Spiritual Care in a Hospital Setting (Empirical Studies in Theology)

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Spiritual Care in a Hospital Setting

Empirical Studies in Theology Editor

Johannes A. van der Ven

VOLUME 13

Spiritual Care in a Hospital Setting An Empirical-theological Exploration

by

Wim Smeets translated by

M. Manley

BRILL LEIDEN • BOSTON 2006

This book is printed on acid-free paper. Library of Congress Cataloging-in-Publication Data Smeets, Wim. [Kwaliteit van de geestelijke verzorging in zorginstellingen. English] Spiritual care in a hospital setting : an empirical-theological exploration / by Wim Smeets ; translated by M. Manley. p. cm. — (Empirical studies in theology, ISSN 1389-1189 ; v. 13) Includes bibliographical references (p. ) and index. ISBN-13: 978-90-04-15189-5 ISBN-10: 90-04-15189-3 (alk. paper) 1. Chaplains, Hospital. 2. Spiritual care (Medical care) 3. Chaplains, Hospital— Netherlands. 4. Spiritual care (Medical care)—Netherlands. I. Title. BV4335.S6413 2006 259'.411—dc22 2006047517

ISSN 1389-1189 ISBN 13: 978 90 04 15189 5 ISBN 10: 90 04 15189 3 © Copyright 2006 by Koninklijke Brill NV, Leiden, The Netherlands. Koninklijke Brill NV incorporates the imprints Brill Academic Publishers, Martinus Nijhoﬀ Publishers and VSP. All rights reserved. No part of this publication may be reproduced, translated, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without prior written permission from the publisher. Authorization to photocopy items for internal or personal use is granted by Brill provided that the appropriate fees are paid directly to The Copyright Clearance Center, 222 Rosewood Drive, Suite 910, Danvers, MA 01923, USA. Fees are subject to change. printed in the netherlands

CONTENTS Acknowledgments ...................................................................... Foreword .................................................................................... List of Abbreviations ..................................................................

xi xiii xv

1 Spiritual Care in a Hospital Setting: A Problem ............ 1.1 Conceptual Framework: Health Care, Worldview and Spiritual Care .................................................................... 1.1.1 Health care ...................................................... 1.1.2 Worldview ........................................................ 1.1.3 Spiritual care .................................................. 1.2 Research Orientation: Questions and Aim .......................... 1.2.1 Research questions .......................................... 1.2.2 Research aim .................................................. 1.3 Research Method .............................................................. 1.3.1 Data collection ................................................ 1.3.2 Data analysis .................................................... 1.4 Research Population ........................................................ 1.5 Résumé ..........................................................................

1 2 2 4 6 8 9 13 14 14 15 17 18

2 Aspects of Quality Assurance in Health Care .................. 2.1 Aspects of Quality Assurance at Meso Level ...................... 2.1.1 Aspects of internal quality assurance: bureaucratisation .............................................. 2.1.2 Aspects of external quality assurance: professionalisation ............................................ 2.1.3 Aspects of quality assurance at meso level: research ﬁndings .............................................. 2.2 Aspects of Quality Assurance at Micro Level .................... 2.2.1 Self-determination ............................................ 2.2.2 Aspects of quality assurance at micro level: research ﬁndings .............................................. 2.3 Résumé ..........................................................................

20 23

3

51 51

Worldview in Health Care .................................................. 3.1 The Medical and the Worldview Approach ......................

25 29 32 35 36 47 49

contents

vi

4

3.1.1 Medicalisation and contingency as its limit ... 3.1.2 Medicalisation and the limits of contingency: research ﬁndings .............................................. 3.2 Dimensions of the Function of Worldviews in Health Care ............................................................................ 3.2.1 Intrinsic and extrinsic function of worldviews ........................................................ 3.2.2 Intrinsic and extrinsic function of worldviews: research ﬁndings .............................................. 3.3 Résumé ..........................................................................

51

The Spiritual Caregivers Worldview .................................. 4.1 Narrative Identity ............................................................ 4.1.1 Some aspects of narrative identity ................ 4.1.2 Narrative identity: research ﬁndings .............. 4.2 Worldview-related Dimension of Identity ............................ 4.2.1 Worldview-related dimension of identity ...... 4.2.2 Worldview-related dimension of identity: research ﬁndings .............................................. 4.3 Résumé ..........................................................................

69 69 70 77 80 80

5 Legitimacy and Position of Spiritual Care in Health Care .......................................................................... 5.1 Legitimacy and Position of Spiritual Care as a Professional Discipline in Health Care ................................................ 5.1.1 Legitimacy and position of spiritual care as a professional discipline .................................. 5.1.2 Legitimacy and position of spiritual care as a professional discipline: research ﬁndings .... 5.2 Ministry and Sanctuary of Spiritual Care .......................... 5.2.1 Ministry and sanctuary in a theoretical perspective ........................................................ 5.2.2 Ministry and sanctuary: research ﬁndings .... 5.3 Résumé .......................................................................... 6

Goals and 6.1 Goals 6.1.1 6.1.2

Tasks of Spiritual Care .................................... .............................................................................. Immediate goals and ultimate goal .............. Goal orientations ............................................

58 60 61 64 66

105 116

120 120 120 124 127 128 136 141 145 145 145 152

contents 6.1.3 Goals and goal orientations: research ﬁndings ............................................................ 6.2 Tasks ............................................................................ 6.2.1 Tasks from a theoretical perspective ............ 6.2.2 Tasks: research ﬁndings .................................. 6.3 Résumé .......................................................................... 7

8

Determinants of Spiritual Care .......................................... 7.1 Determinants of Micro Level Goals: Expectations and Outcome .......................................................................... 7.1.1 Expected determinants of micro level goals .................................................................. 7.1.2 Determinants of micro level goals: research ﬁndings ............................................................ 7.2 A Profession at Risk ........................................................ 7.2.1 Principal determinants of micro level goals .................................................................. 7.2.2 Professional discipline, personal worldview and health care ..............................................

vii

155 162 163 174 182 186 187 187 194 202 202 207

Synopsis and Recommendations ........................................ 8.1 Synopsis .......................................................................... 8.2 Policy Considerations and Recommendations ......................

211 211 222

Appendix 1 Research Population ..........................................

229

Appendix 2 Measuring Instruments ......................................

232

Appendix 3 Tables ..................................................................

245

Literature ....................................................................................

263

Index ..........................................................................................

287

The core of worldview-related communication in spiritual care: “Two people intent on each other, they speak, they are silent, there is warm closeness but also respectful distance. They are sitting on a small platform, a supporting ground, that links them to each other and to the whole.” (R. van de Sande at W. Rooijakkers’s farewell)

Attentiveness (Corry Ammerlaan)

“When Damien returned to Kalawao (Molokai) it was night. He lit a lantern, for he still had to inspect the wards. Most of the children were asleep, but here and there one was still awake and he sat down by their bedsides, listened to their fears, told them a little story. In his pocket he had a few apples, and these he gave to the scared children, then drew a cross on their foreheads. He was proud of his hands, for the parts with which he held the host, the ﬁrst joints of thumb and index ﬁnger, were unmarked by leprosy.” Eynikel, Hilde (1997). Damiaan. De deﬁnitieve biograﬁe, 330 (our translation). Biography of Damien, priest, but also nurse, surgeon, undertaker, teacher, architect, carpenter, organiser, author and . . . leper.

ACKNOWLEDGMENTS I am grateful to the Vereniging van Geestelijk Verzorgers in Zorginstellingen (VGVZ) for sponsoring this research. Translation and publication of this thesis was ﬁnancially supported by the Sormani Fonds.

FOREWORD This book reports on a theoretical and empirical study of spiritual care as a profession in health care, particularly from the angle of quality care. Besides providing insight into this professional discipline, the study was fruitful from the point of view of my own work in spiritual care and supervision. Many people have contributed to the accomplishment of the study. First of all I want to thank my ﬁrst supervisor, Dr Hans van der Ven, who taught me how to do empirical theological research and reﬂect scientiﬁcally. Via him I also thank the Faculty of Theology of the Radboud University Nijmegen for my academic training and for research facilities. I am also grateful to my second supervisor, Dr Frank Gribnau, who taught me to integrate spiritual care with the policy and quality of health care, with special reference to the tension between institutional identity and worldview-related pluralism. Via him I thank the Medical Centre of the Radboud University Nijmegen for the use of its facilities. I am grateful to Berdine Biemansvan Breugel for statistical advice and to Dr Hans Schilderman for theoretical advice. In addition I want to thank the members of the advisory committee of the Dutch Association of Spiritual Caregivers in Care Institutions (VGVZ ). Finally I have pleasant recollections of discussions with Fons Flierman and Martine Bakema. I dedicate this book to: Nicolette, who has become ever more of a helpmeet and alter ego (Gen. 2:18), and our daughter Elsemarijn, who has disarmingly taught me to pause and enjoy. My father and mother, who taught me the value of life, faith, justice and commitment to ‘the man in the street’.

LIST OF ABBREVIATIONS Wet BIG Wet Beroepen in de Individuele Gezondheidszorg BNP Bond van Nederlandse Predikanten CAO Collectieve Arbeids Overeenkomst HBO HOI INK KNMG

NIAZ

NIVEL

NIZW NZf NZR PACE SPSS UvH VGVO VGVZ

Professions in Individual Health Care Act Union of Dutch Clergy Collective Labour Agreement Hoger Beroeps Onderwijs College Education Humanistisch Opleidings Instituut Humanistic Training Institute Instituut Nederlandse Kwaliteit The Netherlands Institute for Quality Control Koninklijke Nederlandse Royal Dutch Medical Maatschappij tot bevordering der Association Geneeskunde Nederlands Instituut voor The Netherlands Institute Accreditatie van Ziekenhuizen for Accreditation of Hospitals Nederlands Instituut voor The Netherlands Institute onderzoek van de gezondheidszorg for Health Services Research Nederlands Instituut voor Zorg en The Netherlands Institute Welzijn for Care and Welfare Nederlandse Zorgfederatie Dutch Care Federation Nationale Ziekenhuis Raad National Hospital Council Proefproject Accreditatie Pilot Project Accreditation Statistical Package for the Social Sciences Universiteit voor Humanistiek University for Humanistic Studies Vereniging van Geestelijk Association of Spiritual Verzorgers in de Ouderenzorg Caregivers to the Aged Vereniging van Geestelijk Association of Spiritual Verzorgers in Zorginstellingen Caregivers in Care Institutions

xvi VGW VPW WO

list of abbreviations Vereniging voor Geestelijk Werkers Albert Camus Vereniging van Pastoraal Werkenden Wetenschappelijk Onderwijs

Albert Camus Association of Spiritual Workers Association of Pastoral Workers University Education

1 SPIRITUAL CARE IN A HOSPITAL SETTING: A PROBLEM From the outset most Dutch care institutions had a minister or rector attached to them: most hospitals, psychiatric centres, rehabilitation centres and old age homes were either Protestant or Catholic. Later they were augmented with humanistic councillors, usually in ‘neutral’ institutions. In the early 20th century the term ‘spiritual caregiver’ surfaced for the ﬁrst time.1 Since then a great deal has changed. Formerly ministers, rectors and councillors focused mainly on guidance to staﬀ and sometimes even sat on the board of directors. Nowadays they are no longer at the hub of the institution and serve chieﬂy as caregivers to patients.2 New developments in health care followed in rapid succession, driven mainly by medical science and technology and all sorts of regulations within the sector and on the part of government. Dutch society, too, changed. As a result of secularisation and individualisation membership of a worldview association can no longer be taken for granted. Spiritual caregivers face the challenge of locating their profession in relation to these developments. This reorientation is essential to give the profession a contemporary proﬁle in modern health care. The present study investigates spiritual caregivers’ views on certain relevant developments in this ﬁeld. In this introductory chapter we ﬁrst look at some key concepts (1.1). Next we describe the research orientation (1.2), followed by the research method (1.3). Then we sketch the research population, being spiritual caregivers in Dutch care institutions (1.4). We conclude with an outline of the contents of the rest of the book and a résumé (1.5). 1 In the early 20th century the term spiritual caregiver was “the title—albeit not oﬃcial yet gradually gaining currency—for ministers of the gospel attached to any of the establishments of the Association for Christian Care of the Insane and Mentally Ill” (Van der Hoogt, 1908, p. 7; our translation). Nowadays the term is much broader; it is the title for professionals dealing with worldview-related communication as a contribution tot physical, mental and social well-being. We thank dr. R. Hunter (Emory University, Atlanta) for his advice on the term ‘spiritual care’. 2 In this book we use the term ‘patient’ to indicate everyone admitted to care institutions: hospital patients, psychiatric centre patients, inmates of nursing homes and homes of the aged, handicapped persons in institutions catering for them, as well as people in rehabilitation centres.

chapter one

2 1.1

Conceptual Framework: Health Care, Worldview and Spiritual Care

The conceptual framework of the book hinges on three key concepts: health care (1.1.1), worldview (1.1.2) and spiritual care (1.1.3). 1.1.1

Health care

Health care is society’s provision in the area of caring for people’s health. It is “the science and art of preventing disease, prolonging life and promoting health through the organized eﬀorts of society” (Maas & Mackenback, 2004, 12). Within this broad deﬁnition health care is organised at three levels. At macro level there is the relation between those requiring care, those oﬀering it and those who insure its quality, as well as its direction by government (Post & Vermey, 1998, 20–21). The meso level comprises care institutions, that is organisational entities whose purpose is to provide care (cf. Quality Institutions Act). The micro level concerns the process of relations between patients and caregivers. A major development characterising present-day health care is the quality of care approach.3 Quality of care may be deﬁned as the totality of activities aimed at systematically achieving, promoting and maintaining quality service (Van Rooijen, Steman & Zomerplaag, 1994, 12). It entails streamlining all activities in an organisation that are aimed at optimising service (Demeulemeester & Callewier, 1997, 42–43). Quality of care is interpreted in a broad and a narrow sense. In the broad sense it refers to the system of agreements between care insurers and care providers. At this level quality means mean-

3 Quality of care is a prominent but not the only development in recent health care. We can mention two other trends crucial for spiritual care, both aimed at quality of care: extra-institutional activities and evidence-based medicine. In addition to intramural health care the emphasis is increasingly shifting to outpatient clinical care, primary health care and home care. This development is referred to as extra-institutional and chain care. So far spiritual care has focused mainly on intramural spiritual care, but recently there have been projects to broaden it (Arends, 2003; Smeets, 2001). In addition health care is increasingly moving in the direction of evidence-based practices so as to utilise the achievements of medical science and technology for the beneﬁt of individual patients (Oﬀringa, 2003). For spiritual caregivers this could present a challenge to conduct research, as other disciplines are doing, with a view to professionalising their occupation by way of evidencebased practices and to benchmarking of practices in diﬀerent health care centra.

spiritual care in a hospital setting: a problem

3

ingful, eﬀective and substantively responsible application of available means by care providers (institutions, caregivers) (Boot & Knapen, 1996, 320). In the system of agreements this is characterised by devising adequate care at a reasonable price. In the narrow sense quality of care refers to the relation between care providers and patients. Here the aim is to set quality criteria (determine the minimal input by care providers to produce the desired eﬀect on patients’ health), quality promotion (the process of bringing the care provided to the desired level) and quality assurance (measurement and evaluation of the eﬀects of the care provision).4 We focus on quality of care in this narrow sense, more particularly on quality assurance. Our study focuses on assuring the quality of care with a view to its current signiﬁcance, its action orientation and its speciﬁcity. In regard to current signiﬁcance: since the 1990s assuring the quality of health care services has been a key topic in the context of modernising the care system. As mentioned already, the aim is to measure and evaluate service. The action orientation derives from the Aristotelian concept of phronesis (Harteloh, 2000, 9–10). To Aristotle the term denoted combining a theoretical and a technical orientation, wisdom (insight into what one seeks to achieve) and ‘cleverness’ (knowing how to achieve one’s goal) (Ricoeur, 1991, 196–197). This phronesis or practical rationality is accomplished through conscientious deliberation on desirable action, in which both psychological and ethical considerations play a role (Arash Abizadeh, 2002, 267, 279; Smith, 2003, 87–89). Applied to care, practical rationality implies ongoing, systematic training of caregivers and their critical self-reﬂection by way of evaluating their professional conduct in interaction with a rationally directed organisation. Quality assurance entails doing the right things for clearly understood reasons and doing them well (Harteloh, 2000, 12–17). Speciﬁcity is deﬁned inter alia in the Quality Institutions Act. The act refers to ‘proper’ care, combining elements of eﬃciency, eﬃcacy and patient-orientation. Quality of care entails setting criteria, promoting and assuring professional

4 The fundamental indeﬁnability of the term ‘quality’ is subject to critical review. Often the term is deﬁned tautologically (‘quality of care is that which contributes to quality’). Some authors maintain that quality means ‘constantly reﬂecting on quality’ (Van Tongeren & Bal, 1998, 314). In that case quality assurance would mean assuring constant reﬂection on quality of care.

4

chapter one

conduct, partly on the basis of operational quality assurance systems and internal and external accountability. The ultimate objective is optimimum patient care (Grol et al., 2000, 32, 39; Casparie & Hommes, 1997, 11–12, 109). In this book, then, the research object is not quality of care in its entirety, and certainly not health care in its entirety. Firstly, the macro level of health care and quality of care in the broad sense are not under consideration. When it comes to care institutions we conﬁne ourselves to intramural health care: current legislation, via the Quality Institutions Act, associates spiritual care with residential admission of patients. Within this context we focus mainly on quality of care in the narrow sense at meso and micro level. Finally, we study health care not as a phenomenon in itself but merely as the institutional context of spiritual care. And under quality of care in the narrow sense we concentrate mainly on quality assurance (see chapter 2). 1.1.2

Worldview

As for the substance of spiritual care, because of the social process of secularisation we prefer to use a concept at a higher level of abstraction than, for example, religion or faith. We opt for the term ‘worldview’. This term covers a broader ﬁeld than that of religions, whose content presupposes a viewpoint on the existence of an ultimate reality. In addition we treat worldviews as a cultural phenomenon. In this regard we follow Geertz’s approach. He deﬁnes worldview as “a system of symbols, which acts to establish powerful, pervasive and longlasting moods and motivations in men [sic] by formulating conceptions of a general order of existence and clothing these conceptions with such an aura of factuality that the moods and motivations seem uniquely realistic” (Geertz 1973, 90). The choice of the term ‘worldview’ raises critical questions (cfr. Hekking, 2003, 48). The ﬁrst concerns the extent to which people have a worldview. Some call themselves agnostics or atheists and reject any reference to existing religious or nonreligious worldviews. Our response to this is that worldview is not an ‘all or nothing’ concept. A worldview can be explicit or implicit. It can be more or less systematised and more or less considered. Even if people’s fundamental notions about life do not manifest a systematic, well thought-

spiritual care in a hospital setting: a problem

5

out pattern and are not always explicitly spelled out, one can still speak of a worldview. A second question is what role worldviews fulﬁl for patients in health care. Does the emotional experience of their situation not feature more prominently for them? Our response to this is that in and underlying that emotionality there are implicit symbolic references, such as the meaning or meaninglessness of life, the bearability or unbearability of suﬀering, the guilt and tragedy of life and suﬀering. People’s emotional experience is tied up with their lifestories and stories from their cultural context; in that sense emotions have a cognitive basis (Stearns, 1995, 41–44). We have said that when it comes to worldviews as the substance of spiritual care we settle for Geertz’s approach. His deﬁnition of a worldview comprises the following elements, to be dealt with more fully in chapter 4: a worldview is a pattern of meanings imbedded in symbols, both at a cultural level and at the level of individual attribution of meaning, and is expressed in a special way in rituals. A worldview is a totality of symbolic ideas expressing a universal order in life. These symbolic ideas combine a description of reality with a model for reality. They arouse moods or profound emotions and motivations to realise the model for reality in actions. Through the performance of rituals the beliefs, moods and motivations of participants acquire an aura of true reality. People direct and assess their attitude to life and their behaviour in accordance with their worldview; that worldviews imparts unity and coherence to their attitude and behaviour. Worldviews form a basis for knowledge of, and attitude towards, life and for communication with others (Geertz, 1973, 89). A worldview gives the person relative subjective security (cf. Brümmer, 1975). According to Geertz people are most strongly challenged to interpret life in terms of a worldview when life reaches its boundaries. Geertz discerns three boundary situations where worldviews come into play: the cognitive boundary of the person’s interpretive capacity, the emotional boundary of endurance in the face of suﬀering, and the moral boundary of judgment in the face of evil. Critics have accused Geertz of having a functionalist approach. They also maintain that he pays hardly any attention to the socially transformative character of worldviews (Frankenberry & Penner, 1999, 625–627, 640). The ﬁrst criticism can be countered as follows. Geertz’s approach to worldviews could be called functional. In his view people create a worldview because of the need to ﬁnd meaning, more especially in boundary situations. But he is not a functionalist in the

6

chapter one

sense of reducing the meaning of worldviews to their extrinsic function (cf. 3.2.1). Geertz always allows for the intrinsic function of worldviews for real-life social communities and individuals. A worldview, he maintains, must in the ﬁrst place be considered in itself; its psychological meaning is secondary. He argues that a worldview should be interpreted on the basis of a primary analysis of its symbolic system of meaning and only then, secondarily, be related to social and psychological processes (Geertz 1973, 122, 125; 1983, 5). In answer to the second criticism one could say that Geertz takes full account of the socially transformative character of worldviews. That is particularly evident in his recent work. There he arrives at the conclusion that there is no question nowadays of reducing worldviews to a private aﬀair but rather a growing role of worldviews at the level of society. While there are cultures in which the public role of worldviews is declining, there are more instances where their role is steadily expanding (Geertz, 2000, 170–173). 1.1.3

