs].

Here the respondent automatically referred patients to the hospice chaplain.

This seemed to be a partial product of the respondent’s comfort level, ability,
and willingness to engage in spiritual assessment. It also assumed patient
willingness to accept a chaplain referral, which was not always the case as
in the next account:

[I asked] “How come you will not let [our chaplain] come up here?”
[He said] “I don’t want a preacher. Back when I was young and work-
ing, my wife ran off with a preacher.” [I] would not harp on it, [but I]
would mention it every other visit. I would say “Maybe you need to
talk to someone who could probably help you more.” I am not the
biggest religious person in the world … I would visit with him more
and talk to him. I would try to [get him to see the chaplain]. Each visit
I would say … “Are you ready to let our chaplain come up now?” I
tried to push him. I felt like he needed some spiritual help [because
he was] mad at God, Church, [and] the preacher. [E]very visit [I would]
ask if he would let the [chaplain] come up … I would visit him 2–3
times a week.

This respondent admitted to feeling unprepared to address the patient’s

spiritual needs when the patient refused a chaplain referral. Respondent
coercion threatened patient self-determination. Nevertheless, the respondent
was able to subsequently find ways to communicate care in a way that was
comfortable for both the patient and the respondent.

Spiritual Care
Spiritual care involved interventions used by the respondent to address the
spiritual needs of patients. These interventions included recognizing person-
hood, therapeutic touch, being present, listening, singing, reframing, affirm-
ing, self-disclosure, normalization, and advocacy. Respondents often reported
using a combination of these interventions for spiritual care as demonstrated
by some of the examples in this section.
 Spiritually-Sensitive Hospice Care 169

BEING PRESENT
Similar to the process of initiating spiritual assessment, respondents had to
first be willing to engage patients in spiritual care interventions that were
based on patient needs as suggested here:

[Patients need a hospice worker who] … is willing to let down their guard
and show that they really care about [them.] If there is ever a time [when
people] … need someone to care, [it is when they are dying.] [I] tell them
[that] I will be looking forward to seeing them next time … . [I] try to
extend physical contact in some way that is not uncomfortable [such as
a] casual patting the arm [and] squeezing the hand.

RECOGNIZING PERSONHOOD
As reflected in this example and the next, one of the most basic forms of
spiritual care involved recognizing the patient’s humanity. This involved the
ability of respondents to “see beyond” a patient’s sickness and relate to the
patient as a whole person. One respondent described it like this:

I was at a patient’s house a few weeks ago. He did not have much to
say … I saw a hiking stick in the corner. He said [he and his wife] both
used to [go hiking. His wife said] he makes those [hiking sticks] … I
started telling him I have a grandson who is starting to whittle. [The
patient] just came alive.

Another respondent said:

If you can just show a person that you care, [that you are] not afraid of
what disease they have … I go in there and give them all the love I
can … . It doesn’t matter what [their religious] denomination [is or] how
their life may have been in the past.

LISTENING/THERAPEUTIC TOUCH
Respondents also said that spiritual care could be communicated “without
ever saying a word” by “the gentleness of the way you turn a patient” and
when you “sit in silence with the patient.” This was important even when
patients were minimally alert as described by one respondent:

A lot of these conversations are one or two words [since] people [are]
going in and out [of conscious] with the disease process. They ask you
not to leave. They fall asleep [in the middle of telling you something and]
you move a little bit and they [wake up and] continue [what they were
saying].
170 A. M. Callahan

SINGING
In addition to nonverbal communication of spiritual care, singing was another
form of spiritual care that patients deeply appreciated as demonstrated by
this account:

[T]he more accepting … loving … and attentive [I am], the more comfortable
and open they become with me … . [One of my patients] … loves hymns
[so I started singing to her. The] next thing I know she is trying to sing with
me. [She is] holding my hand [and] wants me to [keep singing.] I think touch
is so important [so I started to rub] her head. [She said to me when I was
finished singing] “Just sing one more song … just let’s sing one more song.”

REFRAMING
One respondent described using reframing as a spiritual care intervention,
specifically to help a patient find life meaning when the patient struggled to
reconcile regrets over past mistakes. The respondent said:

[He said] I have nothing. [I said] but you do have a daughter finishing high
school about to go in to college. [She] wants to be a pediatrician. That may
be your big purpose in your life. Maybe you were not there … you still
had an impact on her. The world is a different place because of you.

