spiritual care providers in long-term care facilities

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C ENTER FOR R ESEARCH ON A GING 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

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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.

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Page 1: Spiritual Care Providers in Long-term Care Facilities

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

Page 2: Spiritual Care Providers in Long-term Care Facilities

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

Page 3: Spiritual Care Providers in Long-term Care Facilities

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

Page 4: Spiritual Care Providers in Long-term Care Facilities

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]

Page 5: Spiritual Care Providers in Long-term Care Facilities

i

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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ii

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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iii

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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iv

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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v

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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vi

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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vii

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.

Page 12: Spiritual Care Providers in Long-term Care Facilities

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