Spiritual care

In chapters 5 and 6 we deﬁne spiritual care as a profession that is practised in the area of overlap between two social spheres: health care and worldview. The profession focuses on communication on worldviews with a view to promoting health. This means that the profession has distinctive tasks in relation to patients, other caregivers and institutional management. These tasks are linked with competencies, that is the knowledge, insight, skills and attitudes required for professional practice. The term ‘spiritual care’ needs further clariﬁcation. We start with the ﬁrst component, ‘spiritual’. The concept of spirituality crops up in many meanings and contexts. We do not use it in either an ecclesiastic or a religious sense, but in that of worldviews as described with reference to Geertz. Hence in relation to both patients and spiritual caregivers we conceive of spirituality in the sense of a worldview. Quite a number of publications identify spirituality as the focus of spiritual care (Bouwer, 2004; Cornette, 1998; Smeets, 2002a, 234–240; Van den Berg, 2000; Van den Blink, 2002). Spiritual care is the health care profession that has worldviews as its special domain. In chapter 5 we shall look more closely at the implications this has for the legitimacy and position of the profession. Religious spirituality falls under the concept of spirituality in the broad sense. In a reli-

spiritual care in a hospital setting: a problem

7

gious sense spirituality is deﬁned as the ‘transformation’ of life, with the human search process in language and other forms of expression on the one hand, and revelation and obscuration of divine reality on the other (Waaijman, 2003, 421–422). The second component of our chosen concept, ‘care’, is the standard health care term for the help extended to patients. Thus one hears about self-care, volunteer care, palliative care, extended care, et cetera. The choice of ‘care’ also concurs with the tradition of— mainly Protestant—pastoral care, in which pastors communicate personally with patients, mainly the sick and prisoners, at the level of religious problems (Meiburg, 1990, 122; Nauer, 2004, 10–11). As mentioned already, we want to broaden the subject of this communication to worldviews. Care comprises both an attitude and concrete activity, both caring about and caring for. Caring about is an attitude of concern for somebody or something, in our case having the patient’s interest at the forefront of one’s mind and heart. This attitude is prerequisite for all forms of help. Caring for is the activity of looking out for and responding to the patient’s needs ( Jecker & Self, 1991, 294–295). Following Hiltner, anglophone literature refers to four functions of pastoral care activities: guiding, sustaining, reconciling and healing. Guiding consists in assisting people to make good existential choices in their present situation. Sustaining means helping people to endure and transcend a situation in which recovery from illness is impossible or unlikely. Reconciling is to re-establish broken relationships between a person and other persons and between a person and God. Healing means restoring a person to a condition of spiritual wholeness (Hiltner, 1958, 89f.; Clebsch & Jaeckle, 1975, 8–10). We consider the primary activity in spiritual care to be guidance, in the sense of guiding people to make choices and decisions based on a worldview and in this way nurture their autonomous spiritual functioning. Various counselling methods are applied in guidance, for instance patient-centred counselling. Guidance is the key function of spiritual care, the other three functions being subsidiary to it. It is a matter of providing guidance to “troubled persons whose troubles arise in the context of ultimate meanings and concerns” (Clebsch & Jaekle, 1975, 10; cf. Heitink, 1998b, 138–142; Hoekstra & Smeets, 2001, 31–40). As an activity one must distinguish between care and such other terms as ‘cure’ and ‘presence’. Cure refers to methodical assistance— if possible evidence-based—with a view to healing or recovery in

chapter one

8

regard to one or more aspects of health. Care, by contrast, focuses pre-eminently on making health problems endurable. Nowadays it is emphasised that patients need both care and cure; caregivers should allow for varying proportions of both kinds of involvement with patients, care being more aﬀective in nature and cure more instrumental ( Jecker & Self, 1991, 293–294; Raad voor de Volksgezondheid en Zorg, 2001, 15–16, 85–103; De Valck, Bensing & Bruynooghe, 2001). Finally care has a diﬀerent connotation from presence, being an approach in which the relation between spiritual caregiver and patient is seen as a person-to-person relationship without any goaldirected intention on the caregiver’s part. The presence approach is opposed to the professional orientation of helping disciplines (Baart, 2003a; 2003b; 2004, 405f.; cf. 6.1.1 and 6.2.1.1). But spiritual care has a very real professional orientation of its own. Thus it diﬀers essentially from cure and presence in the strict sense. That is why we consider the term ‘care’ most adequate to convey a spiritual care approach. Spiritual care is our chosen translation of the typically Dutch term ‘geestelijke verzorging’. The latter is an umbrella term for the representation of diverse worldviews in spiritual care. Sometimes Dutch speakers, both in the Netherlands and especially in Flanders, also speak of ‘ziekenhuispastoraat’. Comparable terms in other countries are ‘Krankenhausseelsorge’ (German-speaking regions), ‘hospital chaplaincy’ (anglophone regions) and ‘l’aumônerie’ (francophone areas). We prefer not to use these terms, because they imply an exclusively Christian perspective.5 1.2

Research Orientation: Questions and Aim

The reason for this study is the modernisation of the Dutch care system, manifesting mainly in the areas of quality of care and the position of professionals in care provision. This development poses a challenge to reassess the position and nature of the spiritual caregiving profession. After all, quality of care, and more speciﬁcally quality assurance, call for clariﬁcation of the goals of spiritual care, and of the institutional, personal and professional conditions under

5 In education, too, one observes a trend no longer to speak of (teachers of ) religion but of (teachers of ) worldview.

spiritual care in a hospital setting: a problem

9

which these goals can be achieved. This forms the basis of our research questions (1.2.1) and research aim (1.2.2). 1.2.1 Research questions We have said that the development of quality of care, and especially assurance of that quality, call for clariﬁcation of the goals of spiritual care and the conditions under with these goals can be achieved. That is what our research questions are about. We now discuss six questions pertaining to views on health care; worldview in health care; personal worldviews; the legitimacy and position of spiritual care; the goals and tasks of spiritual care; and the eﬀects of the various conditions on the goals of spiritual care. How do spiritual caregivers view the various developments in health care, especially quality assurance? This includes the deﬁnition of certain standards (Casparie, 1992, 1–46; Van der Ven, 1996c, 463f.) aimed at assuring quality of care. On the basis of these standards care procedures and protocols are worked out. If a quality assurance system is considered good, a care institution could be certiﬁed by an independent institution, that is to say, a statement is issued to the eﬀect that it is justiﬁed to believe that the service provided by a department of the organisation or the institution as a whole meets certain quality requirements (Demeulemeester & Callewier, 1997, 157f.; Van Ewijk et al. 1995). Certain quality criteria have been evolved for spiritual care as well and these are applied, for instance in accreditation by the Dutch Institute for Accreditation of Hospitals (Nederlands Instituut voor Accreditatie van Ziekenhuizen, NIAZ ). Following submission of a self-evaluation report to NIAZ, the institution is subjected to an ‘audit’, including an inspection; the result is an action plan for the institution that, together with the the outcome of the audit, culminates in recognition (‘accreditation’) according to NIAZ procedure. In some instances the spiritual care service of the inspected institution also participates in the accreditation process. In view of this it is important to determine the support base for such quality assurance of their activities among spiritual caregivers. This leads to the question: 1. How do spiritual caregivers view quality assurance in health care? (See chapter 2.) In health care the medical approach is the main angle of approach to patients’ health problems. Developments in medical science and technology constitute an important frame of reference for all professions

10

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operating in health care. What are the repercussions of these developments for spiritual care? In health care spiritual caregivers deal with worldview issues. Some maintain that the medical approach takes the place of a worldview approach. Others hold that the medical orientation comes up against the limits of the contingency of existence. The limits of time and chance are fundamental to life, also to life in the health care context. Symbolisation relating to the contingency of life forms the core of worldviews. This could be the distinctive function of worldviews in health care. They could contribute to coping with boundary experiences. But a worldview embraces more than just a response to boundary experiences; it also has intrinsic value. What is spiritual caregivers’ attitude towards the medical approach, cultural-anthropological criticism of that approach and the distinctive function of worldviews in health care? This leads to the question: 2. How do spiritual caregivers view the function of worldviews in health care? (See chapter 3.) Worldviews are not only the substance of spiritual caregivers’ work; they also form part of their personal identity. Since the 1960s Dutch society has changed radically in respect of worldviews. One could call it a pluralisation of worldviews. In 4.2.1 we look in more detail at social changes in regard to worldviews. The traditional worldview and the focus on worldview associations have come under pressure. Spiritual caregivers, too, have to deal with worldviews other than their own. It is necessary to determine how they handle this. This leads to the question: 3. What are the personal worldviews of spiritual caregivers? (See chapter 4.) The legitimacy of spiritual care as a profession is a perennial topic of debate. The point at issue is: why should spiritual care be provided in care institutions? The problem can be approached in various ways. Legitimation can come from health care, from worldview associations and from the domain of spiritual care. At a health care level such legitimation could be based on statutes and regulations regarding health care and on the policy of the care institution. In the case of statutes and regulations the primary source is the Quality Institutions Act, which explicitly refers to the provision of spiritual care.6 In addition one can cite the policy memorandum of the

6 “If anybody is admitted to a care institution for longer than 24 hours spiritual care must be made available” (art. 3; our translation).

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11

National Hospital Council, which deﬁnes the character of spiritual care as an active if unassertive service (NZR, 1987, 17). As for legitimation in terms of policy, active provision of spiritual care can be justiﬁed to some extent in terms of the institution’s perception of care; but it can also be based on patients’ demands and needs for spiritual care. Whereas traditionally care was supply-driven, in the quality approach it is geared to the patient (Casparie, 1992, 1–46; Van der Ven, 1996c, 463f.). Legitimation by worldview associations means that their representatives advocate the right to, and need for, spiritual care in their dealings with health care organisations and care institutions. In such contacts they could argue that guidance by clergy, pastors or counsellors appointed for the purpose is desirable for patients, in addition to medical and other care. Finally spiritual care can be defended in terms of its own domain, namely worldviews. The right and necessity of spiritual care can be substantiated, for example, on the basis of notions regarding the intrinsic value of worldviews and their contribution to the health of patients in care institutions. The question is: how do spiritual caregivers legitimise their profession? In how far do they invoke health care (legislation, institutional perception of care, patients’ demands and needs), worldview associations or their own domain? Apart from its legitimacy, the position of spiritual care is constantly debated. The point at issue is: does spiritual care belong in a care institution? The question is relevant in view of the controversy. Spiritual caregivers often try to clarify the position of their profession in terms of their oﬃcial ministry and the privileged position or ‘sanctuary’ it is said to enjoy (the Dutch term ‘vrijplaats’ denotes the kind of immunity or freedom from persecution granted to sanctuary seekers in earlier times).7 But an oﬃcial position in a worldview

7 The word ‘sanctuary’ in this context needs explanation. It is used in its abstract sense of a state of safety, refuge, immunity from some sort of risk or constraint. The risk in this case is twofold. First, in a clinical environment where science holds sway, patients’ need for spiritual sustenance and support may not be properly taken into account, which violates their human right to freedom of religion and worldview. Secondly, spiritual caregivers may feel hamstrung in their person-to-person dealings with patients if they have to disclose the contents of counselling sessions to the rest of the therapeutic team; they are also unable to “quantify” or objectify their care delivery the way doctors, nurses, pharmacists, etc. can. Against this background both patients and spiritual caregivers can look to the latter’s profession for sanctuary.

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association is a ﬁsh out of water in a health care environment. And the notion of sanctuary is likewise alien to the bureaucratic organisation of health care. This can lead to isolation in the care institution, which is where most spiritual caregivers advocate integration. Where did the ministry of spiritual caregiver originate? It derives from worldview associations, which grant spiritual caregivers ministerial approval. The ministry refers to the separation of church and state according to what is known as the accommodation model (Van der Ven, 2005). In this model the state is not directly involved in the church but ‘accommodates’ it, in this case by entrusting spiritual care in health care to the various denominations. The state does not interfere with the goals and contents of spiritual care; in this respect it recognises the responsibility of the denominations. In other words, the ministry of spiritual caregiver is a legal matter, based on the separation of church and state. Where does the sanctuary conception of spiritual care come from? It stems from freedom of religion and belief. This refers to the freedom of individual citizens vis-à-vis the state. At the level of worldview citizens are assured of protection against interference by the state or its institutions and other organisations, such as care institutions, which, although founded on private law, fulﬁl analogous functions. The sanctuary of spiritual care derives from this civil liberty: liberty at the level of professional communication with patients about worldviews and exemption from accountabillity for such communication in multidisciplinary cooperation. In other words, the sanctuary enjoyed by spiritual caregivers has a legal basis, namely civil liberty. We explore the views of spiritual caregivers both on the ministry and its sanctuary and on their actual position in care institutions. How do they legitimise and position their profession? This leads to the question: 4. How do spiritual caregivers view the legitimacy and position of spiritual care as a professional discipline in health care? (See chapter 5.) The goals and related tasks of spiritual care are equally subject to debate. Often the goals of the profession are left vague; it is even argued that spiritual care need have no goal other than ‘being there’ for the patient. It is important that the goals of spiritual care should be clearly speciﬁed in relation to other health care professions. When it comes to the tasks of spiritual care the focus is often exclusively on tasks in interaction with patients, and even then opinions vary about which tasks should have the highest priority. Nor is there any agreement on whether spiritual care has distinctive tasks at a mul-

spiritual care in a hospital setting: a problem

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tidisciplinary and management level. In quality of care the focus is especially on the extent to which care tasks are performed autonomously, that is, at the initiave of a professional (Casparie, 1992, 1–46; Van der Ven, 1996c, 463f.). In this respect health care shares the common social trend towards professionalisation (cf. Schilderman, 2005, 67–82). What are spiritual caregivers’ feelings about the professionalisation of their occupation? This leads to the question: 5. How do spiritual caregivers see the goals and tasks of their profession? (See chapter 6.) Against the background of all these controversies we focus on the goals of spiritual care in interaction with patients: enhancement of communication about worldviews as the immediate goal, and promotion of the spiritual dimension of health as the ultimate goal. The immediate goal is usually diﬀerentiated into experiential, aﬀective, cognitive, social, moral and ritual aspects.8 We propose examining the goals, including the aforementioned aspects, more closely to determine the inﬂuence of the various views we have studied: spiritual caregivers’ views on quality assurance, the function of worldviews in health care, their personal worldview, and the legitimacy and position of spiritual care as a professional discipline. We examine the eﬀects of these views on the goals in question, also controlling for certain relevant population characteristics, especially biographical ones (gender, training, worldview association, ministerial approval and membership of a professional association) and one institutional characteristic (type of care institution). This leads to the question: 6. What are the eﬀects of health care, the spiritual caregivers’ personal worldviews and the professional discipline of spiritual care on the immediate and ultimate goals of the profession, while controlling for the aforementioned population characteristics? (See chapter 7.) 1.2.2

Research aim

The study has a threefold aim. The ﬁrst is to describe the attitudes of spiritual caregivers in care institutions towards relevant aspects of their work: health care, the function of worldviews in health care, personal factors—including their worldview orientations—and professional factors. Secondly, the study seeks to clarify in an exploratory 8 In chapter 7 it will be seen that empirically the experiential and aﬀective aspects go hand in hand, as do the social and moral aspects.

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sense the goals of spiritual care in contacts with patients in terms of relevant health care processes, spiritual caregivers’ personal worldviews and the professional discipline of spiritual care. Finally the study seeks to contribute, by way of recommendations, to reﬂection and debate on the future proﬁle of spiritual care. The acquisition of knowledge and the reﬂection and debate on this knowledge have two orientations: one internal, the other external. Internally the acquired knowledge, reﬂection and debate help to clarify professionals’ conception of their occupation. This is important for the future of the profession (cf. Schilderman, 2005, 82–91). Externally the acquired knowledge, reﬂection and debate help to justify spiritual care as a health care discipline (cf. Hilhorst & Wisse, 1997; Horstman, 2002; Hulst, 1999, 78–80). 1.3

Research Method

In this section we describe the method of data collection (1.3.1) and data analysis (1.3.2). 1.3.1

Data collection

To achieve the research aim we settled for the questionnaire method. The design of the questionnaire was based on a study of the literature, existing instruments and instruments devised speciﬁcally for this project. The design was amended after consultation with fellow theologians, social scientists and fellow caregivers. The questionnaire comprises four sections, conforming to the conceptual framework of the study. Following an introductory section on population and institutional characteristics, the remaining sections explore attitudes towards quality assurance in health care, worldview and spiritual care as a professional discipline. In each chapter we shall indicate which instruments were taken from which sources. To reach the entire professional group we used, ﬁrstly, the membership list of the Association of Spiritual Caregivers in Care Institutions (Vereniging van Geestelijk Verzorgers in Zorginstellingen, VGVZ) (624 addresses) and, secondly, the list of institutions aﬃliated to the Dutch Care Association (Nederlandse Zorgfederatie, NZf ) (916 addresses). The institutions aﬃliated to the NZf were approached telephonically with two questions: “How many spiritual caregivers are employed by your institution and can you give us their names?” Not all institutions were

spiritual care in a hospital setting: a problem

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willing or able to answer the second question. A small number of institutions could only oﬀer an estimate in response to the ﬁrst question. On the basis of a combination of the VGVZ’s address list of members and the telephonic information obtained from institutions 1125 questionnaires were dispatched, either to the person or to the institution. The spiritual caregivers thus contacted were asked to complete only one questionnaire and to return any second questionnaire— sent on the basis of NZf addresses or of a dual appointment—without completing it. On the basis of telephonic and written reports of duplications we estimate the number of duplicate questionnaires at about 200, giving us roughly 925 contacts.9 After a month a no-response reminder was dispatched. Altogether 545 valid questionnaires were returned, implying a response percentage of 59%. The results described in this study may be seen as representive of the entire population of spiritual caregivers in the Netherlands. 1.3.2

Data analysis

The data from the completed questionnaires were fed into the SPSS statistical program (Miller et al., 2002) and analysed. First we conducted a frequency analysis at item level. Then we conducted factor analyses, on the basis of which we constructed the necessary scales.10 The resultant scales all relate to research questions 1 to 5, that is to attitudes towards quality assurance in health care, the function of worldviews in health care, the spiritual caregiver’s personal worldview, the legitimacy and position of spiritual care as a professional discipline, and the goals and tasks of the profession (see 1.2.1). Next we conducted variance analyses in order to determine the social location of spiritual caregivers’ attitudes towards quality assurance in health care, the function of worldviews in health care, their personal worldview, the legitimacy and position of spiritual care as a professional discipline, and the goals and tasks of the profession.11

9 By way of comparison: in the Trimbos study the number of spiritual caregivers is estimated at 918 (De Roy et al., 1997, 16). 10 In all these analyses we applied the following criteria: communality of items ≥ .20, factor loading ≥ .40, explained variance ≥ .40, Cronbach’s reliability coeﬃcient ≥ .60. Items that did not meet these criteria were eliminated. 11 In all these analyses we applied two criteria: a signiﬁcance criterion of p ≤ 0.05 and, in view of the exploratory nature of the study, a rather low relevance criterion of eta ≥ 0.15.

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To determine the social location of these attitudes we focused on relevant population characteristics: personal attributes and one institutional characteristic. The personal characteristics are gender, training, denomination, ministerial approval by the denomination and membership of a professional association. The institutional characteristic pertains to the type of care institution: general and academic hospital, nursing home, old age home, psychiatric centre, institution for handicapped persons and rehabilitation centre. Our reasons for choosing the population characteristics are as follows. The so-called gender angle has never been properly researched in spiritual care, whereas women constitute a steadily growing proportion of the number of spiritual caregivers. As for training, we assume that critical reﬂection on developments in the profession will increase with training. Membership of a worldview association, according to research ﬁndings, has considerable cultural explanatory power: membership of such an association correlates with certain views on elements of a culture (De Graaf, 2002, 7–8). Ministerial approval is relevant, since it provides a visible link with the worldview association. Communication on professionally relevant themes in a professional association gives rise to critical reﬂection on these themes; because the association seeks to promote professional autonomy, membership implies greater independence in the face of inﬂuences from other professional groups and management. We did not include age among the population characteristics, since in the study as a whole it appeared not to be a decisive factor. The reason for taking type of institution as the institutional characteristic is as follows. Development in the various ﬁelds of health care do not run parallel; thus there are disparities in regard to the nature of the pathology and the chronicity of the cause for requiring care. In determining the association between spiritual caregivers’ attitudes towards quality assurance in health care, the function of worldviews in health care, the spiritual caregiver’s personal worldview, the legitimacy and position of spiritual care as a professional discipline, and the goals, tasks and competencies of the profession we consistently worked with a dichotomous research population: one group is marked by the presence of a particular population characteristic, the other by its absence. Thus we compare theologians with non-theologians, VGVZ members with non-members, humanistic spiritual caregivers with spiritual caregivers from other worldview associations, et cetera.

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Finally, in answering question 6 regarding the eﬀects of spiritual caregivers’ views on goals, we performed regression analyses. In the analyses the goals—promoting communication on worldviews (diﬀerentiated into experiential, aﬀective, cognitive, social, moral and ritual aspects) and promotion of the spiritual dimension of health—functioned as dependent variables, while the independent variables were spiritual caregivers’ attitudes towards quality assurance in health care, the function of worldviews in health care, the spiritual caregiver’s personal worldview and the legitimacy and position of spiritual care as a professional discipline. To control for these eﬀects we incorporated the aforementioned population characteristics in the regression analyses.12 1.4

Research Population

In this section we describe the characteristics of the spiritual caregivers who took part in the study in terms of the personal attributes mentioned in 1.3.2 and the institutional characteristic (cf. appendix 1). Personal characteristics The spiritual caregivers who participated in the study comprised 326 males (60%) and 218 females (40%). The average age is 50. Of these 73% studied theology at a university and 19% at college level (Hoger Beroeps Onderwijs, HBO). Close on 6% did humanistic studies; most of these humanistic spiritual caregivers attended the former Humanistic Training Institute (Humanistisch OpleidingsInstituut, HOI ). The proportion of spiritual caregivers with at most an HBO diploma comes to 18%. The vast majority of the spiritual caregivers we studied belong to a Christian denomination: 43% Roman Catholics, 23% Nederlands Hervormd and 22% Gereformeerd. About 5% are members of the Humanistisch Verbond. Less than 2% (9 respondents) do not belong to any worldview association. Of the spiritual caregivers we investigated 35% are ministers and 5% church workers in a Protestant church. Twenty-four percent are pastoral workers and 12% priests

12 The regression analyses were conducted in two phases. After the ﬁrst phase of analyses we eliminated independent variables that had no signiﬁcant predictive value for the dependent variables. The remaining signiﬁcant variables were subjected to a second phase of regression analyses (cf. 7.1.2).

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in the Roman Catholic Church. Five percent are humanistic counsellors. Of the respondents 15% hold none of the aforementioned positions in a worldview association; 75% operate with ministerial approval from a worldview association. Seventy-three percent are members of the VGVZ, while 33% are members of a professional association that does not focus speciﬁcally on spiritual care: the Association of Pastoral Workers (Vereniging voor Pastoraal Werkenden, VPW) (21%) and the Union of Dutch Clergy (Bond voor Nederlandse Predikanten, BNP) (12%). Fifteen percent of the research population are not members of any professional association. The proportion of respondents belonging to the Albert Camus Association for Spiritual Workers (Vereniging voor Geestelijk Werkers, VGW), which operates completely independently of all other associations, comes to 2%. Institutional characteristic The spiritual caregivers in the research population are predominantly employed in two types of institutions: nursing homes (41%) and general hospitals (31%). Less numerous are respondents working in psychiatric centres (12%), old age homes (9%) or facilties for the mentally handicapped (8%). The percentages of spiritual caregivers in academic hospitals (5%) and rehabilitation centres (2%) are understandably low, considering the small number of such institutions. A small number of spiritual caregivers work in more than one institution simultaneously. 1.5

Résumé

Spiritual care is a discipline situated in the area where worldview and health care overlap. In respect of health care we accounted for our choice of quality of care in the relation between patients and caregivers. The term ‘worldview’ was preferred to indicate the substance of spiritual care. In this regard we opted for Geertz’s approach to worldviews. We deﬁned spiritual care as care in terms of worldviews. Health care, worldview and spiritual care are the key concepts in our study, with health care as the institutional and worldview as the substantive frame of reference of spiritual care. Spiritual caregivers’ personal and institutional characteristics feature in the study as background characteristics. The study has a threefold aim: describing the attitudes of spiritual caregivers in care institutions towards

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19

relevant aspects of their work; clarifying in an exploratory sense the goals of spiritual care in contacts with patients in terms of relevant health care processes; the personal worldviews of spiritual caregivers; the professional discipline of spiritual care; and ﬁnally, its contribution to reﬂection and debate on the development of a proﬁle of spiritual care.