AFFIRMING/SELF-DISCLOSURE
Respondents generally tried to be universal in their approach, but there were
times when they drew from knowledge about a patient’s religious beliefs to
provide spiritual care. In one account, the respondent both affirmed patient
beliefs and engaged in self-disclosure to help the patient find comfort in
their shared belief in an Afterlife.

I will use whatever … [the patient] brings up. [I] will affirm it … . If they
are people of [Christian] faith and they express their faith, I will affirm my
own [Christian] faith. [I will] join them as a believer [by] affirming them … .
[I] try to reaffirm whatever their faith has taught [them]. I can reflect it
back to them [by using the] … words of their [own] church.

NORMALIZATION/ADVOCACY
The last interventions used for spiritual care included normalization and
advocacy. In this example, family members were educated about unusual
experiences that could be associated with the dying process so they would
be more comfortable in supporting their family member:

Many times [patients] will talk with family members who have already
gone on. [I will] tell [those who are concerned about the patient’s
 Spiritually-Sensitive Hospice Care 171

behavior that] it is very common … . We don’t know. … Maybe the

[patients] are talking to their loved ones. [If] … they see things [that] we
do not [see] that does not make it less real [to them].

Experience of Meaning
Although respondents were not asked if they thought spiritual care was life
enhancing, they were asked if they thought spiritual care was a source of
spiritual support. The results suggested a variety of factors led to positive
and negative impressions of spiritual care.

POSITIVE ATTRIBUTION
Respondents described being inspired in the process of providing spiritual
care. One respondent said “I take it to heart … . This is where [God] uses
me.” Another suggested that “[You] can feel God’s presence” when
providing spiritual care. This experience further lent inspiration to resolve
treatment issues like in the earlier account about reliance on chaplain
prayer to relieve terminal agitation experienced by an unresponsive
patient.
In addition, the delivery of spiritual care had the potential to cultivate
emotional intimacy over the course of treatment. One respondent described
having been deeply moved by the intimacy that emerged through the care-
giving relationship:

[Y]ou can’t help it [but to let] your heart get involved [with your
patients.] … [G]oing into someone’s home is a very intimate thing … . [It]
is their domain, their territory. [M]any times [you see the patient in] their
bedroom … . When you are a guest in someone’s home [it changes the
dynamic]. They will ask you how many people do you see a
day … [if] … you have children. [There is a] change in [the] relationship.
[Patients no longer think of you as] “Just [my hospice worker, but that]
this is someone coming to my home.”

Emotional intimacy set the stage for an authentic relationship to emerge

between the respondent and patient. This type of relationship would be
more likely to facilitate personal transformation than a business transaction
that is more impersonal in nature.
Respondent descriptions of how patients reacted to the provision of
spiritual care suggested that spiritual care was meaningful to them as well.
Patients “expressed fulfillment” as they reached out to the respondents to
“hug my neck” and say “thank you” and that “they love me.” Therefore, in
these cases, it appeared that both the respondent and patient thought spiritual
care was a positive source of support.
172 A. M. Callahan

NEGATIVE ATTRIBUTION
Particularly noteworthy were times when the manner of delivering spiritual
care was not spiritually supportive. This included providing spiritual care
that was not desired or without having adequate time for follow-up, not
offering a needed referral to a chaplain, pushing to make a referral to a chap-
lain refused by the patient, referring to a chaplain not respectful of patient
beliefs, and praying for/with patients without their consent.
Several respondents expressed concern about there being adequate
time to address patient spiritual needs; however, time constraints seemed to
compromise the caregiving relationship when respondents did not arrange a
referral for a chaplain to follow-up. One respondent recalled:

[I was working with a patient who was] struggling with her terminal ill-
ness. [The] family was … present. I could tell she was having a hard time.
Finally I asked her, “Are you scared?” She started crying [and we] had a
pretty good session, [but I was] unable to follow up for 3 weeks [given
the number of other people I needed to see.] The family [said] “Where
are you?” [and] they [found] resource reasons to bring me [back] there.

The respondent did not arrange follow-up with a chaplain. A chaplain would
have had official sanction to devote more time to address the patient’s fear
of death. A chaplain might have also reduced the need for the respondent to
follow up for “resource reasons.”
Another respondent had the time to address a patient’s spiritual needs,
but did not report making a referral to a chaplain for follow-up. Based on
this account, it appeared that the patient needed more than what the respon-
dent was able to provide:

[I had a] … patient [who] said that he had walked with the Lord, but had
become very bitter … . He began to cry and [it] turned into a spiritual con-
versation … . [He] began to talk about why [he was] so angry at his church.
[It was] because he had done so many things at his church … and in his
dying days [he felt like] they left him. He needed them … [but denied
it] … because he was angry. [He told me] because I had the time [to listen].

