spiritual care providers in long-term care facilities
DESCRIPTION
The past decade has seen the development of services of spiritual care in Israel's health and welfare systems. In 2006, at the initiative and with the support of the Jewish Federation of New York, a process was initiated to develop a model of spiritual care and a training program for spiritual care providers (SCPs). Until then, there virtually was no such service in Israel. In 2010, JDC-ESHEL (the Association for the Planning and Development of Services for the Aged), the Byspirit spiritual-support NGO, and the NY Federation launched an experimental program to introduce SCPs into long-term care facilities (LTCs). In the first stage, a course was held for key LTC personnel to acquaint them with the topic. In the second, SCPs were placed at six LTCs for some 15 hours weekly. This report presents the findings of the Myers-JDC-Brookdale Institute's evalaution to examine the development and implementation of the program and the integration of SCPs into LTCs as well as its impact on the residents and staff, and to identify challenges and conditions for expanding spiritual care to other services for the elderly. Citation: Resnizky, S., and Bentur, N. 2014. An Experimental Program Placing Spiritual Care Providers in Long-Term Care Facilities in Israel: Evaluation Study. Jerusalem: Myers-JDC-Brookdale Institute. For more information on this report or other studies from the Myers-JDC-Brookdale Institute, email us at [email protected], and visit us at brookdale.jdc.org.il and www.facebook.com/MJBInstitute.TRANSCRIPT
C E N T E R F O R R E S E A R C H O N A G I N G
An Experimental Program
Placing Spiritual Care Providers
in Long-Term Care Facilities in Israel:
Evaluation Study
Shirli Resnizky Netta Bentur
The study was initiated and funded by Eshel
RR-655-14
An Experimental Program
Placing Spiritual Care Providers
in Long-Term Care Facilities in Israel:
Evaluation Study
Shirli Resnizky Netta Bentur
The study was initiated and funded by Eshel
July 2014 Jerusalem
Hebrew editor: Anat Berberian
English translation: Evelyn Abel
Production and print layout: Leslie Klineman
Myers-JDC-Brookdale Institute
P.O.B. 3886
Jerusalem 91037, Israel
Tel: (02) 655-7400
Fax: (02) 561-2391
Website: www.jdc.org.il/brookdale
Related Myers-JDC-Brookdale Institute Publications
Bentur, N.; Resnizky, S. Spiritual Care in Israel. Evaluation of the Program Funded by the
Jewish Federation of New York. RR-530-09.
Bentur, N.; Chekhmir, S. 2007. Nationwide Palliative Training in Israel: Evaluation Study.
RR-498-07.
Bentur, N.; Resnizky, S., Shnoor, Y. 2005. Palliative and Hospice Services in Israel.
RR-459-05.
To order these publications, please contact the Myers-JDC-Brookdale Institute, P.O.B. 3886,
Jerusalem, 91037; Tel: (02) 655-7400; Fax: (02) 561-2391; E-mail: [email protected]
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Executive Summary
Background and Goals of the Study
Spiritual care services have developed substantially in Israel's health and social systems in the
past decade. A pioneering process to develop training programs for spiritual care providers
(SCPs) was initiated and supported by the Jewish Federation of New York in 2006. Israel had
virtually had no such service before that.
In 2010, JDC-ESHEL (the Association for the Planning and Development of Services for the
Aged), Byspirit - Shaarei Zedek Hospital spiritual support program and the NY Federation
launched an experimental program to introduce SCPs in long-term care (LTC) facilities. The
program had two stages. In the first, a course was held for key personnel from LTC facilities to
acquaint them with the topic. In the second, the experimental program was funded and
implemented with the placement of SCPs at six LTC facilities. All LTC facilities in Israel were
invited to apply to participate in the program, stipulating their reasons. Of those expressing
interest, six were chosen based on their commitment to spiritual care, and a member of staff
member was designated to act as liaison and support the SPCs in their work. The selected
facilities were diverse in terms of size, geographic location and type of ownership. In each
facility, the director or liaison recruited the SCPs after interviewing 2-4 candidates. The SCPs
worked with residents, their families and staff for some 15 hours a week. The program was
accompanied by an evaluation study to monitor its development, functioning and implementation
in the first year, the integration of the SCPs and their contribution to the elderly, their families
and the staff. The study also attempted to identify the challenges of the process and the possibility
of expanding and promoting the program in other LTC facilities.