2 ASPECTS OF QUALITY ASSURANCE IN HEALTH CARE This chapter deals with a key development in health care, referred to in the previous chapter as the quality of care approach. In that chapter we deﬁned quality of care as the totality of activities aimed at systematically achieving, promoting and maintaining quality service. This chapter focuses on quality of care in a narrow sense, that is at the level of the relationship between providers and consumers of care. And within quality of care in this narrow sense our more speciﬁc focus is the assurance of that quality. That brings us to the ﬁrst research question: how do spiritual caregivers view quality assurance in care? Attention to quality assurance is a feature of the type of activity that entails a commitment to eﬀort or results. In health care, too, there are rules and systems aimed at assuring the quality of patient care. In the 1990s the Quality Institutions Act in particular, and what are known as the Leidschendam conferences, prompted the introduction and improvement of quality assurance in care institutions. Quality assurance in the relationship between providers and consumers of care can be located at two levels: cooperation between care providers at meso level, and interaction with care consumers at micro level. Quality assurance at meso level has an internal and an external aspect. Internal assurance comprehends activities within the care institution; external assurance refers to national regulations that have implications for care institutions. Both aspects of quality assurance at meso level seek to promote proper use of resources, organising eﬀective implementation of human resources and keeping proper records of such measures. We shall brieﬂy explain both the internal and external aspects of quality assurance at meso level, and then turn to quality assurance at micro level. Internal systems and methods of quality assurance have been developed in all types of care institutions. Institutional management creates conditions to maintain the envisaged quality. It establishes standards, on the basis of which care procedures and protocols are worked out (Casparie, 1992, 1–46). Procedures and protocols should comply with evidence-based practices as much as possible. In addition to standards, procedures and protocols, internal reports and per-

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21

formance reports are valuable means of internal quality assurance, for instance reports on research into client and staﬀ evaluations, and a budgetary cycle and long-term projections of the various disciplines and management. On the basis of indicators derived from such studies results are pursued. Apart from institutionally organised internal quality assurance, health care in the Netherlands since the 1990s has seen the evolution and formalisation of a system of quality assurance accreditation by and for care institutions at the initiative of the Dutch Hospital Association (Nederlandse Vereniging van Ziekenhuizen, NVZ ), the Association of Academic Hospitals (Vereniging Academische Ziekenhuizen, VAZ ), the Order of Medical Specialists (Orde van Medisch Specialisten) and the experimental accreditation project (Proefproject Accreditatie, PACE ). These endeavours culminated in the establishment of the Dutch Institute for Accreditation of Hospitals (Nederlands Instituut voor Accreditatie van Ziekenhuizen, NIAZ ). The NIAZ has laid down a norm that can be used to test the quality of care at an institution by means of a selfevaluation or auditing process, leaving institutions suﬃcient scope to tailor a distinctive service in keeping with their particular nature.1 Apart from the NIAZ there is the Dutch Quality Institute (Instituut Nederlandse Kwaliteit, INK ). Both models link certain organisational sectors that are focal in organisational management (leadership, strategy and policy, personnel management, resources and processes) to a number of outcome areas, where organisational performance is measured (patient, staﬀ and societal evaluation, the organisation’s end results). Since then the NIAZ and INK models of accreditation have drawn closer together, with the result that some institutions have an accreditation process that includes spiritual care. Other institutions are working on their accreditation or are still meeting their quality assurance obligations in other ways, also in regard to spiritual care. As for individual disciplines’ contribution to external quality assurance, for instance that of spiritual care, it includes such measures as society’s evaluation of these disciplines on the basis of a certiﬁcate of registration. Having examined quality assurance at meso level, we turn to the micro level. Here it is a matter of protecting patients’ rights. Patients’ 1 An audit is a systematic, independent investigation to determine the extent to which quality of care is regulated and assured in a care institution; NIAZ and INK are audit systems. Accreditation (see below) entails a stamp of approval indicating that certain criteria have been met (Nederlands-Vlaamse Accreditatie Organisatie, 2005).

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self-determination requires an appropriate attitude on the part of caregivers, who should gear the interaction to patients’ demands and needs. To this end there have been a number of initiatives at the statutory and control levels of the care process. The most important statutory measure is undoubtedly the Medical Treatment Agreement Act (now included in the civil code, Burgerlijk Wetboek, book 7, title 7, article 446f., eﬀective since 1995). With respect to control of the care process the main model is known as demand-driven orientation: criteria have been laid down to intensify institutions’ focus on demand. In this chapter we analyse institutions’ quality assurance at both levels. Which level is decisive for quality assurance—the meso or the micro level? The systems theory perspective accentuates the inﬂuence that meso level models have on interaction with patients at micro level. According to this approach there has to be a balance between caregiver and patient, but the patient’s position is largely dependent. Symbolic interactionism, on the other hand, is critical of the view that the relation between caregiver and patient is, so to speak, subsumed under meso level control. This approach assumes that caregiver and patient deﬁne their situation diﬀerently, envisage diﬀerent aims for the care extended and assign each other diﬀerent roles. Hence the crucial factor is micro level interaction rather than meso level organisation (cf. Persoon, 1991, 154–16). In our view meso level quality assurance is the framework in which micro level assurance takes place. Meso level assurance undoubtedly has enormous inﬂuence at micro level. At the same time observation of the interaction between caregiver and patient shows that it has a dynamics of its own that cannot be dictated from the top. Our study focuses mainly on the micro level, since that is where spiritual caregivers do most of their work (see especially chapters 6 and 7). However, the meso level is the context creating the conditions in which interaction between spiritual caregiver and patients occurs. So this chapter looks at both these levels of quality assurance in a narrow sense. In the case of meso level quality assurance our description of internal quality assurance focuses on two processes known as proceduralisation and protocolisation. We do not examine quality assurance at the level of policy (e.g. a policy cycle, long-term projection and mission statement), administration and the organisation of teamwork in the care institution (e.g. via medical staﬀ consultations and a nursing advisory council). In the case of external quality assurance we

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23

look at the registration of health care professions, which is a public law regulation of the quality of professional practice. Most other components of government’s role in quality assurance are left out of account (e.g. the task of health care inspection and the Council for National Health and Care), as well as the role of care insurers that have a commercial interest in the quality of care. In the ﬁrst phase of quality of care (1990–1995) the accent was mainly on internal quality assurance; in the next phase (1995–2000) it shifted to external quality assurance (Grol et al. 2000, 30). At present the emphasis is on integrated care systems known as quality in process chains (Klazinga & Van der Grinten, 2000, 28–29). In the case of micro level quality assurance we concentrate on patients’ rights and caregivers’ attitudes, as well as a demand-driven orientation in the interaction. We not only describe these selected elements in their own right but also ﬁll in the theoretical background. In regard to meso level quality assurance the theoretical concepts are bureaucratisation and professionalisation, and at micro level it is the concept of autonomy (cf. Van Rooijen, Steman & Zomerplaag, 1994, 9–10; Vinkenburg, 1992; Wierseman, 1992; Wilts, 1992). For the concepts of bureaucratisation and professionalisation we draw on the sociological ideas of Weber and Van der Krogt. Our concept of autonomy is based on Kant’s philosophical notions. In 2.1 we look at the meso level; 2.2 deals with micro level interaction between caregiver and patient. Each section starts with the theoretical background, followed by a scrutiny of spiritual caregivers’ attitudes towards the relevant aspect of quality, based on our ﬁndings in questionnaire research. The chapter concludes with a résumé (2.3). 2.1

Aspects of Quality Assurance at Meso Level

Reﬂection on quality started with the rationalisation of modern society (Fox, 1993, 47–49, 121–128). Weber was the ﬁrst to analyse this process systematically in terms of a distinction between theoretical and practical rationality. In a nutshell: the former refers to theoretical mastery of the world through analytical knowledge and abstract theorising; the latter concerns the methodical achievement of practical goals through ever more exact application of appropriate resources. Both forms of rationality entail cognitive processes aimed at control of reality. Goal-oriented rationality is a cardinal feature of rationalisation,

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chapter two

in the sense that every aspect of behaviour is subordinated to a striving for eﬃciency and eﬃcacy. The choice of both the means and ends of activities is based on the assumption of feasibility. In contrast to goal-oriented rationality there is value-oriented rationality, in which behaviour is geared to what is considered to be a value, duty or task regardless of the outcome; value-oriented rational behaviour proceeds from the religious, ethical or aesthetic value attached to a particular course of action (Weber, 1972, 155–158, 178; 1964, 703–705, 716–718). Weber regards rationality as irreversible. Other authors have commented that Weber’s analysis applies only, or mainly, to the history of Western society and that the universal pretensions he attaches to it lack empirical support (Abrahamowski, 1966, 162–173; Bogner, 1989, 104–110; Schluchter, 1979, 256f.). At all events, rationalisation of behaviour has the eﬀect of what Weber’s translators call the ‘disenchantment’ (i.e. demythologisation) of reality. Two manifestations of rationalisation, to be explained in the next two subsections, are bureaucratisation and professionalisation. The interrelatedness of these two phenomena in health care was demonstrated by Mintzberg in his analysis of care organisations as professional bureaucracies, by which he means a combination of a bureaucratic and a professional organisational model. Insofar as the work performed in health care can be standardised, it conforms to a bureaucratic organisational model. Insofar as it cannot be standardised, professionals need to be autonomous. The combination of the bureaucratic and professional models leads to tension between management and professionals: managers strive for greater control of processes in the care organisation, whereas professionals are intent on maintaining their autonomy (when it comes to standardisation and formalisation of their professional activities) (Mintzberg, 1992, 199–225). In an attempt to harmonise the two organisational models the trend is towards health care organisations in which medical professionals participate in management. This is known as participatory management as an eﬀective managerial approach (Schaaf, 2000, 83–87, 236–254). It is also called integral quality of care, described as a ‘cross-pollination’ between professional concern about quality and an administrative approach (Grol et al., 2000, 30). This section deals, ﬁrstly, with internal quality assurance (2.1.1). Our premise is that the bureaucratisation of care is a typical manifestation of the rationalisation of modern society. In that context we

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25

look into proceduralisation and protocolisation. Secondly, we take a look at external quality assurance (2.1.2). Here our premise is the professionalisation of care as another manifestation of rationalisation. Under that heading we deal with registration. We also look into the ﬂipside of these developments, with special reference to possible tension between meso level quality assurance and quality assurance at the micro level of interaction between caregiver and patient. On the basis of this theoretical discussion we then deal with spiritual caregivers’ attitudes towards meso level quality assurance (2.1.3). 2.1.1

Aspects of internal quality assurance: bureaucratisation

Bureaucracy and bureaucratisation (being the expansion of bureaucracy) are loaded terms, but in our context they are used to describe the (growing) complexity of organisational control, to which end oﬃcial machinery is created (cf. Van Braam, 1972, 18, 217). Weber analyses bureaucracy as an instrument for exercising authority in organisations. He identiﬁes the following attributes: control of the production process, precision, stability, discipline, rigidity, predictability and reliability—all of these linked to the expertise of ‘oﬃcials in an oﬃce’ who ensure that activities are recorded in ﬁles. Bureaucratisation leads to a typical style of vocational practice: oﬃcials perform their tasks according to ﬁxed rules and account for it to management. Standardisation (resulting in rules and regulations for oﬃcial activities) and formalisation (written instructions for all steps to be followed in procedures) play a major role. The proliferation of bureaucratisation is unstoppable. According to Weber its great drawback is that it leads to a straitjacket of slavish subjection. Increased specialisation is not conducive to employee initiative but conﬁnes staﬀ to observing prearranged speciﬁcations. By concentrating knowledge and expertise in the bureaucratic machine there is a danger of growing dependence of individual members on the bureaucracy (Weber, 1972, 125f., 164f., 210–215, 556; 1964, 735–738, 1059–1061). As a result there is widespread ambivalence about rational bureaucracy, as follows. On the one hand bureaucracy oﬀers a solution to the growing complexity of modern society and organisations through concentration of information and power and through standardisation and formalisation. On the other hand it entails a risk of forfeiting democratic control and ﬂexibility in responding to change, hence a loss of individual freedom in organisations (Vroom, 1980, 1–61).

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Two manifestations of bureaucratisation in internal quality assurance are proceduralisation and protocolisation (cf. Nederlands Instituut voor Zorg en Welzijn (NIZW ), 1995, 25–32; Schrijvers, 1994, 133–136). Let us consider these two phenomena. Procedures can be deﬁned as legitimised standard events, in which oﬃcials with clear job descriptions have to follow prescribed steps in pursuit of speciﬁed goals. Their fulﬁlment of their role is regularly evaluated (Vroom, 1980, 33; Leytens & Wagner, 1999, 21). Protocols are often laid down to ensure proper execution of procedures. In health care protocols can be deﬁned as documents that assist caregivers in the performance of care activities; in other words, they provide a code that directs activities and the steps to be followed in performing them. A protocol comprehends a totality of goals, plan of execution, and evaluation and managerial agreements (Leytens & Wagner, 1999, 22; Leparski & Nüssel, 1987; Webster, 1986, 581). In contemporary health care protocols are often products of consensus-oriented consultation with experts who are given the necessary powers for the purpose. Their task is to take proper account of all available evidence in order to ensure that each protocol is an optimal tool in evidence-based medicine. Protocols translate research ﬁndings into evidence-based practice aimed at improving patient care by providing recommendations for appropriate health care in speciﬁc situations (Wollersheim, Burgers & Grol, 2005). Kobus and Carlier distinguish between three kinds of protocols for dealing with health problems: decision-making protocols, goal protocols and performance protocols. A decision-making protocol comprises a multidisciplinary review of the information collected by caregivers for making decisions on prevention, diagnostics and treatment. Goal protocols are worked out for the components of care, whose eﬀects have been described in research. Performance protocols indicate how health problems should be dealt with in practice (Kobus & Carlier, 1990).2 There are certain risks attached to working according to procedures and protocols as bureaucratic manifestations. The literature contains the following three caveats: possible goal modiﬁcation, legal-

2 In the context of NIVEL (Dutch Institute for Research into Health Care) Leytens and Wagner (1999, 29–42) list close on 1000 guidelines and protocols at the level of nursing and care, of which nearly half function at institutional level and a quarter at national level. The remaining quarter is conﬁned to the departmental level.

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ism and conﬂict between managers and professionals. Goal modiﬁcation means that the organisation’s original goal is obscured by undue emphasis on protocols and procedures, which become ends in themselves. When that happens caregivers’ conduct is marked by ritualism. Patients become dependent on caregivers’ application of these bureaucratic mechanisms. Bureaucratic power takes the place of service to those in need of care (Van der Hoeve & Tiems, 1999, 30). Goal modiﬁcation is the greatest danger in bureaucratisation. To obviate the risk, Van Leeuwen maintains, the bureaucracy has to be ethically hedged in, for instance by having to obtain patients’ informed consent and avoid unnecessary harm to patients (Van Leeuwen, 1996, 836–839). We return to these elements in 2.2.1.1. Another possible danger is legalism. This implies that caregivers’ prime concern is whether they are acting within the limits of the law or the prescribed rules (Van der Hoeve & Tiems, 1999, 31). They are less concerned about the eﬀectiveness and eﬃciency of the procedures and protocols, and even less about the ethical accountability of their actions. In the ﬁrst place it is not suﬃciently considered in how far observance of procedures and protocols really reﬂects goal-oriented rationality in the Weberian sense of eﬃciency and eﬃcacy. Secondly, ethics ends up taking a backseat: it merely aﬃrms existing rules and scrutinises their application in speciﬁc situations. According to Liégois the alternative is that caregivers should be alert to possible conﬂicts in the application of protocols and procedures. In such situations they should be called to reﬂect on motives from the angle of worldviews and ethics. Forming opinions on worldviews and ethics is essential if care protocols and procedures are to be applied responsibly (Liégois, 2000, 91–92). In this regard ethical criteria have been developed to appraise palliative care at the levels of both caregivers and care institutions (Hackenitz & Van Ginkel, 2004, 34–35). According to other authors the fear of legalism is unfounded. They propose evaluation of the relevant legislation. In practice statutes in the ﬁeld of health care are applied prudently as a guideline for conduct and there are no signs of a dramatic increase in the number of lawsuits (Legemaate, 2000, 41–42). Finally there is the risk of tensions between two groups in the organisation—management and professionals. Managers have to rely on staﬀ to apply the stipulated protocols and procedures. Staﬀ on their side may be intent on strengthening their position of power and protecting their personal freedom. As a result eﬃciency and

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eﬃcacy may take second place. According to Vroom (1980, 34–53) the only recipe for success is mutual acceptance of authority relations and a shared deﬁnition of reality. Following Mintzberg we believe such tensions to be inherent in a professional bureaucracy; indeed, we have mentioned attempts to use these natural tensions constructively by way of participatory management or integral quality of care. The ﬁrst two caveats strike us as particularly relevant to the ﬁeld of spiritual care. The risk of bureaucratisation as such in the form of goal modiﬁcation can mean that the focus on the patient becomes secondary, to the detriment of the rules governing the activities of spiritual caregivers. In quality of care spiritual care, too, should be primarily patient-oriented. The second caveat—legalism—is pertinent in the sense that spiritual care may well have a major task in preventing this risk: that of encouraging reﬂection on the implications of worldviews and ethics for standardisation of care. After all, the availability of procedures and protocols does not put an end to problems in care, which may include questions arising from worldviews and ethics. In health care these questions are pre-eminently about the possibilities and limits of treatment and of life itself. For instance, how far should one go in applying a performance protocol for treating a disease if the chances of recovery are slim and the endurance of the parties concerned is uncertain? How does the patient’s selfdetermination relate to caregivers’ ideas about appropriate, meaningful action? Caregivers’ and patients’ considerations and choices in this regard are tied up with their worldviews, values, norms and feelings. Together with other caregivers, spiritual caregivers can explore the dilemmas, conﬂicts and paradoxes of their work and put them in the perspective of diﬀerent worldviews (cf. Van der Ven, 1996b, 233–240). Such joint reﬂection, for instance in multidisciplinary consultations and the ethics committee, help staﬀ to apply procedures and protocols in a manner appropriate to the tragic situation in which caregiver and patient are sometimes caught up: when there are no clear-cut answers and one has to discover what makes sense here and now. This is where spiritual caregivers’ expert knowledge of worldviews provides a framework conducive to such reﬂection, since worldviews explore the tragedy of life’s contingency (cf. 3.1.1; Körver, 1997, 103–104). The caveats we have outlined concur with the requirements set in the literature for the future success of rationalisation in organisa-

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tions. These requirements also apply to quality policy in health care. The ﬁrst is recognition of the limits to explicating knowledge in rules and procedures; the ability to apply rules contextually depends on the practical competence and experience of the parties involved. The second requirement is modesty in setting strategic developmental goals and consciously creating scope for ongoing reﬂection, evaluation and revision of formulated goals and procedures. Observance of these requirements will lead to more open policy making. The so-called post-technological organisation paradigm puts less emphasis on goal-oriented rationality and the concomitant control and stability. Instead the accent is on managing uncertainty and unpredictability by simultaneously promoting both stability and ﬂexibility. Such a (quality) policy calls on the learning and negotiating capacity of all parties. In this context procedures and protocols serve as an external memory, constantly renewed in the interaction between ﬁxed standardisation and the actual practice of care. Thus one can establish a relation between reduction of the complexity inherent in procedures and protocols and stimulation of communication between the parties involved with a view to enhanced problem solving. The aforementioned implications of worldviews and ethics for care procedures and protocols also play role in this (Brödner, 1996, 137–144; Luzcak & Fricker, 1996, 165–178; Tacke, 1997, 19–22). 2.1.2

Aspects of external quality assurance: professionalisation

Besides bureaucratisation, professionalisation is another manifestation of rationalisation. The rationalisation of society has repercussions for the way professionals operate (cf. Vroom, 1980, 62–73; Bogner, 1989, 99–100). Weber sees this as another process of increasing goaloriented rationality and objective, technically ‘correct’ behaviour. Professionalisation means that professions are increasingly practised by people who, by virtue of their training, possess the stipulated, hierarchically ranked competencies necessary for their work. Their jobs, like the concomitant responsibilities and powers, are clearly deﬁned. Yet in the performance of their tasks professionals have considerable autonomy (Weber, 1972, 210; 1964, 735). As noted already, professional autonomy can come into conﬂict with the institution’s bureaucratic organisation. Professionalisation, like bureaucratisation, may be seen as a component of quality of care, since several aspects of quality play a cardinal role, such as developing an approach,

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methods and tools, products and services. In quality of care there is great concern about the degree of autonomy in the performance of care-related work (Casparie, 1992, 1–46; Van der Ven, 1996c, 463f.). Professionalisation is accompanied by growing knowledge, which in its turn can translate into customised tasks (Van Delden, 1992, 11–16, 89–95). In this sense professionalisation and bureaucratisation go hand in hand. Among spiritual caregivers professionalism is sometimes rated negatively, since the notion, the very terminology, is said to be cold and calculating, whereas the ﬁeld of spiritual care presupposes considerable humane qualities. We adopt a positive approach to professional spiritual care. Professionalism implies that the work that is performed should patently be that of an expert possessing the requisite knowledge, insight, skills and attitudes. Spiritual caregivers’ professionalism contributes to conduct that fulﬁls patients’ expectations, adapts to altered circumstances and remains geared to the goals of the profession (Van der Ven, 1996c, 467–470). We shall now look more closely at professional autonomy as a cardinal feature of professionalisation, and then at registration as one means of preserving that autonomy. Autonomy relates to scientiﬁc and technical freedom in professional practice (Hulst & Schepers, 1999, 11). It implies a capacity for independent action and codetermination (cf. Knoers, 1987, 7). Another feature is the establishment of a professional association (cf. Van der Ven, 1996c, 479). An approach to professionalisation that emphasises autonomy in professional practice is the power approach, evolved by such scholars as Van der Krogt. This approach centres on the professional group’s actual control over its work and on service to the group by enhancing its organisation and its external inﬂuence. In such a framework professionalisation may be deﬁned as a process of increasing or defending the power of the professional group, mainly by applying its expertise to gain control over the utility and exchange value of its services. The focus is mainly on the collective behaviour of the professional group (Van der Krogt, 1981, 36–179). Van der Krogt’s approach is applied in recent research into professionalisation among pastors and ministers of religion (Brouwer, 1995, 60–63; Schilderman, 2005, 67–80). The approach makes it possible to strengthen the inﬂuence of a particular professional group on the organisation as a whole. In a study of spiritual care in the overall context of health care such a perspective should not be overlooked, partly in order to legitimise the profession’s role in health