In this case, the chaplain could have helped the patient resolve feelings of
abandonment by his church and God. The chaplain may have also contacted
the patient’s church to request church members resume visitation.
Some respondents were hesitant to rely on the hospice chaplain or
other clergy for fear they would not respect the patient’s beliefs. One respon-
dent attempted to “protect the patient [from proselytizing] if they did not find
[it] … helpful.” Another said:

There [can be] a lot of shame … [for patients] when a chaplain goes in. If
he isn’t trying to save this person, [the chaplain thinks] he isn’t doing his
 Spiritually-Sensitive Hospice Care 173

job. [I] wish our chaplains [were] more trained. [They may be a] called-to-
preach chaplain [with] not a lot of seminary training. [The] more trained
[they are the better they are in] … dealing with all different kinds of beliefs.

When respondents lacked confidence in the hospice chaplain, they were in the
difficult position of having to determine whether making a referral to the chap-
lain would expose the patient to the risk of experiencing more spiritual pain.
However, there were times when respondents risked pushing patients
to engage in religious practices that were not espoused by the patient. One
respondent engaged patients in prayer even when the patient was limitedly
able to articulate consent:

I pray with them. I hold their hand [and say] … “Do you want me to pray?
Squeeze my hand if you do. If you have accepted Christ, squeeze my
hand.” [If they have not already accepted Christ and want to,] I will pray
the prayer of salvation. [Then I will ask] “If you feel peace in your heart,
please squeeze my hand.” Many times I have had that happen … . They
are at peace.

Another respondent acknowledged praying silently for patients while pro-

viding them hospice care. Even though these respondents justified their
actions with good intentions, these practices still violated the patient’s right
to refuse spiritual care be it direct or indirect.

DISCUSSION

The purpose of this study was to lend insight into the meaning and provision
of spiritually-sensitive hospice care. More specifically, this information was to
be used to further develop the relational model of spiritually-sensitive hos-
pice care (Figure 1). The way hospice workers engaged in the provision of
spiritual care was assumed to be a reflection of how services would be pro-
vided when respondents were sensitive to the spiritual needs of patients.
There was not enough information to determine if the delivery of spiri-
tual care was considered spiritually sensitive by patients, nor was it possible
to determine if spiritual care was life enhancing. Enhanced life meaning was
modeled to be the outcome and means of verifying that hospice care was
spiritually sensitive. Nevertheless, the information collected does provide
some information for model development and future research.
It was assumed that the delivery of spiritual care first required respon-
dent willingness to address patient spiritual needs and ability to assess
patient readiness to express spiritual needs. Based on respondent interviews,
private prayer helped respondents feel prepared to provide spiritual care.
Sensitivity to patient readiness also seemed important out of respect for
patient right to refuse spiritual care.
174 A. M. Callahan

Respondents then required the ability to conduct a spiritual assessment,

determine patient spiritual needs, and recommend an appropriate disposi-
tion. Respondents varied in their sensitivity to patient spiritual needs, which
became evident when patients refused a chaplain referral and respondents
were unsure how to address patient spiritual needs on their own. This
presented a critical time for respondents to determine alternative modes of
spiritual care that were comfortable for both the respondent and patient.
Hospice workers provided spiritual care by using interventions already
associated with traditional caregiving. These interventions included recog-
nizing personhood, being present, therapeutic touch, singing, listening,
reframing, patient affirmation, self-disclosure, normalization, and advocacy.
Often times, respondents used a combination of interventions to address
patient spiritual needs.
This suggests that the use of traditional skills for spiritual care allows
the provision of spiritual care to be seamlessly integrated into caregiving by
hospice workers across positions, with a variety of patients, and under dif-
ferent treatment conditions, provided the hospice worker is adequately
trained. The current study did not identify, however, if the patients perceived
these interventions as being spiritually sensitive and/or life enhancing.
According to the relational model (Figure 1), hospice care needed to be
spiritually sensitive to enhance patient life meaning. This relationship was
minimally explored in the current study, which represented one of the study’s
most significant limitations. Nevertheless, based on what was identified as
emotional reactions to spiritual care, their experiences did seem to have
implications for life meaning.
One respondent suggested that the provision of hospice care cultivated
emotional intimacy, which would have been expected in the delivery of
spiritually-sensitive hospice care. Patients were also said to have expressed
deep appreciation for what hospice care had meant in their lives. Although
this measure of meaning was indirect, it still suggested that spiritual care
potentially enhanced life meaning for the respondent and/or patient.
There also seemed to be times when efforts to provide spiritual care
were not spiritually sensitive. A variety of negative reactions were described
in response to these circumstances. For example, one respondent demanded
the hospice worker leave the patient’s home upon asking the patient ques-
tions of a spiritual nature. Here spiritual care took on negative meaning,
which could have had a negative impact on life meaning or, at a minimum,
on the caregiving relationship.

