Education for Primary Care (2012) 23: 131–36
Innovations and developments
We start this time with a paper about a workshop
on spiritual care. How much should spiritual care
be the province of general practitioners (GPs)?
How do trainee GPs need to engage with spiritual
care? How do those (patients and doctors) without
religious beliefs engage in spiritual care? These
questions, and many others, are discussed in
John Nicol’s interesting paper.
Our second paper is about the provision of edu-
cational events for GPs. Some readers will
remember the birth of the Postgraduate Education
Allowance over 20 years ago and how this led to
a range of education providers coming into being.
Many of these providers still exist and Jim Mori-
son describes their evolution and development in
the Severn region. Are they still relevant today?
* * * *
The use of a workshop to
encourage trainers to
consider spiritual care
John Nicol MBChB FRCGP
General Practitioner, Trainer and Associate
Adviser
Keywords: general practice trainers, spiritual
care, workshop
INTRODUCTION
As a general practitioner (GP) I have embraced
the physical, mental and social aspects of health-
care1 and I appreciate that a whole-person
approach to medicine may be incomplete if it
does not include a spiritual dimension.2 However,
while I recognise the spiritual nature of some
patients’ problems and I acknowledge the need
for spiritual care, I am often unsure how to meet
that need in the face of various constraints such
as limited time, uncertainty about my own role
and skills, and the perception of professional
boundaries. My own position is in keeping with
the findings of Murray,3 who interviewed GPs
about their perceptions of the experiences and
needs of particular patients who had had a life
# 2012 Radcliffe Publishing Limited
threatening illness within the previous year. He
found that GPs varied greatly in their understand-
ing of their patients’ holistic care needs. Most
acknowledged that they had a role in providing
spiritual care but hesitated to raise such issues
with patients. Reasons for this included lack of
time, a feeling that they should wait for a cue, and
being unprepared or unskilled.
If it is true that GPs approach spiritual care in
this way, then it is likely that trainers take a simi-
larly ambivalent approach to teaching and asses-
sing their trainees in this area.
Over the last year I have facilitated a workshop
on spiritual care for several groups of trainers.
The workshop encourages consideration of how
we teach spiritual care and assess it in our train-
ees. The workshops have been well received and
they have generated a sense of confidence and
fresh understanding among the participants.
This paper outlines the format of the workshop,
summarises issues that have arisen from it, and
suggests some implications for general practice
education.
WORKSHOP FORMAT
The workshop has been an optional part of the
programme for three residential trainers’ confer-
ences. I encourage small group thinking around
four questions in turn, building on the groups’
experiences and views with some Powerpoint
slides and facilitated discussion.
The four questions are:
1 What is spiritual care?
2 How do we deliver spiritual care?
3 How can we teach spiritual care?
4 How can we assess spiritual care?
The question of what is meant by spiritual care
raises various themes: definitions and terminol-
ogy; religion and spirituality; roles and respon-
sibilities as GPs; diversity and spirituality within
society. Consideration is given to how our values
and beliefs underpin our medical decisions and
affect our relationships with patients and with
trainees.
The delivery of good spiritual care requires the
GP to be comfortable taking an appropriate spiri-
tual history. The group is invited to suggest useful
questions which would help to define the spiritual
care problem.
A very significant part of the workshop is my
132 Innovations and developments
use of a series of 12 slides which exemplify spiri-
tual care in everyday general practice. These
have been taken from a slide-based presentation
on spiritual care prepared by PRIME,4 designed
for delivery to medical undergraduates and doc-
tors in training. The slides carry an image or a
phrase illustrating the following themes:
. giving or arranging for specific comfort for spiri-
tual distress
. giving hope for the future
. enabling the development of a patient’s coping
strategies from within their spiritual resources
. focusing on sources of strength and energy and
not on weakness and failing
. enabling the patient to express and manage feel-
ings
. enabling the patient to make sense of their illness
and the associated suffering
. enabling the patient to practise rituals necessary
to maintain their spiritual life
. enabling the patient to deal with regrets over past
thoughts and actions
. enabling the patient to maintain those relation-
ships which give meaning to his/her life
. enabling the patient to give and receive forgive-
ness and restore broken relationships
. supporting the patient’s actions and attitudes
which maintain connection or make reconnection
with God
. enabling the patient to bring their life to a safe
conclusion.
I prepare the participants by asking them to note
down any recollections of relevant personal
experiences as they consider each slide-illustra-
tion in turn. After the final slide, I encourage
large-group discussion. Through our collective
experience I aim for the group to reach a deeper
understanding of what it means to deliver spiri-
tual care.
The same 12 themes are used to encourage the
group to consider how to teach spiritual care and
assess trainees’ competence in this field. I ask
the group to think of these themes as ‘spiritual
care descriptors’, an extension of the descriptors
in the assessment grid that supports the MRCGP
Workplace Based Assessments, and to consider
the following questions:
. Can we recognise these spiritual care descriptors
in ourselves and in our trainees?
. Can they be used positively to reinforce observed
examples of good clinical practice?
. Do they represent a standard to which trainees
should aspire?
. Are they a legitimate set of criteria against which
trainees can be assessed?