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care and partly to ensure the enhancement of professional practice. Accordingly we put the accent on what Schilderman (2005, 67)— following Van der Krogt—calls “directing the institutionalisation and legitimation process of the work of the occupational group”. A useful means of promoting professional autonomy is a register of practitioners. Public law registration of health care professions is a form of external quality assurance (cf. NIZW, 1995, 25–32; Schrijvers, 1994, 133–136). The development of, and admission of professionals to, such a register has ﬁve objectives (see Schilderman, 2005, 82–85). The ﬁrst is enhancement of expertise, often through a coalition between professional associations and universities, thus raising professional standards and providing conditions and means of achieving them. The second objective is to increase the utility value of the profession, that is to gear its work to social demand. Thirdly, it seeks to increase the exchange value of the profession, that is both immaterial rewards (e.g. greater autonomy) and material recompense for work performed (e.g. higher salaries). A fourth objective is to look after the interests and render service to the professional group, inter alia through better organisation and unanimity among members. The ﬁfth objective is to develop collective power or strengthen the profession’s inﬂuence on other groups that aﬀect it. These objectives indicate that professional registration is a facet of quality of care: it is a means of regulating, improving and safeguarding the quality of professional work. Professional registration may be regarded as a hallmark of the ‘certiﬁcation’ of caregivers’ professional activities. Registration of health care professions is required in terms of the Individual Health Care Professions Act (BIG act) of 1993. This act incorporates various professions into the quality system governing the relation between care providers and care consumers and regulates the functioning of professionals. Article 3 of the act, for example, lays down regulations regarding registration, training requirements, reserved procedures and general disciplinary procedures. BIG is an enabling act. The concrete speciﬁcations for each registered profession (article 3), its specialism (article 14) and training requirements (article 24) are elaborated into managerial measures (Brunenberg, Neijmeijer & Hutschemaekers, 1995, 1–2). Spiritual care is not among the professions listed in article 3. Those included are physicians, dentists, pharmacists, clinical psychologists, psychotherapists, physiotherapists, obstetricians and nurses. Neither are spiritual caregivers included among the professionals targeted by

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article 34, such as ergotherapists, radiology technicians and dieticians. These professions have diﬀerent rules from so-called article 3 professions: they are less strictly regulated in regard to registration, specialism, discipline and inaptitude. The aim is simply to specify professional training requirements and areas of expertise and protect their titles (KNMG, 1996, p. 10). The BIG council turned down the inclusion of spiritual care in the list of registrable professions, arguing that spiritual care is not a therapeutic profession in care institutions (Annual Report of Spiritual Caregivers in Care Institutions, 1996). In this regard the relation between government and worldview organisations is a fundamental factor. In the context of the separation of church and state pastoral work and humanistic counselling are regarded as the responsibility of worldview organisations (cf. 1.2.1). Inclusion of the spiritual care profession in the BIG act would have numerous advantages. It would make it possible to systematically pursue and realise the profession’s ﬁve objectives of registration, which would contribute signiﬁcantly to professionalisation. It would be an incentive for a more scientiﬁc approach to spiritual care. It would promote both its integration and status in health care. And ﬁnally, it would provide an organisational framework for the professional work of individual spiritual caregivers. On the other hand, those who—on the basis of the separation of church and state and freedom of religion and worldview—emphasise the signiﬁcance of the spiritual caregiver’s ministry and the sanctuary of patients maintain that these things could not readily be incorporated into public law BIG registration and could be lost sight of altogether.3 2.1.3

Aspects of quality assurance at meso level: research ﬁndings

Having explored some features of quality assurance at meso level in a theoretical perspective, we turn to the question of how spiritual caregivers view and assess these aspects. We have analysed two umbrella concepts: bureaucratisation and professionalisation. We diﬀerentiated the former into two aspects: manifestations of bureaucratisation and critical comments on bureaucratisation. Under the

3 Elsewhere we have reported on the development of a registration system, analogous to the BIG model, speciﬁcally for the spiritual caregivers’ professional association (Smeets, 2002a, 45–47).

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ﬁrst aspect we concentrated on proceduralisation and protocolisation. Previously we had distinguished between these terms, indicating that standardisation applies both in a general sense (procedures) and at the practical level of actual care (protocols). Under the second aspect we considered the danger of bureaucratisation and the need for reﬂection on worldviews and ethics. We discussed the concept of professionalisation from the angle of registration, more particularly the professional registration of spiritual caregivers. We questioned spiritual caregivers about their attitudes towards these aspects. For each aspect of the ﬁrst concept—proceduralisation and protocolisation, the danger of bureaucratisation and the need for reﬂection on worldview and ethics—we formulated two items; for the second concept, registration, we formulated three items; hence a total of nine items. Bureaucratisation Manifestations of bureaucratisation Proceduralisation and protocolisation A procedure is a legitimised standard event in an organisation, carried out by staﬀ with clear job descriptions and subject to regular evaluation. A protocol is a document comprising a totality of goals, plan of execution, and evaluation and managerial agreements. It provides caregivers with a code for the execution of their care activities. Both concepts can be categorised as bureaucratisation in the sense that they pertain to the standardisation and formalisation of professionals’ task performance. Both entail rules and regulations for activities, in which the steps to be followed are spelled out in writing. The following is one example of the items in which the term ‘proceduralisation and protocolisation’ is operationalised.4 c. Increased regulation is essential for good care.5

Critical comments on bureaucratisation Danger of bureaucratisation Bureaucratisation refers to the growing complexity of managing an organisation, to which end administrative machinery is created, bound by explicit rules, goals and resources, 4 Our examples of the operationalisation of concepts in this study are always the items with the highest factor loading. 5 See for the list of all items appendix 2, instrument 1.

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including written reports. One critical comment on this process concerns possible modiﬁcation of goals: the organisation’s original goal may be obscured by overemphasis of bureaucratic measures such as protocols and procedures, which become ends in themselves. Do spiritual caregivers also perceive a danger of goal modiﬁcation, hence a threat to their solidarity with the person in need of care, as a result of one-sided bureaucratisation? We cite one example of the items in which ‘danger of bureaucratisation’ is operationalised: h. The provision of care is impeded by the bureaucratic organisation of care institutions.

Worldview-related reﬂection on care standardisation Forming an opinion on worldviews and ethical issues can contribute signiﬁcantly to proper application of care protocols and procedures by preventing them from becoming ends in themselves. Caregivers’ and patients’ considerations and choices in this regard are tied up with their worldviews, values, norms and feelings. By way of example we cite one of the three items in which we operationalised the term ‘need for reﬂection on worldviews’: b. Forming opinions on worldviews is essential for working with care protocols.

Professionalisation Registration In our study registration refers to the desirability of introducing and maintaining a register of spiritual caregivers, who have to meet certain requirements regarding training, continuing education and professional practice in order to be included. A council is authorised to compile the rules for the register and to exercise control in terms of these. By way of example we cite one of the three items in which the term ‘registration’ is operationalised: a. The fact that ‘spiritual caregiver’ has not yet been included in the BIG act will impact negatively on the future of the profession.

The quantitative data yielded by spiritual caregivers’ responses to these items were subjected to factor analysis. The resultant four factors were used as a basis for constructing four scales (ﬁgure 2.1; cf. appendix 2, instrument 1 and appendix 3, table 1).

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Figure 2.1 Quality assurance at meso level Quality assurance at meso level bureaucratisation manifestations

professionalisation criticism

proceduralisation and protocolisation

danger of bureaucratisation

items: c, i mean: 2.2

items: f, h mean: 3.4

worldview-related reﬂection on care standardisation items: b, g mean: 3.5

registration items: d, e, a mean: 3.3

From the empirical ﬁndings our theoretical classiﬁcation into bureaucratisation and professionalisation in quality assurance at meso level appears to feature in spiritual caregivers’ thinking on this topic. The same applies to the manifestations and criticism of bureaucratisation. As may be seen in ﬁgure 2.1, spiritual caregivers take a negative view of the implementation of proceduralisation and protocolisation in bureaucratisation.6 They agree about the danger of bureaucratisation and the need to reﬂect on worldviews in the standardisation of care. The importance of registration is more or less accepted. As for the social location of the researched scales in terms of the population characteristics described in 1.3.2 (gender, training, denomination, ministerial approval, professional association and care institution), we found no diﬀerentiation that met our criterion of relevance. 2.2

Aspects of Quality Assurance at Micro Level

This section deals with the patient’s self-determination. First we explore what preserving that self-determination means in a theoretical perspective (2.2.1). Then we look at spiritual caregivers’ attitudes towards quality assurance at this micro level (2.2.2).

6

In interpreting the scale value we use the following classiﬁcation: 1.00–1.79: ‘totally unimportant’ or ‘totally disagree’; 1.80–2.59: ‘unimportant’ or ‘disagree’; 2.60–3.39: ‘neither important nor unimportant’ or ‘partly agree, partly disagree’; 3.40–4.29: ‘important’ or ‘agree’; 4.30–5.00: ‘very important’ or ‘totally agree’.

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Self-determination

In this section we examine quality assurance from the angle of patients in their relationship with caregivers. In this context quality assurance pertains inter alia to safeguarding patients’ rights, which are now legally enforceable. This gives quality assurance at micro level a legal basis. The focus on patients’ rights accords with the growing importance of self-determination. In this framework self-determination means that even in the role of a patient people are capable of, and indeed entitled to, free choice in regard to their own lives. The right to such self-determination stems from the patient’s intrinsic dignity as a human being. A self-determined person thinks and acts independently. All human beings, even if they are ill or handicapped, are entitled to decide for themselves what happens to their bodies and their lives. Health problems and admission to health care can put self-determination under pressure in two ways. Firstly, patients are in need of help where their health is concerned; secondly, they have been admitted to an institution where the care provided is assigned to professional caregivers and managers under government supervision. Orientation of the interaction between caregiver and patient to the latter’s self-determination is characteristic of the current quality of care approach. Such an orientation can be assured in various ways. In the next three subsections we examine conditions for assuring patients’ self-determination. From the patients’ point of view it is a matter of ensuring their rights (2.2.1.1). From the caregiver’s point of view it requires a compassionate and symmetrical attitude (2.2.1.2). In interaction it entails an orientation to patients’ demands for care, known as demand-driven care or demand-orientation at micro level (2.2.1.3). 2.2.1.1 Self-determination from patients’ perspective: their rights In health care respect for the patient’s personal uniqueness and concomitant self-determination should be focal. To patients self-determination is important to ensure that the care provided accords with their individual circumstances, needs and lifestyle. Consequently they should be given the opportunity to set their own priorities and make their own choices. Such choices could pertain to the medical care provided, but also to other areas like accommodation, activities, daily routine and contacts.

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To ensure the self-determination of people generally the law translates it into a right. The right implies that a person’s self-determination should not conﬂict with that of other people. In law there are legal principles in the sense of reﬂective expressions of legal grounds. In this context the principle of the right to self-determination is pertinent to our study. The right to self-determination means the right of personal choice regarding norms and values aﬀecting one’s life. Each individual has this right to self-determination by virtue of her or his human dignity. It is grounded in the normative anthropological framework of human autonomy described below (Leenen, 2000, 32–41). In actual fact the right to self-determination is the only fundamental, original human right. People are entitled to it on account of their humanity. The various freedoms in human rights law are aimed at protecting individuals’ freedom vis-à-vis the state. Examples are freedom of religion or worldview (Dutch Constitution, art. 6), the right to protection of privacy (Dutch Constitution, art. 10) and the right to the inviolability of one’s person (Dutch Constitution, art. 11). In addition the law prevents one person’s self-determination from interfering with that of another. While the law cannot impose selfdetermination, it can try to prevent one person from impeding others in the exercise of their self-determination (Scheltens, 1981, 7–10, 117). In health care people’s self-determination comes under pressure. In the ﬁrst place patients are in need of help and dependent on others for care. Secondly, in health care control and evaluation of that care are not in the patients’ hands but are assigned to caregivers and managers (De Swaan, 1989, 33, 44–50, 151f.; Kuiper, 1991, 19). To ensure patients’ self-determination maximally there have been all sorts of developments in health law. This area of law comprises all legal rules that pertain directly to health care and the application of other laws in that regard. Initiatives in health law can be subsumed under one common denominator: the promotion of patients’ rights (cf. Mulder, 1991; Van der Heijden, 1988). They seek to ensure that caregivers help to maintain patients’ self-determination. The right to self-determination accentuates human beings’ right to live according to their own belief in life: patients have a right to make their own decisions about their lives and the values and norms that they choose to live by (Leenen, 2000, 19, 32–35). This includes such things as

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the right to information, to inspect their personal ﬁle, to grant or withhold consent, to have complaints attended to, and the right to codetermination.7 All these rights are stipulated by law. The aforementioned articles 6, 10 and 11 in the constitution also apply to health care. In addition the following acts specify patients’ rights explicitly: the Medical Treatment Agreement Act; the Right of Complaint of Health Sector Patients Act; the Codetermination of Care Institution Clients Act; and the Mentorship Act. The Medical Treatment Agreement Act of 1995 regulates aspects like the right to information, the need to obtain patients’ consent for a given therapy, their right to inspect their medical ﬁle and the conﬁdentiality of that ﬁle. This act has led to regulations regarding informed consent and refusal of treatment. Informed consent means acknowledging patients’ codetermination: before undergoing medical treatment or examination the patient has to grant consent, based on information about the risks and stressfulness of the treatment or examination. We shall deal with written refusal of treatment below under living wills. The Right of Complaint of Health Sector Patients Act of 1995 regulates the right to proper internal or external settlement of complaints about an institution or a professional. It stipulates the obligation of care providers to institute a complaints procedure, with due regard to the rules laid down in the act. Thus the act provides for opportunity to hear both sides’ views. The Codetermination of Care Institution Clients Act of 1996 lays down the legal basis for a clients’ council in care institutions; especially in areas that have no tradition of codetermination (e.g. hospitals) this provides a major lever for change (De Savornin Lohman et al., 2000). The Mentorship Act of 1995 (now included in the civil code, Burgerlijk Wetboek, book 1, title 20, article 450f., eﬀective since 2002) regulates the management of health care interests for people who are unable (or no longer able) to see to it themselves, mainly mentally handicapped and psycho-geriatric patients. Statutory mentorship is meant to prevent abuse of these people’s situation by others; in eﬀect it ensures the necessary clarity. Sometimes a professional

7 Strictly speaking the right to health care does not fall under the right to selfdetermination, since health is not something that can be guaranteed. The right to treatment forms part of self-determination only to the extent that a treatment agreement has been reached with either the caregiver or the institution (Leenen, 2000, 13–43).

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mentor is appointed if there is no relative willing or able to take on the task (Bouman & van Waardenburg, 1997, 21–22).8 Promotion of patients’ self-determination also takes the form of a living will. This is a written document compiled at a time when they are still competent to do so in order to have maximum inﬂuence on decisions taken on the care they are to receive when they are no longer able to make these decisions themselves. In this sense a living will is an important instrument to ease the task of the patient’s representative (Van Veen, 1993, 681–682). A living will could contain directions for decisions on treatment while alive, a request to terminate life, decisions that can only be carried out after death and the appointment of a representative. A number of acts allow for the existence of a living will, for instance the Testing Requests for Euthanasia and Help with Suicide Act and the Organ Donation Act. A living will can be either positive or negative. A negative will is an instruction to the caregiver as stipulated in the Civil Code (art. 7: 450, part 3). The caregiver is bound to carry out a negative living will unless there are sound reasons not to. A positive living will is, for instance, the written ‘intention regarding my life’ of the Dutch Patients Association with reference to medical care in situations where people can no longer express their will; it is aimed at optimal treatment and care and rejects euthanasia as an option. A more general will is a written document stipulating the treatment individuals want in the terminal phase of life and authorising parties to take certain decisions. In contrast to negative living wills there is no onus on caregivers to execute positive living wills. The ﬁnal decision rests with the caregiver, who will take it on medical professional grounds (cf. Kaptein, 1992, 21–22). The orientation to patients’ self-determination is rooted in concern for human autonomy. Immanuel Kant’s philosophy laid the foundation for modern thinking about autonomy. He puts it in the framework of the Enlightenment, which he de describes as “man’s release from his self-incurred tutelage”, that is to say: people should

8 Other acts we could mention are: Donor Data on Artiﬁcial Insemination Act; Termination of Pregnancy Act; Organ Donation Act; Special Admission to Psychiatric Hospitals Act; Medical Research Involving Humans Subjects Act; Embryo Act; and Foetal Tissue Act (Bersee & Nuyten, 2003). In the United States there is a development towards ‘patient safety’ standards, expressed in the Patient Safety and Quality Improvement Act (draft).

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stop not using their reason and stop relying on the authority of others (Kant, 1976, 85–92). In this sense Kant sees human beings as a law unto themselves. His explication of this notion reveals two characteristics of autonomy: it is both moral and rational. Firstly, in Kant’s view autonomy is fundamental to morality. It implies selfregulation in the sense that people will use the moral principles inherent in their existence as rational beings as their moral guideline. In other words, autonomy is not the same as lawlessness, otherwise the possession of free will would, in Kant’s view, be an absurdity. Truly human conduct is possible only if based on morally qualiﬁed autonomy. Autonomy has intrinsic value, not to be bought at any price. Secondly, autonomy is rational in the sense that moral rules are grounded in reason. In scrutinising the norms people set for themselves reason applies the criterion of universalisability. Grounding morality in rationality implies moral obligation without any restrictions. The foundation of moral principles means that people do not make themselves reliant on some authority or on personal likes and dislikes (Kant, 1965, 58–59, 65; 71–74). Hence Kant associates autonomy with freedom in the sense of emancipation from dependence on tradition and authority. Indeed, it implies recognition of the autonomy and dignity of others—every other individual. Autonomy does not obstruct solidarity but actually implies it (Kant, 1986, 37–42; Ludwig & Stark, 1988, 92–106). This clariﬁes a further point: in my view patients’ autonomy in health care is not libertarian in the sense of Mill’s concept of freedom, but an autonomy that—as Kant would have it—has an intersubjective basis (Schotsmans & Meulenbergs, 2005, 121–146; Van der Ven, 2005). Finally, autonomy does not relate only to active behaviour but also to what befalls people. The experience of heartbreak, for instance because of illness or death, can be rationally integrated with the concept of autonomy. Autonomy embraces reﬂection on all personal experiences, including receptive ones, on life in one’s immediate environment and on collective experiences (Walker, 1998, 131–152; 1999, 100–109). Autonomy does not end with the contingent experience of fragility, ﬁnitude, suﬀering and death, but can be maintained (Van der Ven, 2005). 2.2.1.2 Self-determination from the perspective of caregivers: compassion and symmetry The dependence of recipients of care on the knowledge and expertise of caregivers undeniably puts the latter in a position of power. The danger is that they will not do proper justice to

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patients. This is manifested in nonchalant treatment, insuﬃcient information and selective listening, which could mean that the patient’s underlying questions are not heard (Van Leeuwen, 1996, 836–839; cf. Siegrist, 1996, 31–34). Two attitudes on the part of caregivers are essential conditions to assure patients’ self-determination: those of compassion and symmetry. Both attitudes seek to prevent caregivers from assuming an unwarranted superiority. The importance of a proper attitude on the part of caregivers has empirical support: it lessens any possible discrepancy between caregivers’ and patients’ perceptions of the demand for care and patient-oriented care provision (Fiselier, 1983). The relation between compassion and symmetry may be seen as one in which the latter builds on and ampliﬁes the former. We interpret compassion as empathy with others in the perspective of the suﬀering they have to endure. Reﬂection on suﬀering leads to the realisation that the ﬁnitude of life that suﬀering portends does not apply only to the patient. In this way compassion not only engenders a focus on the other but also a sense of equality and reciprocity, in other words: a sense of symmetry. Compassion Compassion can be viewed from various angles. In recent times philosophers have shown renewed interest in the theme of compassion, often proceeding from Schopenhauer’s thinking (Koﬄer, 2001, 3, 95–110; cf. Pott, 1988, 32–36, 66–73). Schopenhauer is in fact the chief exponent in modern philosophy of compassion as the fundamental principle of morality. Following certain schools of ancient Indian philosophy he posits that the true face of reality is not happiness and harmony, but pain, grief and sorrow—in conjunction with an irrational survival drive (what he calls Wille zur Macht). This is the main impulse of Schopenhauer’s philosophy: suﬀering and death— the wretchedness of life—call for, all but demand, reﬂection. No rationality, no science, not even God can make the world habitable (Schopenhauer, 1997, 445–477). Schopenhauer sees two ways to salvation, the one aesthetic, the other ethical. In regard to oneself the ethical way means that one can renounce the will to live. Regarding the ethical way in relation to others, Schopenhauer cites people’s authentic capacity for compassion. To him compassion is a key motive for action aimed at the well-being of others, after the motive of personal well-being. It is also the basis of other virtues like justice (alleviating others’ suﬀering) and love (enhancing their well-being). “Only knowledge of another person’s suﬀering —which is directly