REVISED MODEL

Despite the need for further research, these data expand on the meaning
and delivery of spiritually-sensitive hospice care. The proposed relational
 Spiritually-Sensitive Hospice Care 175

model originally theorized spiritual sensitivity mediated the relationship

between hospice care and relational spirituality (Figure 1). This relationship
seemed to hold true upon closer examination, but there were a variety of
hospice worker and patient factors that seemed to be important as well
(Figure 2).
As seen in Figure 2, the hospice worker must be willing and prepared
to provide spiritually-sensitive hospice care. The patient must also be ready
to communicate the need for spiritually-sensitive hospice care assuming that
the patient is conscious and responsive. If not, patient nonverbal cues and
family members must be referenced to guide the selection of interventions
that are consistent with patient preferences.
Characteristics of spiritual sensitivity were extrapolated from spiritual
care interventions reported in this study. The communication of spiritual
sensitivity might include recognizing personhood, therapeutic touch, being
present, listening, singing, reframing, affirming, self-disclosure, normalization,
and advocacy. A combination of these interventions would likely be used to
communicate spiritual sensitivity, again, depending on the circumstances.
The way spiritually-sensitive hospice care informs life meaning would
also depend on hospice worker and patient factors. For example, the meaning
ascribed by the hospice worker and patient to the delivery of spiritually-
sensitive hospice care would depend on the person’s role and role expectations,
but the hospice worker and patient could both potentially experience
relational spirituality. This relationship is more tenuous, however, given the
study’s limitations.
Based on this revised relational model (Figure 2), the delivery of spiri-
tually-sensitive hospice care and consequent experience of relational spiritu-
ality is the product of a dynamic interaction between the hospice worker and

FIGURE 2 Relational model of spiritually-sensitive hospice care. A model of the moderating

effect of individual factors and the mediating effect of spiritual sensitivity in the relationship
between hospice care and relational spirituality.
176 A. M. Callahan

patient. This suggests that what leads to the communication of spiritual sen-
sitivity and interpretation that enhances life meaning depends on the combi-
nation of conditions in the caregiving relationship.

Limitations
The goal of this study was to define how hospice workers communicated
spiritual sensitivity based on the analysis of interpersonal exchanges that
involved the provision of spiritual care. By default, the content of those
accounts influenced the results of the study. That is why it is important to
identify errors that might significantly threaten study validity and if these
errors might be avoided upon study replication.
One of the first limitations was a small and relatively homogenous
study sample. Although this sample provided detailed information about this
particular group of hospice workers, greater variation in the sample was
needed to develop the model for broader application. More information was
particularly important to explain which variables potentially moderated the
relationship between key constructs in the proposed model.
These accounts were retrospective in nature, thus documentation
depended upon the accuracy of respondent memory. Furthermore, these
interviews were not audiotaped, which required researcher accuracy in note-
taking and additional respondent follow-up to review the transcript and
forward comments to the researcher. Even though the majority of respon-
dents did not suggest changes, some respondents may not have time to
follow up.
Respondents may have had different ideas about what represented the
provision of spiritual care. They may have provided interventions that met
patient spiritual needs but did not recognize that these interventions facili-
tated spiritual care. Social desirability also limited information about the dif-
ficulties involved in providing spiritual care. Full disclosure of failed efforts
to meet patient spiritual needs would have been important to explore.
One of the most critical oversights was the collection of limited infor-
mation about the experience of enhanced life meaning. There were no ques-
tions in the interview schedule that directly asked about the experience of
meaning beyond the patient’s general response to spiritual care provision. In
addition, the study did not include interviews with patients to help verify
respondent accounts.