To obtain a comprehensive picture of the SCPs’ integration and contribution, data were collected
from them, from the directors of the LTC facilities, the liaisons within the facilities, the residents
and family members. At the start and end of the year, face-to-face and telephone interviews were
held with all six directors and with the liaisons. The SCPs were interviewed a number of times
and kept an online log of their activities. In addition, about 20 residents were interviewed.
Findings
Characteristics of the Facilities Participating in the Program and of the SPCs
Five of the SPCs are women, aged 40-55, and secular; the man of the group is a Reform Jew.
All had prior experience of spiritual care though only one had worked with older adults in
long-term care or suffering from dementia.
They all noted that the training they had been given before starting to work at the LTC
facilities had lent them tools to cope with and support patients approaching the end of their
lives. They said, however, that they lacked training to cope with older people in long-term
care or suffering from dementia.
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As a result, and due to the difficulty of coping as the only professional in a facility, a decision
was made to offer the SPCs monthly meetings.
The Activities of SCPs with Residents
Most (80%) of the individual meetings held by SPCs at the LTC facilities were with residents,
11% were with family members and 9%, with both the resident and the family.
There were generally several reasons for referring a resident to an SPC. The main ones were:
- Change from independence to dependence: Residents moving from the community to a
facility or within a facility, from the ward of independent adults to the long-term nursing
care ward; deterioration such as loss of hearing or sight
- Change in a resident’s emotional, mental and spiritual condition: restlessness and
disquiet, repeated appeals to facility staff (pestering), sense of loneliness or a need for
attention
- To cope with a life-threatening illness or end-of-life situation
- Requests from family members due to feelings of guilt and the difficulty of accepting the
resident’s institutionalization
Two-thirds of the residents receiving spiritual care were women of an average age of 78.8 in
an age range of 40 to 100. About a third (33%) were independent in walking, the rest had
mobility difficulties. About two-thirds (62%) required considerable assistance or were totally
dependent on another person for the performance of daily activities. Cognitively, half of the
residents had no problems, about a third suffered from slight deterioration, and the rest (about
a fifth) were disoriented in time and space. About half (42%) had been in an open facility for
less than half a year; about a third had been there for more than three years.
The characteristics of the meetings were gleaned from the online log developed for purposes
of the study. The SCPs documented their activities at the LTC facilities over a two-month
period during which time there were 67 personal meetings with residents and with four family
members.
About a third of the meetings took a holistic approach, addressing the residents' families,
memories and hobbies; a third revolved around the difficulty of aging and nearing death, for
example, or physical deterioration, loneliness, moving from the community to a facility or to a
different ward in the facility. In about a tenth of the meetings the SPC simply spent time with
the resident ("being"). In another tenth, there was discussion of existential questions and a
resident’s attitude to life. About half dealt with more than one topic, for instance, with
memory and attitude to life.
The meetings with families discussed the difficulty of seeing the resident’s deterioration and
the feelings of guilt sometimes accompanying care.
With regard to the SCP's tools and methods, 80% of the meetings included conversations
about a variety of topics; in 29%, there was physical contact such holding hands, a caress or
healing touch; in some 20%, a text was read and discussed; and in about a tenth of the
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meetings or less, there was singing, listening to music, prayer or composing a personal prayer,
meditation or working with guided imagery. In about a fifth of the meetings, there were other
activities such as excursions, the use of cards, pictures and additional tools. Significant
differences were found in the extent to which SCPs employed the various tools.
Apart from the work with individuals, one SCP held three discussion groups a week with
independent and frail residents; two other SCPs held groups that met several times to focus on
a single topic, for example, photography on the theme of the changing body or a group for
family members on life stories.
The Integration of the SCP in the LTC Facility
The liaisons chosen from the LTC staff were an integral part of the program, mediating
between SCPs and other staff members. The liaisons presented the facility to the SCPs,
introduced them to the staff, and opened doors for them. At times, they also represented and
took pains to promote the field before directors and senior staff. In some facilities, the liaisons
were responsible for referral and accepting new residents, as well as, to some extent, setting
the SCPs’ daily schedule and coordinating meetings with residents and family members. For
the SCPs, the liaisons were also a resource to consult, a quasi-shoulder to lean on, and a
source of sharing and comradeship. The extent of involvement of the liaisons in the ongoing
work of the SCPs, however, differed from one facility to another.