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comprehensible in terms of one’s own and equated with it—can move magnanimous people to perform good deeds and acts of charity. But this implies that pure love (agapè, caritas) is essentially compassion, whether the suﬀering it alleviates is small or great” (Schopenhauer, 1997, 541; our translation). More recently Ricoeur, too, dealt with compassion, albeit in a very diﬀerent context from Schopenhauer’s. The philosophical anthropology in which Ricoeur deals with compassion is based on the interface between narrative and ethics. In our stories about ourselves and others, and in others’ stories about themselves, the dialectic of self and other, the reciprocity of self-love and love of others, continually emerges as the crux of the narrative. In fact, the stories contain an appeal to mutual love, and hence to solicitude for the other. The French word ‘sollicitude’, like its English equivalent, has overtones of loving devotion, which is also implicit in the notion of compassion. A compassionate attitude is not in the nature of a moral obligation; it is prompted by benevolent spontaneity (spontanéité bienveillante). In that sense the concept applies to the interaction between caregivers and patients in health care as well. Transposing and immersing oneself in the other’s suﬀering leads to compassion (Ricoeur, 1992, 191–194). To Ricoeur compassion is not a naive, uncritical attitude; contemplating suﬀering invites reﬂection and deliberating with others so as to ﬁnd an appropriate attitude—he cites the example of ‘bad news conversations’ at a patient’s bedside (Ricoeur, 1992, 269–273; cf. Jansen, 2002, 282–284). We see compassion as an attitude of concern and solicitude for others. It requires solidarity with the other, endless concern for, and reﬂection on, the other’s suﬀering. In this sense the concept of compassion is associated with that of care. It follows logically that compassion should be seen as a concept of fundamental signiﬁcance in caring for people. Three elements are identiﬁed: the cognitive and aﬀective dimension of compassion on the part of the caregiver, and its eﬀect on patients’ insight into their own experience. First the cognitive dimension: compassion entails observing how the other experiences the world and articulating and conceptualising that experience. Secondly, the aﬀective dimension: compassion presupposes sensing what the patient is going through, being in touch with and emotionally transposing oneself to that person’s world. Thirdly, compassion expressed in this manner helps patients gain more insight into their own experience: if one empathises with others and gets to know

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their experiential world, it gives them scope to explore that experience; compassion also helps them to probe deeply submersed, hidden and unconscious feelings and desires (Egan, 1994, 129–131; Van Saane, 2003, 78). A compassionate attitude is not easily achieved. Two conditions for developing it are introspection and authentic altruism. The ﬁrst condition for viewing patients compassionately is that caregivers should be aware not only of the other but also of themselves and their own experience (Müller, 2000, 19–32, 60). Self-reﬂection could reveal that their attitude is really pseudo-compassion, especially when they turn out to be primarily intent on their own well-being (Van Saane, 2003, 74–76). The second condition is that compassion should emanate from authentic altruism. Compassion stems from genuine concern for the well-being of the aﬄicted person; it is a practice aimed at alleviating distress. Compassion goes hand in hand with awareness of the ‘fellowship of the weak’; that gives it a universal quality (Van der Ven, 2003, 27–32; cf. Danneels, 2004, 43–46; Eisenberg, 2002). Hence compassion links up with the attitude we shall be discussing next: symmetry. Symmetry A sense of ﬁnitude and impotence to control life is common to all human beings. Not only patients but caregivers and helpers, too, cannot evade it. It is fallacious to speak of autonomous caregivers as opposed to dependent, passive recipients of care. Autonomy and contingency apply to caregiver and patient alike (Van der Ven, 2005). In other words, one person’s dependence on another at a social level is secondary to the fundamental experience of ﬁnitude that is common to everybody. An attitude of symmetry stems from this shared experience of ﬁnitude (Verhoeven, 1996, 71). It is essential for caregivers to realise that their relation to patients is not just that of authoritative expert to supplicants for help but also a person-to-person relationship. On this score many present-day care ethicists are inspired by Ricoeur, who refers to ‘asymmetrical reciprocity’. On the one hand there is asymmetry: one party is a caregiver, the other a recipient. At ﬁrst glance it would seem that the initiative lies exclusively with the party providing the care. The patient seems to be at the receiving end. On the other hand there is reciprocity: the contrast between strength (the caregiver’s) and weakness (the patient’s) becomes insigniﬁcant in a care relationship in which the patient’s weakness

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makes caregivers aware of their own fragility and ﬁnitude. According to Ricoeur an attitude of symmetry, the term we shall be using, implies both equality and reciprocity. Equality between two partners in a care relationship proceeds from mutual awareness of the fellowship of the weak, provided the caregiver is sensitive to what the suﬀering fellow human has to oﬀer. This attitude prevents caregivers from expressing merely the kind of involvement with patients “in which the self is secretly pleased to know it has been spared”. Reciprocity features in the sense that each has something to oﬀer the other: the caregiver oﬀers the care the patient is in need of, the patient oﬀers her experience of life, her way of coping with vulnerability and mortality. Such deepened awareness of the vulnerability and transience of life can make caregivers feel that they are receiving even more than they are giving. In Ricoeur’s view symmetry derives from an interdependence of self-esteem and care for the other: “I cannot myself have self-esteem unless I esteem others as myself ” (Ricoeur, 1992, 190–194). Thus the following two expressions are equivalent: ‘esteem of the other as another’ and ‘esteem of myself as another’.9 2.2.1.3 Self-determination from the perspective of interaction: demand-driven care Caregivers’ attitudes of compassion and symmetry are conditions for assuring the patient’s self-determination. Not only the caregiver’s attitude but the interaction as a whole is geared to selfdetermination. We have shown, with reference to Kant, that selfdetermination is grounded in the philosophical, normative concept of autonomy. Orienting the interaction between caregiver and patient to the latter’s self-determination is, we have said, a hallmark of the current quality of care approach. To this end a model of demanddriven care has been developed. Broadly speaking, this is a process which combines two elements: the patient’s self-determination and the professional’s orientation to quality of care, which is tailored to the patient’s needs (Guijt & Van Megchelen, 2005, 8; Van der Kraan, 2001, 21–23, 51–54). We call this patient-oriented demand-driven care, or demand-driven care at micro level. It entails solving problems together with patients in terms of the care they demand, their responsibility and their self-determination (cf. Pörtner, 1998, 18–19). 9 “Becoming in this way fundamentally equivalent are the esteem of the other as a oneself and the esteem of oneself as an other” (Ricoeur, 1992, p. 194).

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Orienting the care oﬀered to patients’ needs is a complex aﬀair. For various reasons it cannot be taken for granted that the proﬀered help will necessarily meet the patient’s need. Goldberg and Huxley express this in a ﬁlter model. Their ﬁlter starts with the patient’s need for care, which may be more or less wide-ranging. The next level in the ﬁlter is the care patients demand. Not all needs are translated into explicit demands for care. The last level is the care extended by the caregiver, which does not always comply with every aspect of the patient’s articulated demand (Boot & Knapen, 1996, 55–59). Patient-oriented demand-driven care takes into account various factors associated with the patient, factors associated with the caregiver and factors associated with the care system. We shall not dwell on the macro level factors here. First we look at factors associated with the patient that enter into patient-oriented demand-driven care. They may be divided into psychological and sociological factors. Psychological factors are the experience of illness and notions about it, as well as the experience of and notions about health care and its potential for treating a disease. The more acute patients’ complaints, or the longer they continue to inconvenience them, the more inclined patients will be to deﬁne them as health problems (Mootz, 1991, 162–169). Sociological factors have to do with patients’ socio-economic status, their accommodation, social network and socio-cultural background generally. Research shows that when people make use of informal assistance from their network, they are more likely to invoke professional help. If they have fewer supportive contacts, there is a greater likelihood that physical health disorders will be accompanied by psychosocial problems (Hosman, 1984, 314–319). These factors collectively determine how patients formulate their demands for care. Empirical research reveals clear diﬀerences between people in this respect. The most signiﬁcant conclusion is that patients’ articulation of demands for care is a tip-of-the-iceberg phenomenon: only a limited number of problems are communicated (Hosman, 1984, 314–319). That means that not only care providers but patients themselves ‘ﬁlter’ their needs for care. The phenomenon of ‘proto-professionalisation’ is also encountered: patients formulate their demands for care in the jargon of the various helping disciplines (cf. De Swaan, 1983, 156–157, 195; Verbeek-Heida, 1991, 170–176). Secondly, factors associated with the helper play a role in patientoriented demand-driven care. As in the case of patients, notions

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about disease and health care and its potential enter into it. Helpers interpret patients’ demands for care on the basis of their perception of health and rank them in some sort of hierarchy: what strikes them as the principal demands take priority when it comes to providing help (Tronto, 1993, 137–141). Thus observation of the interaction between patients and physicians shows that the latter can have a biomedical, a bio-psychosocial or a psychosocial focus. Physicians who use a bio-psychosocial disease model such as Engel’s interpret patients’ demands for care far more broadly than those who favour a biomedical model (cf. Van Spaendonck & Kraaimaat, 2004, 18–19, 55–57). Empirical research shows that help seekers and helpers have diﬀerent views regarding the exact nature of the care required. The helpers that were investigated often identify more problems than the patients and view them from a more personal and relational perspective than patients do. The latter tend to emphasise their circumstances and blame others for their problems. Also in regard to the substance of the assistance helpers focus more on personal change in their patients or in their relations with others, as opposed to patients who put the accent on changes eﬀected by others or through some agency. In determining the form of assistance the helpers that were studied assigned themselves a predominantly advisory role, whereas patients tended to see them as experts who had to move into action to ﬁnd a solution. Helpers were also far more modest about the results achieved than their patients (Fiselier, 1983, 116–244). From this it is evident that orienting care to patients’ needs as the key premise of interaction between caregiver and patient is a complex matter. A host of factors have to be considered when one tries to interrelate care needs and care provision, the two terminals of Goldberg and Huxley’s ﬁlter. Hosman advocates an integral analysis of care needs, in which diﬀerent methods are used to combine diverse information from various sources, linking up with diﬀerent helping strategies such as removal of stressors, oﬀering compensating experiences or enhancing self-conﬁdence (Hosman, 1984, 44–58). As yet we have little insight into the eﬀectiveness of articulating demands for care and the ensuing care provision, although there has been some research into patients’ and helpers’ satisfaction with the help provided. The research ﬁndings do not reveal a uniformly positive experience of the eﬀectiveness of care (cf. Bosman, 2001). More positive results can only be expected if patient-oriented care becomes an entrenched professional approach (Zonneveld, 1993, 248–249). Another important condition is that meso level quality systems should

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be transparent and patient-oriented (cf. Bosselaar et al., 2002, 236–250; Le Grand-van den Bogaard, Munsterman & Spaay, 1997, 66–77). Nowadays one also reads about emotion-oriented care: organising quality of care at meso level so as to correspond with patients’ experience of their care needs and the care provided (De Lange, 2004; Verbeek, 2003). 2.2.2

Aspects of quality assurance at micro level: research ﬁndings

Having explored quality assurance at micro level in a theoretical perspective, we now need to see how spiritual caregivers perceive this assurance at micro level and how they assess it. We analysed four concepts: lack of self-determination from the patient’s perspective, compassion and symmetry from the caregiver’s perspective, and demand-driven care from the perspective of the interaction. We questioned spiritual caregivers on their attitudes towards the processes entailed by the four concepts. We formulated three items for each of the four aspects, giving us a total of twelve items. Patient’s perspective Loss of patients’ self-determination Self-determination implies people’s ability and right to make free choices about their own lives, including the norms and values they consider to direct their conduct. In view of our interest in spiritual caregivers’ attitudes towards patients’ self-determination we focus on the possible eﬀects of admission to a care institution in this regard: in how far does it aﬀect patients’ selfdetermination? By way of example we cite one of the three items in which we operationalised the term ‘loss of self-determination’: b. Patients lose their autonomy in complex care organisations.

Caregiver’s perspective Compassion and symmetry in the relationship between caregiver and patient Compassion is an attitude of concern for the other on account of the person’s suﬀering. Symmetry is an attitude of equality and reciprocity between caregiver and patient; it refers to equality in their relationship based on patients’ assimilation of their situation. In practice this means not only that the caregiver should give to the patient, as is manifestly expected in this relationship, but also that patients give to their caregivers, which is not always taken for granted—that is why we studied this aspect. By way of example we cite one of

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the three items in which we operationalised the two terms ‘compassion’ and ‘symmetry’: ‘Compassion’ i. Confrontation with aﬄiction in a care institution evokes fundamental compassion. ‘Symmetry’ k. Clients can give the caregiver a great deal through their personal assimilation of aﬄiction.

Interaction perspective Demand-driven approach to the care relationship A demand-driven approach entails a combination of two elements: the patient’s selfdetermination, and an orientation to quality of care focused on the patient in customised tasks. By way of example we cite one of the three items in which we operationalised the term ‘demand-driven approach to the care relationship’: c. I am a strong proponent of what is known as demand driven care

The quantitative data yielded by spiritual caregivers’ responses to these items were subjected to factor analysis. The resultant four factors were used as a basis for constructing four scales (ﬁgure 2.2; cf. appendix 2, instrument 2 and appendix 3, table 2). The theoretical classiﬁcation into three perspectives in quality assurance at micro level—those of patient, caregiver and interaction— appeared to feature in spiritual caregivers’ thinking on this theme, including the subdivision between compassion and symmetry in the caregiver’s perspective.10 Figure 2.2 Quality assurance at micro level Quality assurance at micro level patient’s perspective

caregiver’s perspective

interaction perspective

loss of self-determination

compassion

symmetry

demand-driven approach

items: b, d mean: 3.4

items: g, i, j mean: 3.9

items: h, k mean: 3.9

items: a, c, e mean: 3.0

10

Item ( j) of the compassion scale has a rather low communality (.16) and fac-

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As may be seen in ﬁgure 2.2, spiritual caregivers believe that patients do not experience suﬃcient self-determination in health care. They manifestly agree with the attitudes of compassion and symmetry. In regard to patient-oriented demand-driven care their position is ambivalent. We could ﬁnd no relevant diﬀerentiation in social location on the scales we used in terms of the population characteristics described in 1.3.2 (gender, training, denomination, ministerial approval, professional association and care institution). 2.3

Résumé

Present-day health care is very much characterised by ideas on quality of care. Our study is conﬁned to quality development at meso and micro level. At meso level, we indicated, bureaucratisation and professionalisation form the core of the processes directing quality of care. The hallmark of these phenomena is a focus of eﬃciency and eﬃcacy. As a result of bureaucratisation one observes increasing proceduralisation and protocolisation in care institutions. Professionalisation is evident inter alia in professional registration. Spiritual caregivers reject proceduralisation and protocolisation as bureaucratic mechanisms. They reject bureaucratisation as such, since they consider the attendant dangers to be too great. The importance of reﬂection on care standardisation in terms of worldviews evoked the greatest agreement. Spiritual caregivers more or less positively endorse the importance of registration of their profession. When it comes to the relationship between caregiver and patient at micro level there is a growing orientation to patients’ self-determination. We pointed out that this stems from the value attached to autonomy ever since the Enlightenment. From patients’ point of view protection of their rights is a major condition for realising their self-determination. That self-determination is under pressure. The condition for a patient orientation on the part of caregivers is an attitude of compassion towards the patient’s plight and a symmetrical attitude towards their relation to patients. The condition for good interaction is patient-oriented demand-driven care.

tor loading (.29); overall the reliability of the scale is fairly low (.49). We did not eliminate the scale, however, since it would have impaired the empirical picture of spiritual caregivers’ attitudes towards patients.

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Spiritual caregivers believe that patients do not experience suﬃcient self-determination. We found that the attitudes of compassion and symmetry evoke clear agreement. In the case of patient-oriented demand-driven care respondents show ambivalence. We conclude that spiritual caregivers agree with quality of care at micro level but not at meso level. Table 2.1 Attitudes towards quality assurance Mean Meso level Proceduralisation and protocolisation Danger of bureaucratisation Reﬂection on care standardisation in terms of worldviews Registration Micro level Loss of self-determination Compassion Symmetry Demand-driven approach to the care relationship

Standard deviation

2.2 3.4

.53 .70

3.5 3.3

.62 .81

3.4 3.9 3.9

.68 .50 .58

3.0

.59

No relevant diﬀerentiation was found in regard to social location.

3 WORLDVIEW IN HEALTH CARE The previous chapter dealt with aspects of quality assurance in health care. We have deﬁned health care as the science and art of preventing disease, prolonging life and promoting health through the organised eﬀorts of society. Within this framework spiritual care has its place. We have indicated that its substantive domain is worldviews. In this chapter we consider the second research question: how do spiritual caregivers view the function of worldviews in health care? The question can be broken up into two sub-questions. Firstly, how does a worldview approach relate to the medical approach (3.1), and secondly, what are the dimensions of the function of worldviews in health care (3.2)? The chapter concludes with a résumé (3.3). 3.1

The Medical and the Worldview Approach

This section deals with the medical and worldview approaches to human beings. First we examine the two approaches in a theoretical perspective (3.1.1); then we look at spiritual caregivers’ attitudes to these approaches (3.1.2). 3.1.1

Medicalisation and contingency as its limit

The ﬁrst question to be answered in this chapter is: how does a worldview approach relate to the medical approach? In ﬁnding an answer we start by looking at what we shall call the medicalisation of health care. Then we locate the function of worldviews in health care in the area where the medical approach comes up against its limit: the contingency of life. Medicalisation At ﬁrst glance health care would seem to have an obvious need for symbolisation in terms of a worldview. Following Geertz, we indicated in chapter 1 that the premise of worldviews is the need to cope with boundary situations that human beings encounter (cf. 4.2.1). One such situation is the experience of suﬀering and death, which is very much at issue in health care. Normal living and selfdetermination are interrupted. Health problems make people aware

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of their vulnerability. Hence admission to a care institution can give rise to existential problems, accompanied by all sorts of fears and spiritual questions (Swift, 2000, 180–182). Some authors maintain, however, that the scope for worldview-related symbolisation in health care is restricted by the dominance of the medical approach. Its dominance stems from people’s expectations of the capacity of medical science as well as the expectations raised by medical scientists. Our umbrella term, ‘medicalisation’, includes both elements. Our discussion of this social phenomenon is based on that of De Swaan, the ﬁrst Dutch scholar to analyse it in detail. Illness has an impact on physical, social, psychological and spiritual functioning. In the treatment of disease in Western society physical functioning was given priority, with the result that the medical approach came to dominate health care. That is the ﬁrst aspect of medicalisation: in health care disorders are dealt with primarily from a medical angle. Both staﬀ and patients have made this ‘shift’ from what was seen as an original multidimensional approach to illness to a medical approach. Accordingly patients’ emotional, social and spiritual problems are often translated into medical terms. They are ‘somatised’, that is translated into physical complaints and concomitant therapies. Caregivers convey patients’ anxiety and uncertainty to colleagues as a request for information about the disease and its treatment. By articulating a somatic complaint patients are assured of caregivers’ attention (De Swaan, 1983, 155f., 177–181). The phenomenon of medicalisation applies not only to patients in health care but also to people who are not (yet) ill. The second aspect of medicalisation is the growing impact of the medical approach on the lives of more and more people in more and more situations. This has to do with the aging of the population, which means that an ever larger group, simply on account of their age, is in contact with medical science. The impact of the medical approach in more and more situations is evidenced by early identiﬁcation of health risks, the expansion of medical advice and decisions, and the medicalisation of everyday life. Early identiﬁcation of health risks is a result of developments in the ﬁelds of technology and health care organisation (large-scale population studies). In addition medical advice is becoming increasingly decisive at critical moments in people’s lives. There is also a tendency in socially controversial issues to circumvent conﬂict by putting the onus of making the decision on the medical profession (e.g. abortion, euthanasia). Finally, in everyday life

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people increasingly observe behavioural rules laid down by doctors, or plan to do so (De Swaan, 1983, 203–219). This second aspect of medicalisation, in other words, has to do with prevention in health care and with faithful adherence to medical advice or therapy, known as medical compliance. Medicalisation is not an isolated phenomenon but forms part of a broad process of social scientisation and professionalisation. In the ﬁeld of medicine this process has a special impact: the inﬂuence of the medical approach extends beyond what can be claimed on the basis of scientiﬁc medical knowledge. It extends to the area of worldviews as well (De Swaan, 1983, 202). We shall now look more closely at this last point, namely that medicalisation is penetrating the domain of worldviews. First we consider the view that medicalisation is increasingly superseding existing worldviews, whereupon we examine this notion critically. Our discussion is conﬁned to medicalisation in health care. In olden times medicine was linked to magic and religion. This historical link has been severed (Porter, 1993, 1450–1461). Instead modernity looks predominantly to medicine for its salvation. This new soteriology has four characteristics: individualisation (the individual human body receives overriding attention), materialisation (body has priority over spirit), immanentisation (everything happens in this life) and activism (remedying the disorder and suﬀering through intervention) (Ter Borg, 1997, 15–38). The supersedence of existing worldviews by the pre-eminence assigned to the medical soteriology has meant that health and ill health have taken the place of suﬀering and salvation. Medical science prescribes behaviour and oﬀers people hope. In a systems theory perspective one could say that the ‘binary code’ or key perspective of the medical system has replaced the binary code of the worldview system (Van der Ven, 1996a, 47f.; Fahrenfort, 1991, 30–31; Wolﬀers, 2004). The physician, it is said, has taken over the function of the minister or priest and has become, as it were, the bringer of ‘salvation and healing’. Medical interventions are more than technical procedures, at least inasmuch as they are assigned a symbolic meaning of healing. As a result the medical approach may end up functioning as a worldview (Van der Geest, 1997, 42–55; cf. Stevens, 1999, 38–40; Weiher, 1999, 92–95). Limits of contingency Yet the extension of medicalisation does not rob worldviews of their distinctive meaning. This is evident where

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the medical approach reaches its limit: the limit of contingency. In a negative sense this limit is reached in cases of incurable illness, suﬀering and death, and in a positive sense when it is possible to assimilate the contingency authentically. Worldviews seek to relate to the contingency of life by giving it meaning and structure. Reﬂection on the experience of contingency is the very core of every worldview (Van der Ven, 1996b, 235–240). First we examine the meaning of the concept of contingency; then we clarify the medical and worldview approaches to the limit of contingency. In its Aristotelian sense contingency pertains to the possible: that which, though not impossible, will not necessarily come about. It refers to what is but does not necessarily have to be. ‘Contingent’ signiﬁes ﬁnite existence. It comprehends both human reality as a whole and individual existence. Human reality as a whole, as we know it, is the outcome of a particular evolution that could have turned out very diﬀerently. Thus evolution theory tells us that our present reality is contingent; history, too, is a train of contingent events. Concretely realised possibilities, moreover, restrict future possibilities. Among innumerable possibilities only one is realised at any given juncture. Contingency is a precondition for action: actions only happen within a range of possibilities. We cannot realise or leave open every possibility (De Mul, 1994, 9–10). The contingency of life brings all human endeavours to their limit. Human beings have a sense of existential limitation, the impossibility of utilising all possibilities to the full. Both in looking back on their lives and looking ahead to the future they experience this tragedy (Scherer-Rath, 2001, 87–97). The experience of contingency has two aspects. The ﬁrst aspect is the experience of time in relation to mortality. The second aspect is the experience of chance in relation to suﬀering. The ﬁrst limit of contingency is time. The medical approach is characterised by a quantitative, linear concept of time: it seeks to control time in a typically scientiﬁc and technological framework of speeding up or acceleration (cf. Laeyendecker & Veerman, 2003, 57–59). From a physical perspective time is a stretch to be covered and is subject to physical laws. It is an object of standardisation (De Laet, 1992, 122–125; 135–137). In this context there are various models, such as that of quality-adjusted life years (QALY). These calculations work with a linear concept of time. They seek to evaluate health outcomes in terms of lifespan and medical functions dur-