The strong consensus to emerge from the work-
shops has been a positive response to these
questions. This has led to further discussion
about practical ways to teach spiritual care and
assess trainees in this area.
ISSUES ARISING FROM THE
WORKSHOPS
Specific words, such as religion, belief, forgive-
ness and reconciliation can be very emotive.
Even the word spiritual caused a degree of ten-
sion within one group, and some participants
have preferred to use words such as holistic,
humanitarian, and ethical. Other words, such as
church, chaplain and healing meant slightly differ-
ent things to different people. By facilitating a
consideration of the meaning of key words such
as these early on in the workshop, I establish a
shared understanding of terminology, and an
environment of trust which is conducive to open,
honest discussion.
When thinking about spiritual care we usually
consider a patient’s sense of connectedness,
their sense of meaning, particularly in relation to
an illness, and their values and beliefs. By dis-
cussing these issues at the workshop, partici-
pants found themselves considering their own
sense of connectedness and meaning, and their
own values and beliefs. These are issues not
commonly discussed among groups of trainers,
and when strong feelings and firmly held attitudes
were expressed, there was some dissonance
within the group. However, although they found it
challenging, the workshop participants appre-
ciated the opportunity to consider how these
aspects of spiritual care have shaped their own
attitudes, both personally and professionally.
The words religion and spirituality are closely
related, and while both words share some conno-
tations, I have made a point of clarifying their dif-
ferent meanings. Religion tends to be community
focused, formal and organised, while spirituality
tends to be individual, informal and less systema-
tic. Religion can be more easily recognised and
observed than spirituality, and is often behaviour
orientated rather than experience orientated.
Some participants have felt that spiritual care
should be carried out by counsellors, chaplains,
or recognised spiritual leaders within the commu-
nity. Others have felt that it is the task of GPs but
acknowledge that, if a particular GP is unskilled
in the task, then they should at least be able to
recognise a spiritual problem and be able to
direct the patient to appropriate sources of help.
Many participants found that they had already
engaged with the concepts of spiritual care but
they had previously never had the opportunity to
discuss them in a group.
Symptoms indicative of a spiritual problem
were identified as hopelessness, despair and an
absence of meaning. However, there is some
overlap with symptoms of depression and anxiety,
and it has been helpful to share examples of
questions designed to assist in a spiritual assess-
ment.5 Such questions ask about what gives
meaning to life, what things are considered
important, and what sort of support structure
exists for a patient.

Effective general practice training requires a
safe environment, supported by all members of
the healthcare team. With regard to teaching
spiritual care to trainees, workshop participants
highlighted the need for trainers to be willing to
discuss issues such as limits and boundaries,
sharing feelings and emotions with patients, and
how to remain engaged with the patient during
their illness, anguish, or imminent death.
In summary, among trainers there is a spec-
trum of opinion as to what constitutes spiritual
care and occasionally some disagreement about
whether it is properly the task of GPs. Trainers
may lack the necessary vocabulary to discuss
spiritual care comfortably and this could poten-
tially hinder a spiritual care discussion between
trainer and trainee. There is wide variation in
the level of skill, confidence, and willingness to
develop a trainee’s competence in spiritual care.
Consequently, the quality of spiritual care train-
ing offered by trainers is likely to be variable.
IMPLICATIONS FOR GENERAL
PRACTICE EDUCATION
Trainers valued the opportunity to consider
spiritual care issues in a carefully facilitated dis-
cussion. Workshops following a similar format to
the one described can offer new perspectives
on teaching spiritual care and represent a valu-
able means of professional development for
trainers.
Among trainers the willingness and ability to
teach spiritual care is variable. There is a collec-
tive challenge for GP training programme direc-
tors to ensure that spiritual care is incorporated
Innovations and developments 133
into local training programmes. This workshop is
an effective and acceptable way to equip trainers
with the skills needed to encourage their trainees
to deliver meaningful spiritual care. With due
regard to the points made in this paper, this work-
shop could be replicated and adapted to suit the
specific needs of trainer groups throughout the
United Kingdom.
Spiritual care descriptors could be included in
the assessment grids that support the MRCGP
Workplace Based Assessments. The 12 themes
listed in this paper represent the essence of spiri-
tual care and could form the basis of such
descriptors. Their inclusion in the grids would
ensure that trainers and trainees recognise the
value and importance of the specific skills
required to deliver spiritual care.
References
1 World Health Organisation (1948) Constitution of the
World Health Organisation. WHO: Geneva.
2 Sheldon MG (1989) The Christian approach to whole–
person medicine. Journal of the Royal College of Gen-
eral Practitioners 39:166.
3 Murray SA, Kendall M, Boyd K, Worth A and Benton TF
(2003) General practitioners and their possible role in
providing spiritual care: a qualitative study. British Jour-
nal of General Practice 53:957-59.
4 Chaput de Saintonge D (2009) Whole Person Medicine.
PRIME: East Sussex.
5 Puchalski CM and Romer AL (2000) Taking a spiritual
history allows clinicians to understand patients more
fully. Journal of Palliative Medicine 3:129-37.
Correspondence to: Dr John Nicol, Maryhill Practice,
Elgin Health Centre, Elgin, IV30 1AT, UK. Tel:
+44(0)8453370610. Email: john.nicol@nhs.net
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