Over time, the integration of the SCPs in the facilities increased, they became more
independent, and developed direct contact with the staff. Gradually, the liaisons dealt less
with mediation and more with referral and consultation to the SCPs. The relations between
them became mutually beneficial.
In some of the facilities, building a relationship between the SCPs and the rest of the staff
proved to be a lengthy challenge. For example, in two institutions, the SCPs met with
opposition at the start of their work and lack of cooperation. Cooperation developed
gradually.
An examination of their activity repertoires shows that the SCPs worked with three
population groups – residents, family members and staff – in individual and group meetings.
They devoted about three-quarters of their time to individual care; a tenth – to group work
with residents and family; and a tenth – to individual and group work with staff. The working
patterns nevertheless varied greatly between SCPs.
The integration of SCPs as staff members in LTC facilities raised basic questions about their
commitment and loyalty: should they be committed to the facility? To the residents and
family? This issue came to the fore in several areas. For instance, to what extent were the
discussions between the SCP and residents to be reported and open to everyone? Should the
SCPs be a locus for complaints and requests? Some of these questions remained unanswered
in the course of the year, some were resolved.
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Over time, the working patterns of the SCPs were modified. This was reflected in structuring
and consolidation, in the patterns and features of resident referral, and in stronger relations
and greater trust with staff members beyond the liaison.
The Contribution of the Program
The directors, liaisons and staff interviewed at the six LTC facilities judged the integration of
the SCPs to be a great success and a real contribution to the residents. Staff members
commended the SCPs both personally and with regard to the new profession. The main areas
of contribution reported by the directors were: treating the residents as individuals, with their
own history and memories, accompanying them on their final journey, accompanying the
family at the end of life, raising the subject of death to the consciousness of the staff,
soothing residents who had repeated complaints and appeals, giving attention to quiet
residents.
One of the most significant contributions of the program was to create the very need for
SPCs; to create a situation in which the staff feel that SPCs are necessary. This was the
salient change following the program. Many of the directors and staff members noted “they
are indispensable.” They are anxious about the experimental program ending and their
inability to continue employing SCPs.
Insights and Recommendations
The study findings furnish several insights. The first relates to the importance of having many
parties and components building the program together, which contributed to its success.
Funding Sources: The employment of SCPs was made possible by the funding of the Jewish
Federation of New York. The LTC institutions could not be expected to finance the
employment of an SCP without external funding.
Recognition by a respected body that initiates, organizes, implements, and supports the
project: ESHEL, a leading reputable organization developing services for the aged, initiated
and implemented the project. The fact that ESHEL deemed the project important and
invested in it impacted on the willingness of directors to participate.
Early exposure of the staff: In all the LTC facilities, some staff members were familiar with
the program prior to the placement of the SCPs.
Showing initiative and being proactive: LTC facilities willing to participate in the program
had to apply on their own initiative to ESHEL’s call, substantiate their interest in an SCP, and
state how they would help the SCP integrate.
Recruitment of the SCPs: The LTC facilities had to locate and select an SCP on their own.
Allocating a liaison: Each facility was asked to appoint a liaison for the SCP, introduce
her/him to the facility, the working patterns and procedures; to act as a resource of assistance
and support, and to promote the integration of the SCP in the LTC facility. The presence of a
liaison was found to be a vital component in the introduction of an unknown profession into
the facility.
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The variety of components contributing to the integration of the SCPs in LTC facilities and to the
success of the program yielded the second insight; namely, that to develop and implement a
program of this type, both external and internal catalysts are required. The funding from the
Jewish Federation of New York and the initiative of ESHEL and Byspirit, as well as holding
meetings of colleagues – are external components stemming from, and performed by, external
parties not directly connected to the LTC facilities. ESHEL was involved in constructing and
developing the program for an entire year, as is true of its other experimental programs, the
ongoing involvement including examination and an evaluation of progress and development.
They were assisted by the professional guidance of Byspirit's directors and teachers, who were
extremely experienced in developing the discipline. The three other components are internal,
connected directly with initiative, being proactive, and the responsibility of each of the facilities.
The third insight is that the process of introducing a new profession, such as spiritual care, into
LTC facilities is gradual and requires mutual learning, receptiveness, and a willingness for
change. The obstacles encountered by some SCPs in their contact with staff members may shed
light on one component that was missing from the model and is deserving of attention: a need for
greater exposure of LTC staff members to the SCPs prior to, close to, and during the year of their
placement.