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ing that period, resulting in an index which can be used to compare illnesses and the eﬀect of medical therapies with a view to optimal health care decisions (Krabbe, 1998, 10–48). A linear time concept is often associated with some form of belief in progress (Mieth, 1997, 203–210). The strength of this medical approach lies in combating disease by preventive, curative and palliative means. In recent times it has chalked up some dramatic successes. Besides the quantitative, linear concept there is a qualitative, narrative concept of time. This is the concept operating in worldviews. It seeks to relate to subjective experience of time, expressed inter alia in stories (cf. De Laet, 1992, 13–48, 186–192). Ricoeur maintains that the experience of time is marked by disparity between past, present and future; in that experience the present has primordial signiﬁcance. In the narratives of worldview traditions and individual life stories the present is linked to both past and future, so that, via the present, past is linked with future. In such narratives the meaning of past, present and future are continually reconstructed and interlinked. Through the promises and memories contained in stories people extend the present to the future and the past (Ricoeur, 2000, 454–459). In this qualitative, narrative conception time is not ‘measured’, as it is in (medical) science and technology; instead it is assigned meaning. Accordingly some authors speak of ‘meaning time’ or ‘cultural time’, which has both a psychological and an existential dimension. According to Ricoeur time becomes human time to the extent that it is articulated as narrative time (Ricoeur, 1983, 105; cf. Laeyendecker & Veeerman, 2003, 220–221). Time is not controlled— it is a matter of quality of life in the broadest sense of the word. Mortality is connected with time in a special way. Mortality—in itself a logical consequence of human corporeality—gives time the quality of a limit. With the passage of time mortality looms larger in people’s minds. Partly for this reason time has a more rapid, irrevocable character for humans than it has for the rest of nature: time is ﬁnite. People experience their mortality as frightening and threatening, contradicting their will to live. Awareness of their mortality is associated with the experience of the loss of loved ones—for whom they grieve—and the death of anonymous others in the world and in history. The experience of mortality assumes a special form in health care. As soon as people fall ill, mortality enters their consciousness and starts colouring the story of time as a limited commodity. Admission to health care orients patients to the future. In

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the process they have to consider not only recovery from illness— and, absurdly, the promise of eternal youth—but also ﬁnitude and death. That is why human mortality and time as a limited commodity feature prominently in health care (Theunissen, 1992, 37–88;197–217). Care is extended to people to whom mortality is an invasive presence. How do the medical and worldview approaches deal with time as something limited by human mortality? A quantitative, linear concept of time has repercussions for the approach to incurable illness, suﬀering and death. In the medical approach death is the quantitative end of life. At the moment of physical death medicine withdraws. The patient ceases to be a patient. The medical orientation to life, with its linear concept of time, has no answer to human mortality. It is signiﬁcant that theories of health care tend to regard mortality as an external factor instead of an essential component (Sulmasy, 2003, 14; cf. Krakauer, 1996, 22–32). Worldviews have a diﬀerent approach. In Ricoeur’s view the meaning of mortality in the experience of time should be interpreted not so much in Heidegger’s sense of Sein zum Tode, but as être face à la mort, contre la mort and jusqu’à la mort (Ricoeur, 2000, 459–480). In the narratives of worldview traditions and people’s life stories death is not necessarily an end in the linear sense but is given an integral place. Mortality colours people’s life stories and the narratives of worldviews. The latter dispose people to learn to accept their mortality, which is a form of wisdom (Ricoeur, 2000, 466–468). The second contingent limit is chance and, related to it, suﬀering. Chance is not divorced from the temporality of human life, but focuses mainly on two aspects, already identiﬁed by Aristotle: accident and fate. Accident refers to incidentals. Whereas physical existence and having a biography are essential to human life, a speciﬁc bodily constitution and an individual biography may be seen as accidental. Fate relates to good and bad fortune in life. One moment you are in luck, the next calamity strikes. In this sense our birth can be seen as a coincidence, an event that befalls one. The same applies to lucky encounters, but also to suﬀering and death. These examples show that ﬂukes of fate also have an unforeseen/unforeseeable character: the course of life is not determined (De Mul, 1994, 7–14). Because fate sometimes has the character of misfortune, chance is also linked with suﬀering. Whereas time is conditionally determined by mortality and becomes ﬁnite, suﬀering is conditionally determined

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by chance. Human beings ﬁnd it hard to live with the possibility of suﬀering, because it thwarts their desire for control and poses a constant threat to life. Suﬀering that befalls people accidentally is always harder to endure than the suﬀering they incur themselves. Fortuitous, innocent and irremediable suﬀering is an experience that pushes human life to its limit. For in itself the experience is pointless; chance aﬄictions appear to have no purpose. In the medical approach to chance epidemiology provides calculations of probability regarding disease and health generally. Public health surveillance systems use statistical methods to calculate the chances of epidemics occurring, map the course of a disease and evaluate the impact of health care interventions. This yields a body of data on, for instance, morbidity associated with a given disease (Stroup, Brookmeyer & Kalsbeek, 2004, 2–10). The medical approach ensures that much less is left to chance. It provides for prevention and treatment of disease; even the moment of death becomes increasingly predictable. In public health surveillance systems chance is a factor in oversight of risks and risk behaviour. But chance cannot be banished by technical means. The fact remains that an incurable disease, suﬀering and death happens to a given person at a given time (De Mul, 1994, 16). The medical approach oﬀers the stricken person no answer to the existential question: why do illness, suﬀering and death choose me and not someone else, and why now? The experience of chance, more particularly chance suﬀering, gives life an unmistakably tragic quality. Power and impotence, meaning and meaninglessness play a major role in this. Worldviews seek to ﬁnd some relation to chance and especially to suﬀering. One strategy of worldviews has always been to attribute meaning to suﬀering, discovering a structure in it (e.g. ‘God’s design’) which strips chance of its tragic caprice (cf. IJsseling, 1999, 7–11). We shall examine this more closely when we deal with the approach to suﬀering in worldviews (cf. 4.2.1). We arrive at the following conclusions. The contingent limits— time and chance—are integral to health care (cf. Klessmann, 1996, 23–25). We have said that they can easily be understated in medicalisation. Firstly, it has a quantitative, linear concept of time; secondly, it oﬀers no explanation of why illness, suﬀering and death happen to certain people. In a positive sense this experience of contingency in health care could imply a function for worldviews. They have a qualitative approach to time, illness, suﬀering and death, as

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well as a grasp of the fortuitousness of these phenomena. Often they explain it by way of narratives; oral and written stories can convey a diﬀerent approach to illness (cf. Fox, 1993, 111–115). Research shows that narrative reconstruction of the experience of illness entails a restructuring of time and the chance events of life. In this way it gives meaning to the experience of mortality and suﬀering (Donders, 2004, 215–230; Plantier, 1994, 131–134). By invoking the narrative tradition of worldviews spiritual caregivers can guide people in their assimilation of contingent experiences (Zuidgeest, 2001, 138–140). This distinctive role of worldviews in health care may be seen as the speciﬁc domain of spiritual care, to be discussed in more detail in chapter 6. The distinctive province of worldviews is fundamentally important to all caregivers and care organisations. In this way the value of a worldview perspective can be underscored by representatives of other disciplines (Bauduin, 1991; Goudswaard, 1998; Hasper 1994; Van Ree, 2003; Tiesinga, 2004; Vandermeersch, 1996; Vellenga, 1992). There are also organisations in health care that explicitly focus on worldviews as a source of meaning (e.g. the Religious Belief and Worldview Foundation in home care). Finally there are institutions that choose to reﬂect a worldview-related character, expressed in a special focus on worldviews in the practical provision of care (e.g. Reliëf, an umbrella organisation for Protestant and Christian care institutions; cf. Bakker, 2004; Gribnau & Pijnenburg, 2004; Leget (ed.), 2004; Pijnenburg & Ten Have, 2004; Schepens, 1997, 130–139). 3.1.2

Medicalisation and the limits of contingency: research ﬁndings

Having outlined medicalisation and the limit of contingency, we now examine how spiritual caregivers assess these phenomena. We analyse two broad concepts: medicalisation and contingency in health care. We have noted that medicalisation can come to function as a worldview. We explore it with reference to two sub-concepts: ‘somatisation’ and medical compliance. The distinctive role of existing worldviews, we said, lies in dealing with the limit of contingency, which has two aspects: time in relation to mortality, and chance in relation to suﬀering, as we said in 3.1.1. Here we conﬁne ourselves to the ﬁrst aspect, focusing on mortality as the condition of time in health care. We shall look more closely into the experience of chance in relation to suﬀering in 4.2. For each of the aforementioned

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aspects—the two sub-aspects of medicalisation and mortality in health care—we formulated three items, giving us a total of nine items. Medicalisation The social phenomenon of medicalisation refers partly to the prioritising of bodily functioning in the approach to illness and hence the dominance of the medical approach in health care, and partly to the increasing impact of that approach on the lives of more and more people in more and more situations. In view of the focus of our study we conﬁne ourselves to the signiﬁcance of medicalisation in the health care context, and more particularly the fact that medicalisation is penetrating the territory of worldviews. We investigate two sub-aspects. Firstly, the physical aspect of health receives the greatest emphasis, so that one can speak of somatisation. Secondly, one expression of the medicalisation of worldviews is a focus on the physician as the bringer of ‘salvation and healing’; doctors take over the function of ministers of religion or priests. We cite one example each of the two-times-three items in which we operationalised the terms ‘somatisation’ and ‘medical compliance’: Somatisation: b. Patients’ are totally preoccupied with their own bodies. Medical compliance: e. People ﬁx their hopes mainly on doctors.

Mortality in health care Mortality gives time the character of a limit. This experience of contingency is also to be found in health care. Admission to health care orients patients to the future, in which not just healing of the disease but also ﬁnitude and death have to be taken into account. The experience of mortality as a temporal condition is a key element in health care. Care is extended to people to whom mortality is acutely relevant. We cite one example from the three items in which ‘mortality in health care’ is operationalised: i. Our care for others relates to our mortality.

The quantitative data yielded by spiritual caregivers responses to these items were subjected to factor analysis. This gave us two factors, which we used as a basis for the construction of two scales (ﬁgure 3.1; cf. appendix 2, instrument 3 and appendix 3, table 3 and 4).

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Figure 3.1 Medicalisation and contingency Medicalisation and contingency medicalisation somatisation

medical compliance

mortality in health care

items: b, d, g mean: 3.1

a, e

items: c, f, i mean: 3.1

Our theoretical division into medicalisation and mortality appears to feature in spiritual caregivers’ thinking about this problem as well. At the level of the sub-concepts of medicalisation—somatisation and medical compliance—factor analysis revealed a combination of the two aspects, which we had already established theoretically. As is evident in ﬁgure 3.1, spiritual caregivers doubt whether medicalisation exists and whether the experience of mortality has any crucial signiﬁcance in health care. Finally we indicate the social location of the scales we investigated according to the ﬁve personal characteristics described in 1.3: gender, training, denomination, ministerial approval, professional association and care institution. In regard to medicalisation, spiritual caregivers employed in general hospitals tend to think that patient care is characterised by medicalisation (mean: 3.3); their colleagues in psychiatric institutions are more ambivalent about it (mean: 2.8). As for the crucial signiﬁcance of mortality in health care, Catholic spiritual caregivers view it more positively than those of other denominations (mean: 3.2). 3.2

Dimensions of the Function of Worldviews in Health Care

The second question to be answered in this chapter is: what are the dimensions of the function of worldviews in health care? In this section we analyse two possible functions, the one intrinsic, the other extrinsic. Once again we start with a theoretical overview (3.2.1). We then focus on spiritual caregivers’ attitudes towards these functions, as inferred from our empirical research (3.2.2).

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Intrinsic and extrinsic function of worldviews

Following Geertz we deﬁned a worldview in 1.1.2 as a process of symbolisation expressed in culture, individual meanings and ritual. Geertz locates the origin of such symbolisation in confrontation with boundary experiences in life. One instance of a boundary experience is the contingency of life, which has two aspects: time and chance. Symbolisation of the contingent experience of time and chance is focal in worldviews. Illness, suﬀering and death bring people face to face with this contingency. From this we conclude that worldviews have a distinctive function in health care. That function is twofold. In the health care context worldviews can be seen as values in themselves, not necessarily linked directly to any utilitarian purpose; that is what we call the intrinsic function of worldviews. In addition a worldview can be ancillary or functional in health care in the sense of promoting the healing and assimilation process; that is what we call its extrinsic function.1 The intrinsic and extrinsic functions of worldviews can be examined from the perspectives of both caregiver and patient. The intrinsic function of worldviews in health care may be regarded as experiencing worldviews as values in their own right, demanding a place in every context of human life. That is how we shall deal with article 3 of the Quality Institutions Act in chapter 5. This article regulates the availability of spiritual care in care institutions. In health care, too, people want to experience their worldviews: read spiritual books, take part in rituals, discuss their worldviews. It is not so much that it helps them to get well, it is simply an important domain in their lives. The patient is not focusing on anything other than the worldview itself. The goal is determined exclusively by that worldview and the driving dynamics is geared to that intention. The aim of this intrinsic function could be, for example, to integrate the worldview more thoroughly. In this regard the literature emphasises that worldviews should not be reduced to their possible function for health; they have value in their own right. Even if their substance 1 The intrinsic function may be termed ‘religion as end’, implying that “which concerns the degree of devout adherence to religious beliefs and practices”; the extrinsic function may be termed ‘religion as means’, implying that “which concerns the degree one uses religion as a means to other, self-serving ends” (Batson & Ventis, 1982, 168–169).

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is geared to happiness and fullness of life on earth, worldviews envisage far more than the person’s psychological equilibrium (Arts, 2000, 26–28). This is corroborated by patients’ own reports (see e.g. Oenema & Vandermeersch, 1999, 101–116). The intrinsic function of worldviews is also described as a desire, a search for a relationship with and commitment to the ‘ultimate reality’ symbolised in a particular worldview. As a transcendent reality this is often referred to as God. In terms of the intrinsic function of worldviews patients in health care may call God the source and goal of their longing. The patient is directly motivated by the worldview itself. It is an ‘unselﬁsh receptiveness’ (Vergote, 1984, 39–49; Houtepen, 2005). A typical expression of an intrinsic attitude is ‘celebration’, which brings life in harmony with the order perceived in that worldview (Vergote, 1984, 156f.). Church services conducted in care institutions may be viewed in that perspective. Health care creates the conditions for experiencing worldviews per se. The extrinsic function of worldviews concerns its ‘usefulness’ for patients’ health, especially the processes of healing and assimilation. Some authors insist that the therapeutic eﬀect of worldviews should not be underestimated. Worldviews promote healing and cure; they contribute to empowerment (Bohlmeijer, Anzion & Franssen, 2003; Danneels, 2000, 15–16; Hutschemaekers et al., 2004). This function has been assessed diﬀerently in the course of history. Whereas formerly the positive inﬂuence of worldviews on health was taken for granted, the 1950s brought a reversal of this approach: worldviewrelated experience can cause mental disorders. After a period of alienation between the spheres of religion and health, there appear to be fresh overtures in recent times (Westhoﬀ, 1997, 10f.). Various studies have shown that it is particularly important how worldviews function in people’s overall mental ‘management’ (Van Uden & Pieper, 1996, 12–37; 2003, 43–48). The extrinsic function provides the primary motivation for a worldview. This motivation combines the person’s emotional dynamics, intentions and social context. In themselves these elements do not necessarily relate to a worldview, but they motivate people to ﬁnd symbolisations in a worldview. According to this approach patients in health care engage in worldview-related activity in pursuit of a goal external to that worldview. The idea is that the worldview helps to change their inner state of need or discontent or to change their existential context. Worldviews are used in health care to further its

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aim, which is the patient’s health. Typical expressions of the extrinsic function of worldviews are supplications, as well as special notebooks in meditation centres in which patients record their intentions, prompted by functional interests such as hope of a cure or relief of pain (Vergote, 1984). A speciﬁc approach to the extrinsic function of worldviews in health care is coping theory. Its basic premise is systems of meaning as “general dispositions to use particular means to attain particular ends in living” (Pargament, 1997, 59). According to this theory people are searching for meaning and control, drawing on elements of the meaning systems prevalent in their culture. They do so in order to cope with problematic situations and the ambiguity, doubt and insecurity these entail. One of the systems of meaning they may resort to is a worldview. A worldview combines means (e.g. beliefs, feelings and behavioural orientations) and ends (e.g. ‘reframing’ a crisis situation) (Pargament, 1997, 29–49, 144–157). Whereas all this demonstrates the diﬀerence in orientation between the intrinsic and extrinsic functions of worldviews in health care, the eﬀect may well be the same. The intrinsic function of worldviews may also have some sort of ‘use’, although that would not be its intended eﬀect. Unintended eﬀects could include experiences of gratuitous pleasure, of life as a totality, of peace, receptiveness, acceptance, reconciliation, inner tranquillity (cf. Vergote, 1984, 156f.). In these cases the intrinsic function has a distinctive ‘eﬀect’. In the case of the extrinsic function the eﬀect is intended, in the sense that worldview-related engagement by and with patients is undertaken in pursuit of speciﬁc interests in the assimilation and cure of health problems. Is health care intent mainly on the intrinsic or the extrinsic function of worldviews? Health care can be aimed both at creating conditions for experiencing a worldview as a value in itself and at the possible contribution of that worldview to assimilation and recovery. That means that both the intrinsic and extrinsic functions of worldviews for patients are considered important. Intrinsic and extrinsic should not be seen as mutually exclusive opposites in the same dimension but as two diﬀerent dimensions of the function of worldviews (Hood, Spilka, Hunsberger & Gorsuch, 2003, 30–31;392–401; Van der Slik, 1992, 161–163). Both the intrinsic and the extrinsic function of worldviews can be meaningful in a health care context when it comes to the contingent experience of time and chance.

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Intrinsic and extrinsic function of worldviews: research ﬁndings

Having explored the intrinsic and extrinsic functions of worldviews in a theoretical perspective, we turn to the question of how spiritual caregivers assess these functions. We analyse the two functions from the perspectives of both spiritual caregivers and patients in health care. Both the intrinsic and the extrinsic functions occur in empirical reality, not as mutually exclusive models but as diﬀerent dimensions of the function of worldviews. In the case of the intrinsic function of worldviews we formulated four items respectively for the perspectives of spiritual caregiver and patient. In the case of the extrinsic function of worldviews we formulated three items respectively for the perspectives of spiritual caregiver and patient. That gave us a total of fourteen items. They were taken in a somewhat modiﬁed form from previous research (cf. Van der Slik, 1992). Intrinsic en extrinsic function of worldviews from the spiritual caregiver’s perspective The intrinsic function of worldviews pertains to the spiritual caregiver’s own experience of worldviews as values in themselves. The extrinsic function of worldviews pertains to their ‘usefulness’ to the spiritual caregiver. We cite one example of the items in which we operationalised the two terms ‘intrinsic function’ and ‘extrinsic function’ from the spiritual caregiver’s perspective: Intrinsic function of worldview from the spiritual caregiver’s perspective: m. I consider it important to live in accordance with my worldview.

Extrinsic function of worldview from the spiritual caregiver’s perspective: n. The main thing about my worldview is that I derive support and peace of mind from it.

Intrinsic and extrinsic function of worldviews from the patient’s perspective The intrinsic function of worldviews pertains to the patient’s experience of a worldview as a value in itself, which demands a place in every context of human life, including health care. The extrinsic function of worldviews pertains to their ‘usefulness’ for the patient’s health, especially in the processes of healing and assimilation. We cite one example of the items in which we operationalised the two terms ‘intrinsic function’ and ‘extrinsic function’ from the patient’s perspective:

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Intrinsic function of worldview from the patient’s perspective: c. In my view health care should allow for the patient’s worldview because even in the context of illness, suﬀering and death life should respond to what a Supreme Reality requires of people (e.g. the will of God).

Extrinsic function of worldview from the patient’s perspective: d. In my view health care should allow for the patient’s worldview because even in the context of illness, suﬀering and death people’s worldview gives them support and peace of mind.

The quantitative data yielded by spiritual caregivers’ responses to these items were subjected to factor analysis. This produced four factors, which we used as a basis for constructing four scales (ﬁgure 3.2; cf. appendix 2, instrument 4 and appendix 3, table 5 and 6). The theoretical classiﬁcation of intrinsic and extrinsic functions of worldviews from both the spiritual caregiver’s and the patient’s perspective was empirically conﬁrmed. As is evident in ﬁgure 3.2, spiritual caregivers put the emphasis mainly on the extrinsic function for health care patients, whereas they assign their own worldviews a predominantly intrinsic function. They also assign greater weight to the extrinsic function of worldviews for patients in health care than to the intrinsic function of their own worldview, even though it concerns diﬀerent perspectives.2 Figure 3.2 Intrinsic and extrinsic functions of worldviews Intrinsic and extrinsic functions of worldviews spiritual caregiver

patients

intrinsic

extrinsic

intrinsic

extrinsic

items: h, i, m mean: 3.5

items: j, l, n mean: 3.0

items: a, c mean: 3.0

items: b, d, e, g mean: 4.1

2 Item (l) of the extrinsic function from the spiritual caregiver’s perspective scale has a low communality (.12) and a fairly low factor loading (.35); overall the reliability of the scale is quite low (.52). We did not eliminate this scale, however, since it would have impaired the empirical picture of spiritual caregivers’ perception of the function of worldviews.

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Finally we present the social location of the scales that we investigated in terms of the ﬁve personal characteristics described in 1.3: gender, training, denomination, ministerial approval, professional association and care institution. Graduates in humanistic studies assign the intrinsic function of worldviews from the spiritual caregiver’s perspective a low rating (HOI mean: 2.4; UvH: 2.6). Respondents who do not belong to a professional association give it a higher rating (mean: 3.8), with a somewhat lower rating for VGVZ members (mean: 3.4). Spiritual caregivers in psychiatric institutions are ambivalent about the intrinsic function from their own perspective (mean: 3.1). Women give the intrinsic function of worldviews from the patient’s perspective a low rating (mean: 2.8), and graduates of humanistic studies rate it even lower (HOI mean: 2.3; UvH: 2.1). VGVZ members are ambivalent about the intrinsic function of worldviews from the patient’s perspective (mean: 2.9). 3.3

Résumé

The key question in this chapter is: what is the function of worldviews in health care? First we described the nature of the medical and worldview approaches, whereupon we dealt with two dimensions of the function of worldviews in health care. The function of worldviews is to critically explain an aspect of life that, it is said, easily becomes peripheral in the medicalisation process in health care. Medicalisation comes up against the contingent limits of life: time (and, related to that, mortality) and chance (and, related to that, suﬀering). The special function of worldviews in health care is to symbolise the contingency of life. Worldviews have two functions, one intrinsic and the other extrinsic. Via these two functions they can be valuable during patients’ stay in a health care institution. Empirical measurements reveal the following picture. Spiritual caregivers are doubtful about the process of medicalisation, that is, they decline to say whether the medical approach curtails the scope of worldviews. They are also doubtful about the signiﬁcance of mortality as a theme in health care. From the patients’ perspective they put greater emphasis on an extrinsic, as opposed to an intrinsic, function of worldviews; when it comes to their own worldview it is the other way round. Table 3 collates the ﬁndings.