Future Research
Patients will need to be interviewed to explain what they believe is spiritu-
ally sensitive in the caregiving relationship. It is likely that patients will report
some behaviors are more spiritually sensitive than others. It would be
interesting to interview the hospice workers described by these patients to
 Spiritually-Sensitive Hospice Care 177

determine if there is any continuity in the behaviors identified as being spiri-

tually sensitive. Unobtrusive worker and patient observation could be used
to provide additional data that could be triangulated with interview data.
Research could be used to further determine if some hospice workers
are better at cultivating meaningful caregiving relationships than others. If
so, it would be important to determine what makes these relationships dif-
ferent and what kind of meaning patients and hospice workers attach to
those relationships. There might be some interventions that do not consistently
enhance life meaning, depending on the circumstances. Thus, additional
research is needed to explore the conditions associated with spiritually-
sensitive hospice care.
As more information is collected, this can be used to expand the rela-
tional model of spiritually-sensitive hospice care. Once spiritually-sensitive
hospice care is clearly defined, then it might be compared to hospice care
that is not spiritually sensitive to determine if spiritual sensitivity mediates
the relationship between hospice care and relational spirituality. This would
include clarifying and testing for the moderating effects of individual factors
as well as modeling the potential role of treatment environment factors that
have yet to be explored.

CONCLUSION

The relational model for spiritually-sensitive hospice care suggests that hos-
pice care has the potential to enhance life meaning provided that it is spiritu-
ally sensitive. There are many factors that seem to influence the provision of
spiritually-sensitive hospice care; however, the role of these factors still
remains largely unknown. Given the importance of addressing patient spiri-
tual needs at the end of life, the relational model for spiritually-sensitive
hospice care provides an important first step in many required to further this
research.

REFERENCES

Belcher, A., & Griffiths, M. (2005). The spiritual care perspectives and practices of
hospice nurses. Journal of Hospice and Palliative Nursing, 7(5), 271–279.
Beresford, P., Croft, S., & Adshead, L. (2008). ‘We don’t see her as a social worker’: A
service user case study of the importance of the social worker’s relationship
and humanity. British Journal of Social Work, 38, 1388–1407.
Boeije, H. (2002). A purposeful approach to the constant comparative method in the
analysis of qualitative interviews. Quality & Quantity, 36, 391–409.
Buber, M. (1970). I and thou (W. Kaufmann, Trans.). New York, NY: Touchstone.
(Original work published 1923)
Bullis, R. (1996). Spirituality in social work practice. Washington, DC: Taylor &
Francis.
178 A. M. Callahan

Callahan, A. M. (2010). Spiritually-sensitive care in hospice social work. Journal of

Social Work in End-of-Life and Palliative Care, 5(3–4), 199–215.
Callahan, A. M. (2012). A qualitative exploration of spiritually-sensitive hospice care.
Journal of Social Service Research, 38(2), 144–155.
Canda, E. R. (1999) Spiritually sensitive social work: Key concepts and ideals. Journal of
Social Work, Theory, and Practice, 1(1). Retrieved from http://www.bemidjistate.
edu/academics/publications/social_work_journal/articles/canda.html
Canda, E. R., & Furman, L. D. (1999). Spiritual diversity in social work practice: The
heart of helping. New York, NY: Free Press.
Canning, D., Rosenberg, J. P., & Yates, P. (2007). Therapeutic relationships in specialist
palliative care nursing practice. International Journal of Palliative Nursing,
13(5), 222–229.
Catty, J. (2004). ‘The vehicle of success’: Theoretical and empirical perspectives on
the therapeutic alliance in psychotherapy and psychiatry. Psychology and
Psychotherapy: Theory, Research and Practice, 77, 255–272.
Cooper, M. (2005). Therapists’ experiences of relational depth: A qualitative interview
study. Counseling and Psychotherapy Research, 5(2), 87–95.
Crits-Christoph, P., & Gibbons, M. B. C. (2003). Research developments on the thera-
peutic alliance in psychodynamic psychotherapy. Psychoanalytic Inquiry, 23,
332–349.
Eisenhardt, K. M. (2002). Building theories from case study research. In A. M.
Huberman & M. B. Miles (Eds.), The qualitative researcher’s companion
(pp. 5–35). Thousand Oaks, CA: Sage.
Emanuel, L. L., Alpert, H. R., Baldwin, D. C., & Emanuel, E. J. (2000). What terminally
ill patients care about: Toward a validated construct of patients’ perspectives.
Journal of Palliative Medicine, 3(4), 419–431.
Faver, C. A. (2004). Relational spirituality and social caregiving. Social Work, 49(2),
241–249.
Hall, T. W. (2004). Christian spirituality and mental health: A relational spirituality
paradigm for empirical research. Journal of Psychology and Christianity, 23(1),
66–81.
Hermann, C. (2001). Spiritual needs of dying patients: A qualitative study. Oncology
Nursing Forum, 28(1), 67–72.
Hubble, M., Duncan, B., & Miller, S. (1999). The heart and soul of change: What
works in therapy. Washington, DC: American Psychological Association.
Huberman, A. M., & Miles, M. B. (1998). Data management and analysis methods. In
N. K. Denzin & Y. S. Lincoln (Eds.), Collecting and interpreting qualitative
materials (pp. 179–210). Thousand Oaks, CA: Sage.
Kellehear, A. (2000). Spirituality and palliative care: A model of needs. Palliative
Medicine, 14(2), 149–155.
Kim, S. C., Kim, S., & Boren, D. (2008). The quality of therapeutic alliance between
patient and provider predicts general satisfaction. Military Medicine, 173(1),
85–90.
Lambert, M., & Barley, D. (2002). Research summary on the therapeutic relationship
and psychotherapy outcome. In J. C. Norcross (Ed.), Psychotherapy relationships
that work: Therapist contributions and responsiveness to patients (pp. 17–32).
New York, NY: Oxford University Press.
 Spiritually-Sensitive Hospice Care 179