The fourth insight relates to consolidating the SCP position in LTC facilities and cultivating a
positive attitude towards the practice. Thus, for instance, in facility inspections by the Ministry of
Health (MoH), a few of the directors cited the project with pride. Nonetheless, despite the great
change of involving SCPs in LTC facilities that occurred in the first year of implementation, the
process of complete, successful integration appears to be long and continuous. Integration
differed from one facility to another in terms of length of time, characteristics of the process,
satisfaction, and the confidence developed by SCPs and staff.
The fifth insight relates to the importance of continued funding of the program and for purposes
of expansion. All the directors and liaisons noted that without ESHEL’s initial funding, they
would not have undertaken the project. Nor was there readiness to assume the financing of SCPs
at the time of the mid-year interviews although some facilities were prepared to participate in
funding; indeed, this was the case in advent of the second year of the project. Clearly, it is
necessary to intensify the search for financial resources to employ SCPs. A few directors
suggested applying to the MoH to make the position binding and ensure financing.
The final insight concerns the training of SCPs. Though all were skilled, experienced
professionals, they had little prior knowledge or training in the area of aging or the spiritual care
of the elderly. It would be appropriate to expose them to these topics, to the functional and
cognitive limitations of the elderly, before they are placed in LTC facilities. Furthermore, there is
a need for more documentation and the development and compilation of tools to work with the
elderly in long-term nursing care, such as, for example, the use of texts, poetry and physical
contact. It is also important to develop and equip the SCPs with non-verbal tools for work with
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people suffering from dementia or other communication problems as a result of stroke, for
instance.
In conclusion, the study findings show that the project was very successful and should be
expanded. Moreover, the aspiration is to do so. At the same time, the findings shed light too on
unresolved issues. These require further consideration in the continuing process of developing the
profession of spiritual care in long-term care facilities and nursing homes.
The findings were extensively presented to the management of ESHEL and Ashalim, and to LTC
directors and senior staff of the Ministry of Social Affairs and Services, which helped to identify the
necessary activities for broader incorporation of the new profession into the social services. On the
basis of the findings, the program was expanded to additional LTC facilities. Moreover, new
experimental programs of spiritual care have been implemented at daycare centers for the elderly and
in Ashalim services for at-risk children and youth.
The study was commissioned and funded by ESHEL.
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Acknowledgments
We would like to thank everyone who generously helped us conduct the study and write this
report. We are profoundly grateful to the six SCPs at the LTC facilities for giving of their time to
the data collection process, sharing their knowledge and helping us greatly to understand the
research topics in depth. Our gratitude goes to the liaisons and directors of the institutions for
opening their doors to us and devoting precious time to deepen our understanding of the process
of integrating the SCPs.
We especially thank the Jewish Federation of New York for its ongoing support of spiritual care
services, of the program and of the study. We thank Chani Kroizer, director of Byspirit, as well as
Yehudit Glick Tuvia Mendelssohn of ESHEL for their involvement and commitment to the
experimental program and the study, and their fruitful cooperation.
Finally, we would like to express our appreciation of our colleagues at the Myers-JDC-Brookdale
Institute for their valuable comments during the study and the composition of the report; we owe
warm thanks to Jenny Rosenfeld, head of the Editing Department for her support and assistance
in producing the report, Anat Berberian for editing it, and Leslie Klineman for layout and
production.
Table of Contents
1. Background and Study Goals 1
2. Study Design 2
3. Findings 2
3.1 Placement of the SCPs in Long-Term Care Facilities 2
3.2 Residents Receiving Spiritual Care 4
3.3 Activities of the SCPs with the Residents 6
3.4 Relations between SCPs and Facility Liaisons 11
3.5 Relations between SCPs and Facility Staff 13
4. The Contribution of the Program 16
5. Insights and Recommendations 18
List of Tables
Table 1: The LTC Institutions Participating in the Program 3
Table 2: Characteristics of the Meetings between the SCP and the Residents 8
Table 3: Distribution of SCP Activities in the LTC Institutions 14
List of Figures
Figure 1: Demographic Characteristics of the Residents Receiving Spiritual Care 5
Figure 2: Functional Characteristics of the Residents Receiving Spiritual Care 5
Figure 3: Residents Receiving Spiritual Care, by Ward and Length of Residence 6
Figure 4: Reasons for Referring Residents to the SCP 7
Figure 5: Reasons for Terminating the Meeting 11