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Table 3.1 Function of worldviews in health care

Medicalisation Mortality in health care Intrinsic function of worldviews from the spiritual caregiver’s perspective Extrinsic function of worldviews from the spiritual caregiver’s perspective Intrinsic function of worldviews from the patient’s perspective Extrinsic function of worldviews from the patient’s perspective

Mean

Standard deviation

3.1 3.1

.55 .76

3.5

.71

3.0

.59

3.0

.81

4.1

.44

Regarding personal characteristics in our inquiry into social location, the conclusions are as follows. In regard to gender females assign a low rating to the intrinsic function of worldviews from the patient’s perspective. As regards training, graduates in humanistic studies assign a low rating to the intrinsic function of worldviews from both the spiritual caregiver’s and the patient’s perspective. In regard to membership of a professional association, VGVZ members attach little value to the intrinsic function of worldviews from both the spiritual caregiver’s and the patient’s perspective. As for denomination, Catholic spiritual caregivers are more inclined to agree with the focal signiﬁcance of mortality in health care. Regarding type of care institution we came to the following conclusion. Spiritual caregivers employed in a general hospital agree about the medicalisation of health care, whereas their colleagues in psychiatric institutions do not. The latter assign a low rating to the intrinsic function of worldviews from the spiritual caregiver’s perspective. Table 3.2 summarises the ﬁndings in regard to social location. Ministerial approval from the worldview denomination has no diﬀerentiating inﬂuence. The greatest inﬂuence derives from the caregiver’s training, professional association and type of care institution.

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Table 3.2 Worldview in health care: social location variables medicalisation mortality WV intrinsic spiritual caregiver WV extrinsic spiritual caregiver WV intrinsic patients WV extrinsic patients

M/F training

professional association denomination approval

care institution *

*

*

*

*

*

*

*

4 THE SPIRITUAL CAREGIVERS WORLDVIEW It is generally accepted that the person of the spiritual caregiver plays a major role in the exercise of spiritual care. This assumption is a key premise in the supervision and further training of spiritual caregivers (cf. Heitink, 2001; Immink, 2003b, 32; Van der Ven, 1998a). The question, ‘What is the spiritual caregiver like as a person?’, refers to her or his identity. There are diﬀerent approaches to identity: philosophical, historical, psychological (with diverse sub-approaches) and cognitive scientiﬁc approaches (cf. Bosma et al., 1994, 162–169; Glover, 1991; Shalom, 1985). Among these we opt for a narrative approach, and among the various philosophical theories of narrativity we settle for Ricoeur’s narrative anthropology. His theory of narrativity incorporates other philosophical approaches, such as linguistic analysis and action theory (Ricoeur, 1992, 3f.). The ﬁrst section of this chapter focuses squarely on Ricoeur’s notion of narrative identity (4.1). As for the personal identity of the spiritual caregiver, we want to narrow it down to the following question: what dimension of spiritual caregivers’ identity relates to their worldview? After all, spiritual caregivers’ communication with patients is conducted in the domain of worldviews. In that communication patient and spiritual caregiver alternate as sender and recipient and the worldviews of both parties are at issue. Among the various theories on worldviews we base ourselves on Geertz’s approach, which was also our premise in earlier parts of this reﬂection. The second section of the chapter deals with the worldview-related dimension of identity with reference to Geertz’s view (4.2). That brings us to our third research question: what are the personal worldviews of spiritual caregivers? The chapter concludes with a résumé (4.3). 4.1

Narrative Identity

We start with the identity of the human being as a person on the basis of Ricoeur’s narrative perception of it (4.1.1). Then we look at narrative identity as perceived by spiritual caregivers (4.1.2).

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Some aspects of narrative identity

From Ricoeur’s vast oeuvre we conﬁne ourselves to Oneself as another (1992) and La mémoire, l’histoire, l’oubli (2000). These two works provide a synthesis of his narrative anthropology. A key concept in his theory is that human identity is not a static phenomenon but a process—a narrative process. By this Ricoeur means that human identity takes shape in the stories people tell about themselves and the stories that are told about them, and that the form and content of human identity correspond with the structure of a narrative. We shall explore this narrative identity and the various dialectics discernible in it. Ricoeur distinguishes between the following human activities: doing, speaking, narrating, imputing and naming God. Hence narrating is one of the actions people perform. Ricoeur links action and narration in three ways. Firstly, narrating a story is itself an action. In modern action theory acting entails far more than just doing in the narrow sense; it includes all intentional human activities (Ricoeur, 1992, 57, 73f.). Secondly, actions are embedded in people’s present stories, which helps us to understand their actions. Finally, the stories people tell about themselves implicitly or explicitly involve future actions. Thus doing—as a component of human behaviour—is also linked to narration. The other types of action likewise relate to narration: speaking is its substructure, and imputing and naming God occur in a narrative mode. People are constantly telling stories about themselves. Put diﬀerently, they narrate themselves. At the core of these stories, Ricoeur (following Aristotle) maintains, is a plot (Ricoeur, 1992, 88–112). Disparate elements assume meaning and are integrated with the plot of the story. The plot is the organising principle that interrelates a plurality of actions and events in human lives. Via the plot a link is forged between actions and events in the past and the present, as well as possible future actions and events. Hence narratives are characterised by temporal coherence (cf. Ricoeur, 2000, 204, 305–306, 516). Narratives have a certain coherence. The emphasis may be prospective or retrospective; they may extend over a short or a long period of time and over one or several spheres of life, such as stories about family, professional or civic life in society. Stories may unify these diverse spheres and actions in a single, umbrella perspective. They imply a certain continuity in life over and above the temporal dis-

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continuity of past, present and future. Ricoeur refers to this as a discordant concordance, being the continuity that the story establishes between past and future (cf. 3.1.1). Narratives comprehend a coherent set of goals that people pursue. These relate to so-called standards of excellence, such as being a good parent or a good spiritual caregiver. Stories refer to the realisation of the good life. They include the ethical choices people have made and are making with a view to these goals. Their choices do not pertain only to the separate spheres of life but also to life as a whole; thus they include choices regarding the relation between work and private life or between self-love and love of others. In this way narratives show how people appraise themselves, others and society (Ricoeur, 2000, 312–317). Ricoeur distinguishes between life connection (connexion de vie) and narrative coherence (cohérence narrative). Life connection refers to the whole of human life in time, from birth to death. Narrative coherence relates to people’s stories about that connection. Telling stories makes people aware of the meaning of life; they read life as they would read a text and interpret it. This narration is reconstructive and open. The stories people tell at diﬀerent stages of life are never identical: as a result of new experiences and fresh understanding of themselves and their circumstances they compose the narrative diﬀerently each time. The openness of their narratives stems from the fact that people control neither the beginning nor the end of life. Others tell them about their birth and in due course will tell the story of their death (Ricoeur, 1992, 131–136; 2000, 312–317). This conception of narratives and their signiﬁcance for human life helps us to understand Ricoeur’s view of narrative identity. To know someone’s identity one has to hear and tell the story of that person’s life (cf. Haker, 2000; Mieth, 2000; Meuter, 1995, 245).1 Narrative identity has three structural aspects: historicity, sociality and praxis, and within each structural aspect Ricoeur discerns a dialectic that is expressed in the narrative. The dialectic at the level of historicity is that of idem-ipse, that is the relation between continuity and discontinuity of identity. Applied to narratives it is the relation between more or less ﬁxed elements in the story about a person’s character 1 The modern narrative theory of personal identity goes back to Dilthey. He was the ﬁrst to conceive of personal identity as an experiential context or unit that can be traced in the individual biography (Meuter, 1995, 245–247).

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and open (to the future), unique elements in it. At the level of sociality the dialectic is that of self-other, which involves the ethical nature of identity. At the narrative level it is expressed in the protagonists and antagonists in the story. Finally, at the level of praxis the dialectic is that of activity-passivity, referring to the self-constructive and receptive sides of identity. At the narrative level this is expressed partly in elements that people construct for themselves, and partly in elements heard or taken over from others. Let us examine these aspects more closely. Idem-ipse dialectic The ﬁrst dialectic is that of idem and ipse identity; one could also call it a dialectic of continuity and discontinuity over time. People talk about themselves as if they are characterised by continuity, but how is that possible when time changes everything about them? First we consider the aspect of idem or sameness. In the course of their life’s history people evolve a kind of consistency, which manifests itself in various ways. Thus one can identify a person at diﬀerent points in time; from memory one can trace the degree of sameness that a person displays over the years; one also experiences a kind of underlying structure in the person throughout changes in the passage of time; lastly, certain personal traits remain stable in the past and the present (Ricoeur, 1992, 113–123). These examples illustrate how personal consistency extends from the past to the present and the future. This form of identity is what Ricoeur calls the idem aspect. It makes it possible to compare one person with others (who possess the same or diﬀerent traits). One could call the idem aspect the objective side of personal identity (Stiver, 2001, 168–171). Next we look at the ipse aspect. To Ricoeur the key concept to grasp this aspect of identity is the word ‘henceforth’ or ‘anticipatory resoluteness’, expressed in a future-oriented promise. This could be a promise of either maintaining continuity or doing certain things diﬀerently in future. The promise presupposes the idem aspect in the sense of self-permanence, but remaining the same is secondary to the experience of uniqueness. I become myself in new choices that I am continually making. It is this ipse aspect that permits me to appropriate my body, my experiences, emotions and thoughts as mine. Through their grounding in the idem aspect people in their selfhood are the source of present and future realisation of identity. In contrast to the more or less ﬁxed character identity based on

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their past life history, this aspect of identity is marked by dynamic openness to the future (Ricoeur, 1992, 123–139). One could call the ipse aspect the subjective side of personal identity (Stiver, 2001, 168–171). Applied to the narratives people tell this ipse aspect means that a life story is not just retrospective but also prospective. The prospective element means that life stories address an appeal for action, engagement. The engagement is future-oriented. I become myself in new choices that I make in my narrative. From our stories about ourselves a person emerges who declares her intention to keep her word, however diﬃcult it may be (Ricoeur, 1992, 141–150). The narrative is, so to speak, a project which addresses an appeal to the narrator. The two aspects—idem and ipse—are not divorced from each other. They both overlap and diﬀer. Firstly there is some overlap. The ipse aspect is not altogether discontinuous, nor is it wholly future-oriented. It also displays continuity: being true to the promise one has made links past, present and future together. In addition the idem aspect does not pertain only to continuity, nor is it wholly conﬁned to the present and the past. Although by and large Ricoeur sees human character as a constant factor, it is also subject to development over time; character has a history, which extends into the future.2 In short, the idem aspect is not totally ﬁxed and the ipse aspect is not totally new. The promise we undertake to keep in the future is tied up with the person we have become in our life up to now. It is rather a matter of emphasis: the idem aspect relates to the temporal dimension mainly from the perspective of the past, the ipse aspect from the perspective of the future. Hence the relation between the two aspects is dialectical. According to Stiver (2001, 170) the dialectic is clearly manifested in one’s body: objectively my body has certain attributes (le corps object), subjectively I experience it as my own body (le corps sujet) (Stiver, 2001, 170). In the idem-ipse dialectic Ricoeur, as noted already, puts the accent on the ipse aspect. By virtue of its grounding in the idem aspect the ipse

2 Whereas character psychology formerly put the accent on the stability of character (cf. Kretschmer, Eysenck)—according to Van der Ven (2002, 40–41) Ricoeur’s theory of character adheres closely to this view—nowadays character is seen more dynamically as an interactive process between person and context (cf. BrunasWagstaﬀ & Geluk, 2000; Orlebeke, 1985).

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aspect is the source of the realisation of present and future identity; it always implies a qualitatively new beginning of identity. That is how Ricoeur explains personal uniqueness. Self-other dialectic Like most modern philosophers Ricoeur rejects an approach which ﬁrst examines the self in isolation and only then turns to the other. The dialectical relation between self and other is evident inter alia in language. Let us look more closely at the relation between self and other via language, the dialectic in the relation between self and other, and the attestation expressed in this relationship. In his discussion of language Ricoeur shows that one cannot ﬁrst scrutinise the self and only then turn to the other. Oneself as another starts with a linguistic analysis of the self (Ricoeur, 1992, 27–55). In acquiring and using language the self is reliant on others. And the only access we have to the self is indirect, via language; that is to say, access to the self is eﬀected indirectly through the other’s interpretation of linguistic expressions. Personal identity is created in communication with others (Ricoeur, 1992, 3f ). At the narrative level this implies the following. People tell their story to others. To do so they use the language they have learnt from others. In their story about themselves their relations with others moreover play a primordial role. In the ongoing reconstruction of their life story others also supply new narrative elements, of which they were previously unaware. According to Stiver (2001, 174) people are not the absolute authors of their lives but at most co-authors. As pointed out already, the narrative synthesises continuity and discontinuity in remaining true to one’s given word, which the presence of the other—to whom the promise was addressed—implies. Self and other are reciprocal concepts. To me the other is another, a non-self. But from their own perspectives others are also selves. To myself I am not just a self; by switching my perspective I can see the other as another self. In the other as another I encounter my fellow being. This encounter makes it possible to see myself, too, as another. That explains the title of Ricoeur’s book: Oneself as another. In the other’s revelation as another to me I can be revealed to the other and also to myself as another to me. In this mutual revelation the promise to each other may be made. The promise is characterised by a structure of attestation. Epistemologically this falls somewhere between veriﬁable knowledge

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and doxic belief. Our commitment to our fellow beings is in the nature of an attestation, that is, characterised by both trust (in the sense of knowledge on which one can build) and fragility (in the sense of opinion or doxic belief ). Ricoeur’s concept of attestation is a further elaboration of his idem-ipse dialectic: the things people tell us about themselves always reveal a tension between what may be regarded as self-evident knowledge and that which remains precarious, uncertain. Future-oriented commitment is always fragile, contingent and vulnerable. The surest guarantee of such a commitment is personal integrity. That is why attestatory speech is diﬃdent. An attestatory narrative is more than merely the airing of an opinion; it is a personal testimony. In addition attestation is not conﬁned to narration: it is also manifested in personal behaviour towards the other (Ricoeur, 1992, 248–271, 293–303; 2000, 98–100). The attestatory nature of identity means that identity cannot be proved theoretically; it is not a fact but a challenge, marked by fragility and vulnerability. Accordingly Van der Ven (2002, 45–46) calls attestatory identity a ‘wounded identity’ that has to be conquered anew each time. Activity-passivity dialectic The third dialectic is that between activity and passivity and is located on the level of praxis. It is expressed in narration and is linked with the two preceding dialectics at the level of historicity and sociality. It also includes the themes of tragedy and suﬀering. Let us examine these various elements. The dialectic between activity and passivity expresses the nature of human praxis in a special way. In the ﬁrst place praxis has an active side. Life is not deterministically governed by facts. Human beings can transcend these in their actions and intervene in them. In their actions people are the authors of their own lives (Ricoeur, 1992, 157, 193). According to Van der Ven (2002, 51) Descartes’s ‘I think, therefore I am’ should be amended, in the spirit of Ricoeur, to read: ‘I am what I (can) do, I (can) do what I am.’ But praxis also has a passive side. Firstly, outside events befall people, things they have to suﬀer and endure. These are events governed by external causes that have repercussions for people’s praxis. Secondly, praxis is also activated from within by people’s motives and drives. These are often a mix of more or less extraneous causes that inﬂuence people, and personal intentions that they generate and cherish. Recognising this passivity of praxis implies that identity is

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not purely self-determined and self-determining. It is a wounded identity, as we pointed out under the contingent and vulnerable nature of attestation. According to Ricoeur the passivity of praxis is most manifest in three instances of otherness that determine human beings, as it were from outside, but without total loss of self-determination: the body, friendship and conscience. The body is not only marked by a quality of being mine; it also has a quality of otherness that inﬂuences me from without. The body is in fact a bridge between the self and the (biological) world (Ricoeur, 1995, 94). Intersubjective relations assume many forms; an outstanding example, according to Ricoeur, is friendship. This reciprocal relationship consists in both parties’ actions and reactions. The self is always both the active pole in the friendship (which the other receives from or undergoes) and the passive pole (when the initiative rests with the other) (Ricoeur, 1992, 157). In addition to their bodies and friends, people have a third experience of otherness: conscience, a voice from without or above speaking inside the person (Ricoeur, 1992, 153–159, 273–279). The dialectic between activity and passivity is expressed in people’s stories about themselves, more especially in the relations between actions and events, between being aﬀected by the past and active engagement with the future, and between narrating oneself and being narrated by others. Thus it is evident that the dialectic at the praxis level also relates to the idem-ipse dialectic and the dialectic between self and other (Ricoeur, 1992, 144–157). The ﬁnal component of Ricoeur’s dialectic between activity and passivity is the themes of suﬀering and tragedy, both of them crucial experiences of life’s contingency. To Ricoeur an action theory must take cognisance of both people’s active praxis and the suﬀering and tragedy in their lives. Tragedy and suﬀering create solidarity between people based on their common awareness of fragility and mortality (Ricoeur, 1992, 192–193). In this context Ricoeur deﬁnes attestation in interpersonal interaction as the “assurance of being oneself acting and suﬀering” (Ricoeur, 1992, 22). Suﬀering and tragedy assail people’s thoughts, feelings and actions, that is, every dimension of human life. The praxis level oﬀers an answer rather than a solution: to combat suﬀering. At the emotional level Ricoeur refers to emotional catharsis that occurs in the transformation of lament and complaint. At the level of thought there are various forms of expression: myth, wisdom, gnosis and theodicy. This last

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form will be dealt with in the next section. Through a combination of thought, feeling and action, Ricoeur maintains, we arrive at practical wisdom for coping with suﬀering and tragedy. This means that in concrete situations our praxis is aimed at what we consider and sense to be good here and now; when dealing with other people’s suﬀering practical wisdom entails opting for a course of action which optimally accommodates exceptions to the rules laid down for care to others, but which also deviates as little as possible from those rules (Ricoeur, 1992, 268; 1992b, 31–45, 62–69; 1995a, 290–292). The themes of suﬀering and tragedy also feature at the narrative level. They are focal elements in the narrative traditions of humankind. Ricoeur ﬁnds them articulated par excellence in classical tragedy. But suﬀering and tragedy also have a special place in everyday life and its stories. They are experiences of the contingency of life— experiences that feature particularly prominently in the stories of health care patients (cf. 3.1.1 and 4.2.1). 4.1.2

Narrative identity: research ﬁndings

Having explored personal identity in the perspective of narrative theory, we turn to the question of how spiritual caregivers experience their personal identity. We analysed four umbrella concepts: uniqueness, attestation, passivity and narrativity. To inquire into spiritual caregivers’ attitudes towards the experiences associated with the four terms we formulated three items for each of the four aspects, totalling twelve items. Uniqueness When it comes to caregivers’ views of their personal identity we are interested, ﬁrstly, in the ontological distinction between the idem and ipse aspects. Ricoeur puts the accent on the ipse aspect. He regards it as the main determinant of personal uniqueness, that is, the way in which—between past and future—every individual always embodies the relation between continuity and discontinuity anew. Human beings have a unique identity based on the relation between their character and their life commitments. That is what distinguishes them from other people. In how far are spiritual caregivers open to this uniqueness? Here is an example of the operationalisation of the term ‘uniqueness’: c. There is something unique about me that is not reducible to other people’s lives.

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Attestation The second aspect of Ricoeur’s anthropology that we investigate is attestation at the level of the relation between self and other. In attestation identity ﬁnds ethical expression: here am I. People’s talk about themselves is a personal testimony, which may be contested because of hidden inner motives and drives, as well as external circumstances. Our main emphasis is on the vulnerable nature of attestation, the wounded identity. In how far are spiritual caregivers aware of this wounded identity? Here is an example of the operationalisation of the term ‘attestation’: a. Personal judgments are always tentative.

Passivity The third aspect of Ricoeur’s anthropology that we examine is passivity as the counterpart of activity. People’s praxis has an active side: they intervene in the facts of their lives. ‘I am what I (can) do, I (can) do what I am.’ But praxis also has a passive side. People undergo things and have to endure them, both external circumstances and inner states. The passive side of praxis is most evident in three instances of otherness: the body, friendship and conscience. Ricoeur maintains that people should get rid of the illusion that identity is wholly self-determined and self-determining. Tragedy and suﬀering occupy a focal place in their biographies. That is the dialectic we explore, with special reference to life’s suﬀering and tragedy. Particularly in health care that is a relevant issue. What we want to know is what it means to spiritual caregivers in their reﬂection on their own identity. Here is an example of the operationalisation of the term ‘passivity’: d. I have to undergo many things in life.

Narrativity The foregoing three elements also feature in people’s stories about themselves. On the one hand the uniﬁed structure and organisational principles of human life correspond with the coherence of a story that is or can be narrated. On the other hand human identity is shaped by narrative. Disparate elements in life are integrated with the plot of the story they tell about themselves or that is told about them. The story reveals their identity and their identity takes shape in the story. The self is a story. In how far are spiritual caregivers aware that telling stories is important for identity construction? They often listen to other people’s stories, but our concern is with the signiﬁcance of their own stories for their own identity. Here is an example of the operationalisation of the term ‘narrativity’:

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h. Talking about the course of my life clariﬁes my essential self.

The responses to these items were subjected to factor analysis. This yielded four factors that we used as a basis to construct four scales (ﬁgure 4.1; cf. appendix 2, instrument 5 and appendix 3, table 7 and 8). The theoretical classiﬁcation into the four terms was empirically conﬁrmed.3 As is evident in ﬁgure 4.1, spiritual caregivers concur with the notion that the uniqueness of the human person forms the core of identity; the same applies to the notions of the passivity of human identity and the pertinence of narrative to identity. They more or less agree with the concept of the attestatory nature of personal statements.4 Finally we look at the social location of the scales we investigated in terms of the ﬁve personal characteristics and the institutional characteristic described in 1.3: gender, training, denomination, ministerial approval, professional association and care institution. In the case of uniqueness academically qualiﬁed spiritual caregivers assign it a higher rating than their colleagues who have only a college education (means: resp. 3.9 and 3.5). Those who have studied theology subscribe more strongly to uniqueness as the core of personal identity (mean: 3.9). Spiritual caregivers with no denominational standing assign it a lower rating (mean: 3.5). In regard to attestation, passivity and narrativity we encountered no diﬀerentiation that met our criteria. Figure 4.1 Spiritual caregivers’ personal identity Personal identity

uniqueness

attestation

passivity

narrativity

items: c, g mean: 3.8

items: a, e, l mean: 3.3

items: d, f mean: 3.6

items: b, h, k mean: 3.6

3 The items of the uniqueness scale have a low correlation (r. 24) and item (c) has low communality (.13) and a rather low factor loading (–.33). Item (l) of the attestation scale has low communality (.14) and a fairly low factor loading (.31). We did not eliminate these scales, however, since it would have impaired the empirical picture of spiritual caregivers’ perception of their personal identity. 4 Emphasis on the passivity of human identity correlates positively with recognition of the transience of life—and, related to that, mortality—as key factors in patients’ experience (Pearson’s R: .19; signiﬁcant at 0.01 level).