Martin, D. J., Garske, J. P., & Davis, M. K. (2000). Relation of the therapeutic alliance
with outcome and other variables: A meta-analytic review. Journal of Consulting
Clinical Psychology, 68(3), 438–450.
McGrath, P., & Newell, C. (2004). The human connection: Study of spirituality and
disability. Journal of Religion, Disability & Health, 8(1–2), 89–103.
Millison, M. B. (1988). Spirituality and the caregiver: Developing an underutilized
facet of care. American Journal of Hospice & Palliative Medicine, 5(2), 37–44.
Murray, S. A., Kendall, M., Boyd, K., Worth, A., & Benton, T. F. (2004). Exploring the
spiritual needs of people dying of lung cancer or heart failure: A prospective
qualitative interview study of patients and their carers. Palliative Medicine,
18(1), 39–45.
Norcross, J. C. (Ed.). (2002). Psychotherapy relationships tbat work: Therapist contri-
butions and responsiveness to patients. New York, NY: Oxford University Press.
Priebe, S., & McCabe, R. (2008). Therapeutic relationships in psychiatry: The basis of
therapy of therapy in itself? International Review of Psychiatry, 20(6),
521–526.
Puchalski, C. M. (2006). A time for listening and caring: Spirituality and the care of
the chronically ill and dying. New York, NY: Oxford University Press.
Reis, H. T., Clark, M. S., Gray, D. J. P., Tsai, F., Brown, J. B., Stewart, M., & Underwood,
L. G. (2008). Measuring responsiveness in the therapeutic relationship: A patient
perspective. Basic and Applied Social Psychology, 30, 339–348.
Rogers, S. A. (2007). Where the moment meets the transcendent: Using the process
as a spiritual intervention in object relations psychotherapy. Journal of
Psychology and Christianity, 26(2), 151–158.
Sandage, S. J., & Shults, F. L. (2007). Relational spirituality and transformation: A
relational integration model. Journal of Psychology and Christianity, 26(3),
261–269.
Stanworth, R. (2006). When spiritual horizons beckon: Recognizing ultimate meaning
at the end of life. OMEGA: Journal of Death and Dying, 53(1–2), 27–36.
Staude, J. (2005). Autobiography as a spiritual practice. Journal of Gerontological
Social Work, 45(3), 249–269.
Stephenson, P., Draucker, C. B., & Martsolf, D. S. (2003). The experience of spirituality
in the lives of hospice patients. Journal of Hospice and Palliative Nursing, 5(1),
51–58.
Strauss, A. L., & Corbin, J. M. (1998). Basics of qualitative research: Techniques and
procedures for developing grounded theory (2nd ed.). London, United Kingdom:
Sage.
Watson, N. J. (2006). Martin Buber’s I and thou: Implications for Christian psycho-
therapy. Journal of Psychology and Christianity, 25(1), 34–43.
Wright, M. C. (2002). The essence of spiritual care: A phenomenological enquiry.
Palliative Medicine, 16(2), 125–132.
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