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Worldview-Related Dimension of Identity

Having expounded the concept of identity according to Ricoeur’s narrative anthropology, we come to the second question to be considered in this chapter: what dimension of spiritual caregivers’ identity relates to their worldview? To conceptualise this dimension we once again turn to Cliﬀord Geertz. His approach to worldviews concurs with Ricoeur’s concept of identity as follows. Ricoeur worked out a narrative view of identity, based on the premise of language. In people’s stories, Ricoeur (1986, 253–266) argues, linguistic symbols occupy a focal position. Geertz’s approach to worldviews likewise focuses on symbols: the worldviews of individuals and groups centre on linguistic symbols. Not surprisingly, these two authors inspired each other. Ricoeur takes over Geertz’s ideas on the constitutive role of narratives in the identity of societies and their individual members and the importance of symbols in these stories (Ricoeur, 1986, 256–281; 2000, 100–102). Geertz, too, cites Ricoeur as a source of inspiration, inter alia for his theory of symbols (Geertz, 1973, 4–5; 1989, 9). The advantage of Geertz’s approach to worldview is that it accommodates both religions and humanistic worldviews, as will be seen below. In spiritual care one deals with both kinds. We now look more closely at Geertz’s theory of worldviews (4.2.1). Then we examine the worldview-related dimension of spiritual caregivers’ identity according to their own perceptions (4.2.2). 4.2.1

Worldview-related dimension of identity

In his cultural anthropological research among groups and peoples Geertz analysed the worldviews he encountered among them. In Western countries it struck him that worldviews are gaining ground in the secularised public domain (Geertz, 2000, 170–172). As noted in 1.1.2, Geertz (1973, 90) deﬁnes a worldview as “a system of symbols, which acts to establish powerful, pervasive and long-lasting moods and motivations in men by formulating conceptions of a general order of existence and clothing these conceptions with such an aura of factuality that the moods and motivations seem uniquely realistic”. Hence his premise is that, like the rest of human culture, worldviews are systems of symbols. He sees people as dependent on symbols and symbolic systems for their interpretation of the world. Symbols are meanings expressed in concrete, observable form (Geertz,

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1973, 91–94, 99). This is most pertinently highlighted when human life comes up against its limits. Geertz distinguishes between three such boundary situations: the limit to the human capacity for meaning (he calls it a ‘deep disquiet’); the limit to endurance of suﬀering; and the limit to moral judgment of evil. Worldviews originate against the background of what people experience as the inadequacy of a common sense attitude in boundary situations. Worldviews put everyday realities in an ultimate context, thus enabling people to cope with these boundaries (Geertz, 1968, 95, 110; 1973, 100–108). One can approach the concept of worldview either substantatively or functionally. Substantatively one would speak of a worldview if one adopts a substantative position on the existence of ultimate reality; in Western cultures this would apply mainly to the world religions and humanism (cf. Van der Ven, 1998b, 8; Speelman, 2001, 48). Functionally it includes all phenomena that function as worldviews. Thus one could regard health, sport, music and the economy as worldviews (cf. Ter Borg, 2000, 23–43; 2004). For pragmatic reasons we do not exclude the functional approach—spiritual caregivers do have to deal with it in their work. In 3.1.1, for instance, we looked at medicalisation as a worldview. But our main focus is substantive worldviews because of their content: according to Geertz worldviews centre on a perception of ultimate reality. In this regard he refers to a general order of existence; he also uses synonymous terms such as ‘cosmic framework’, ‘cosmic order’, ‘conception of all-pervading vitality’ and ‘wider sphere’. This category comprehends both nonreligious and religious worldviews. We shall now explore the dimensions contained in Geertz’s deﬁnition of a worldview: worldview-related culture, worldview-related meaning and worldview-related ritualism. Worldview-related culture comprises elements pertaining to worldviews that people encounter in their living environment and their social relations with others in time. Worldview-related meaning concerns the way individuals symbolically construe a worldview in relation to the general order of existence. Here we shall look more particularly at religiously and nonreligiously symbolised ultimate reality and at how people’s various ways of handling suﬀering and death are symbolised. Finally, worldview-related ritualism refers to symbolic actions that establish a link between everyday reality and a symbolic order (cf. Inglis, 2000, 119).

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Worldview-related culture People do not evolve their worldviews from scratch. They come across various notions derived from worldviews in their cultural environment. They adopt a stance towards these notions and work out their own worldviews in a dialectical relation to them. Individual symbolisation occurs in the context of cultural symbolisation. A culture’s worldview includes both current and historical inﬂuences on individuals’ construction of a worldview. Geertz points out that the symbols in worldviews are more than just reﬂections of social reality: they constitute that reality. There can be no personal worldview without these socially transmitted, culturally objectiﬁed symbols (Geertz 1968, 18–19, 92;1973, 12–13, 119–122; 2000, 170–184; cf. Inglis, 2000, 121). In Ricoeur’s terminology one would say that people create their personal narratives on the basis of the narrative traditions in which they were brought up. By appropriating texts from the major worldviews’ traditions they come to understand themselves (Ricoeur, 1986, 117). In Geertz’s terminology one would say that people create order out of the chaos of life on the basis of symbolic systems that their culture has developed for the purpose. Individual praxis is socio-culturally symbolic (Geertz, 1973, 9–10). Hence we regard a worldview as a socio-cultural process. All this is encapsulated by the term ‘collective worldview’: it shapes individual meaning and in its turn is shaped by individual meanings. This does not mean that the dialectic between individual and collective worldview proceeds without any dynamics, jolts or ﬂuctuations. On the contrary. In Western societies it is inﬂuenced by three processes: de-institutionalisation, de-traditionalisation and multiple worldviews (Hellemans, 2001, 9–11). We shall discuss de-institutionalisation and de-traditionalisation together, because they are interrelated in what is known as the individualisation of society and worldviews (Peters & Schepers, 2000, 41–44). De-institutionalisation refers to the gradual erosion—as regards both participation and importance—of traditional institutions, and de-traditionalisation to dwindling agreement with the traditional ideas conveyed by these institutions. The process of de-institutionalisation means that institutions are becoming less powerful. Research shows that this does not apply to all institutions—for instance, not to those associated with leisure time and welfare. But worldview-related institutions are subject to de-institutionalisation: their membership and participation in their ritual activities are declining (De Hart, 2005,

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57–61; Peters, Felling & Scheepers, 2000, 67–96; Peters & Schepers, 2000, 238–240). It has been pointed out that churches try to counteract their members’ lack of involvement by increasingly adapting to the environment. The result, it appears, is a further decline in involvement: the less they distinguish themselves from the environment, the less challenged people feel to become or remain members of these institutions (Sengers, 2003, 137–162). Worldview-related deinstitutionalisation is a self-generating process: the more people leave the institution, the more undecided members are tempted to follow suit (De Graaf, 2002, 11–12). The process of de-traditionalisation relates to the current phase of ‘high modernity’ (cf. Beck, 2004), in which traditions and their set patterns are being stripped away. What remains are empty customs, that is, customs devoid of the meaning traditionally assigned to them. The only way traditions can survive is either in the form of fundamentalism or in open, argumentative communication with other traditions (Giddens, 1994, 66–105). Empirical research shows that de-traditionalisation is by no means total at this stage. People have not totally lost their trust in traditional institutions such as churches, although there is a downward trend. It also appears that the number of people who explicitly subscribe to the traditional images of the Christian faith is stabilising (Peeters & Schepers, 2000, 240–241; Becker & De Wit, 2000, 30–31). Hence we can only speak of relative de-traditionalisation. The result of de-institutionalisation is not that there are no worldviewaﬃliated institutions left, but that the existing ones are seen as just one possible structural form alongside other institutions (Hellemans & Tieleman, 2001, 33–35). The result of de-traditionalisation is that people are open to diverse worldviews. This openness is what we mean by a multiple worldview. It refers to the plurality of worldviews in society and the possibility of associating with various traditions by adopting diﬀerent perspectives. Openness to other worldviews accords with our ‘high modern’ culture: people increasingly come into contact with other worldviews and are challenged to account for their own position in communication with these. The openness generated by a multiple worldview does not mean detachment from the cultural tradition in which one was raised; after all, no-one is born without cultural baggage (Arts, 2000, 83–86; Maas, 1998, 22). But neither does one always have an insider perspective on that baggage. Because of the plurality of worldviews one may adopt an outsider view, not only of other worldviews but also of one’s own (Van der Ven, 2004,

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165–176). Interaction with diﬀerent worldviews from diﬀerent perspectives can enrich one’s own worldview (Dupont & Hermans, 2003, 54; Jespers, 1999, 36–38; Sterkens, 2001, 63–73). Worldview-related meaning We have said that cultures provide a broad framework within which individuals assign meaning to the world in terms of their worldviews. On the one hand these individual meanings are embedded in the worldview of that culture, on the other they concretise it. These individual meanings have a cognitive and an aﬀective side. Cognitions are ideas about things that are fundamental to human life and the world. Geertz calls worldview-related ideas symbolic transformations of reality. Adherents of a particular worldview assume that their ideas are rooted in reality itself. They believe in the reality of their symbolic transformations, hence Geertz refers to them as beliefs. In part these beliefs are descriptive models of reality, but they also oﬀer normative models for reality. Models of reality mean that people’s beliefs oﬀer them “a graspable depiction of that reality”; models for reality mean that the beliefs oﬀer guidelines for proper behaviour. People assume that there is an indissoluble connection between the way things are and the way they ought to live. As noted already, such beliefs counteract chaos and are considered to bring or restore order to human life. In the face of all sorts of contradictions, perplexities and discontinuity they give life universal meaning (Geertz, 1960, 28–29; 1968, 97–98; 1973, 93–94). Beliefs create an aﬀective orientation. Geertz associates the aﬀective side of worldview-related meaning with moods and motivations that a worldview engenders in people. By motivations he means fairly permanent emotional orientations to certain actions. Beliefs create a motivation to continue seeing the symbolised models of reality as meaningful and to concretise the symbolised models for reality in actions. Moods, on the other hand, are determined by particular conditions. Motivations have an orientation, moods merely have a certain intensity. Geertz describes motivations and moods as powerful, profound and lasting. They determine “the tone, character, and quality of their life, its moral and aesthetic style and mood; it is the underlying attitude toward themselves and their world that life reﬂects” (Geertz, 1973, 127). Together with moods, motivations colour people’s cognitive slant on reality; they make beliefs convincing (Geertz, 1960, 373–381; 1966, 40–41). This gives worldview-related

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meanings a permanent ﬂow. The individual comes to realise that they provide the only meaningful way of coping with reality, especially in boundary situations (Geertz, 1973, 94–97, 104, 122; cf. Hanegraaﬀ, 1999, 345–346). We now turn to individual meanings in relation to three key themes: ultimate reality, suﬀering and death. Ultimate reality According to Geertz’s theory, formulated conceptions of a general order of existence form the core of every worldview. They determine people’s perception of the relation between reality here and now and the symbolised, ultimate reality. By and large ultimate reality can be assigned two diﬀerent meanings: religious and nonreligious meaning. Among religious meanings one can further diﬀerentiate between transcendent, immanent and transcendent-immanent meaning. Among nonreligious meanings one can diﬀerentiate between immanent and atheistic meaning. Let us examine these distinctions more closely. First we look at religious meaning. Religious worldviews always profess some concept of transcendent reality, usually referred to as God or the divine. References to God or the divine are focal in their speciﬁcally religious speech acts. Poetic expressions in particular open up a transcendent reality (Ricoeur, 1995a, 38–71, 215–235). We shall now look at theism and deism, which put the accent on God’s transcendence; pantheism, which focuses on God’s immanence; and panentheism, which occupies a position midway between theism and deism on the one hand and pantheism on the other. These terms refer to people’s everyday ideas about ultimate reality, but also to philosophical and theological theories as a critical systematisation of that lived faith (Van der Ven, 1998b, 173–174). Firstly, there is theism. The basis for this view of God lies in the Greek philosophy of Plato and Aristotle. In modernity it takes the form of a reaction against burgeoning atheism and materialism. Theism has three aspects: a cosmological, a religious and a philosophical aspect. The cosmological aspect implies that God is the ultimate ground for explaining the world and its order. The religious aspect is that God does not coincide with the world but transcends it and acts independently of it. The philosophical aspect implies that this view of God is not based on the revelation of any particular religion but forms the common core of all monotheistic religions; this is theism’s attempt to overcome the contradictions between

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Christian denominations and even between monotheistic religions generally. On this basis proponents of theism work with a speciﬁc God concept and are particularly concerned with what was once termed ‘proofs of God’s existence’ (Dalferth, 2003, 257–274). The theistic God concept puts the accent on God’s transcendence and personal character. The following divine attributes are identiﬁed: he is perfect and eternal, immune to suﬀering and powers, omniscient, omnipotent, omnipresent. God is absolute reality, increate creator of all that exists, beyond whom nothing greater can be contemplated. This divine being created the whole of reality and continues to do so. The existence of this transcendent, personal God can be conceived of intellectually, as articulated in the so-called proofs of his existence. By way of these proofs theists ﬁnd arguments to prove the possibility, necessity, reality and singularity of God. Possibility implies that the concept of God is coherent. Necessity means that such a being is absolutely necessary—an ontological proof. Reality is inferred from the existence and nature of the world, hence a cosmological proof. God’s singularity entails the existence of only one supreme being, based on the uniqueness and singularity of this world. The argumentation can be deductive or inductive, based on the existence of the world and its regulating structures, divine worship in history and subjective awareness or conceptions of God. Whereas traditional theism tried mainly to prove God’s existence (i.e. adduce positive arguments for his existence or refute arguments for his non-existence), modern theism seeks mainly to justify belief in God’s existence, again with the aid of positive arguments or refutations of criticism. A major theistic problem—that of reconciling God’s love and omnipotence with the reality of evil and innocent suﬀering— will be examined below (Dalferth, 1994, 15–43; 2003, 274–283). Like theism, deism positions itself at the pole of God’s transcendence. It has a positive and a negative aspect. On the negative side, in contrast to theism, it radically rejects any form of divine revelation and salviﬁc involvement in creation. Revelational religions are considered incompatible with science, which is a major yardstick for deists. On the positive side it entails a kind of natural religion in response to the natural sciences’ erosion of God’s plausibility. Deists maintain that God set the world in motion, whereupon he withdrew from it. God is the ultimate hypothesis at the root of reality, the cause of the cosmos. In his absolute transcendence God exercises no inﬂuence whatever on the course of history and individual lives.

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Compared with theism, the deistic God cannot be described as a living God. God leaves creaturely reality to its own laws, which he instituted in the world and which science is gradually discovering. For knowledge of God, therefore, we should turn to nature rather than to the Bible or the Qur’an. Theologians have tried to adapt the Christian God concept to deism, concentrating mainly on the principle of a divine substructure in nature. Nowadays deism is reﬂected in such beliefs as the following: God set the world in motion, but the subsequent history of creation can only be grasped and inﬂuenced by the intellect (Locke); human beings have the task of executing the divine moral scheme in creation (Shaftesbury); divine providence exists in the sense of an overall design for a good life for humankind (Huchtenson) (Dalferth, 2003, 261–262; Kraus, 1994, 75–77; Wildiers, 1977, 207–215, 271–275). The other pole of the continuum representing the relation between transcendence and immanence is pantheism. This approach identiﬁes the absolute with reality as a whole, that is to say, transcendence and immanence (all but) merge. Spinoza is the father of this approach. Like the deists, he conceived of God purely philosophically. God is known through the rational mind, not through revelation; the laws of logic are God’s own thoughts and express his essence. Pantheism diﬀers from theism and deism in respect of the proper category to indicate the relation between God and the world. To theists and deists God is the cause and the world the eﬀect, hence world is dependent on God. To pantheists there is no such thing as a transcendent God who can arbitrarily intervene in nature. They reject the notion of an extramundane relation between God and reality. For, says Spinoza, that would imply two substances, neither of which would be inﬁnite because the one would be limited by the other. There is only one all-embracing substance: deus sive natura. All that exists is in God and nothing can exist or be conceived of without him. Everything that exists is characterised by an inﬁnite number of divine attributes, of which we know two: intellect and extension. Accordingly human beings consist of mind (intellect) and body (extension). One could call God the mind of the world and the world the extension or body of God. Things exist only in a necessary, perfect manner. Whereas deism claims that after creating the world God left it to its own laws, pantheism sees God as the permanent guarantee of the perfect laws of nature (Meckenstock, 1994, 117–129; Wildiers, 1977, 200–207).

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Panentheism occupies an intermediate position between theism and deism on the one hand and pantheism on the other. It is a transcendent-immanent approach that seeks to link transcendence and immanence in God. According to this approach the divine is not a wholly supernatural omnipotence but an immanent energy in all living beings and the driving force in human history. The distinctive character of God’s transcendence—that is, his presence in actual life—requires immanence (Van der Ven, 2001b, 69–71). The ﬁrst major attempt in modern times to integrate God’s immanence with his transcendence was made by Schleiermacher. In describing God’s love and wisdom he put the accent on the union of God’s transcendent being with human nature; this self-communication by God introduces order and purpose into the world (Schleiermacher, 1980, 344–356). The transcendent-immanent approach is typical of the transformation of Christian belief in recent times. One could call it a humanisation of God’s image, partly as a result of modern exegesis (Häring, 2001, 9–20). It gives God’s transcendence a biblical basis, invoking his holiness and glory, his omnipresence and eternity, and the prohibition of images. His immanence is biblically substantiated with reference to his activity in the natural order and— salviﬁcally—in human history. Jesus’ discourses on God’s kingdom in the New Testament convey a perception of God as both distant and near (Kraus, 1994, 128–144, 183–185). Process theology concentrates particularly on the relation between God’s transcendence and his immanence. On the one hand it stresses his transcendence. In Whitehead’s theory it is called the primordial side of God’s nature: ontologically God, the unmoved mover, antedates the world. That primordial nature has no notion of consciousness, love or hatred; its sole concern is the creation of the physical world (Whitehead, 1978, 164, 220, 344–345; cf. Oomen, 1998, 266–268, 292–294). On the other hand Whitehead refers to the consequent side of God’s nature. By this he means that God also has physical aspects: from a worldly perspective the world inﬂuences God, from God’s perspective he encompasses the world. The consequent side of his nature does have consciousness, implying that God also has an immanent side. Immanence inﬂuences transcendence. But we should not take this to mean that God is dependent on the world. God deals with the world in absolute independence and the primordial side of his nature is not inﬂuenced by its consequent side (Whitehead, 1978, 344–351; cf. Oomen, 1998, 303–306).

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Process theologians, notably Hartshorne, developed Whitehead’s notion of God’s consequent nature further (Hartshorne calls it his concrete aspect). The crucial category in speculation on God is not inﬁnitude but all-encompassment—what Hartshorne calls surrelativism. God is in everything and everything is in God. He is seen as the primary condition for human autonomy and as the origin and end of history; he is called Lord of all possibilities (in terms of his abstract aspect) and Lord of all existing realities (in terms of his concrete aspect). God is both cause and eﬀect. The universe is grounded in God and God is in the world as a concrete presence. In contrast to pantheism, this world is contingent: everything in the world could have been diﬀerent. God had the choice to create a physical world with certain attributes. The real God is the one known in particular religious traditions. In this sense God, too, is individual: “this is with the understanding that, as the unique because unsurpassable individual, he is also absolute cosmic or universal in his capacities, interacting with all others, relevant to all contexts, and in this sense absolute universal—the only strict universal individual, or individual universal” (Hartshorne, 1967, 136). Hartshorne sees this as expressing belief in a personal God who is personally concerned with every human being and who sees to it that good vanquishes evil. Some scholars maintain that by stressing both the immanent nature of God’s transcendence and the transcendent nature of his immanence, this God concept accords better with the Judaeo-Christian tradition than one which locates him exclusively at either the transcendent or the immanent pole (Hartshorne, 1976, 12–20, Peacocke, 2004; Van der Veken, 1990; Van der Ven, 1998b, 159–161). Apart from religious interpretations there are nonreligious ones, which have two dimensions: one immanent, the other atheistic. By the term ‘immanentism’ we mean total earthly immanence (Peters, 1996, 18–26). According to this approach the meaning of life lies wholly in this world. Good and evil reside in human beings, who have to ﬁnd a way of making the best of things. A typical representative of immanentism is humanism. Like modern theism, deism, pantheism and atheism, modern humanism has its roots in the Enlightenment. From that time onwards human beings and human dignity increasingly became the sole premise and goal (cf. 2.2.1). Modernity brought secularisation and critique of religion, partly because it broke with tradition, partly because it broke with a transcendent moral order in favour of moral autonomy (Beck, 2004).

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Radical immanentism is apparent in such famous declarations as the American Humanist Manifesto (1933) and the Amsterdam Declaration (1952). In the Humanist Manifesto many prominent scientists of that era based themselves on such premises as the following: “Man will learn to face the crises of life in terms of his knowledge of their naturalness and probability. We assume that humanism will take the path of social and mental hygiene and discourage sentimental and unreal hopes and wishful thinking.” The updated version of the Amsterdam Declaration of 2002 states that “humanism recognises that reliable knowledge of the world and ourselves arises through a continuing process of observation, evaluation, and revision; humanists believe that morality is an intrinsic part of human nature based on understanding and a concern for others, needing no external sanction”. Humanism has its own emphases regarding the source of knowledge about ultimate reality, the nature of that reality and the consequences for behaviour. Firstly, it relies entirely on human reason to explain reality. In this respect it concurs with deism, pantheism and atheism. Over against heteronomy (the authority of tradition) humanism invokes autonomy (the ability to think for oneself ). Human beings have to ﬁnd answers to ultimate questions for themselves and they can do so only on the basis of rational, scientiﬁc insight. This independence is invariably cited as a hallmark of humanism and has an emancipatory, progressive outlook. Religion, too, assigns human rationality and autonomy some importance. Secondly, human beings and this world are the ultimate reality. Over against a theocentric worldview of human subordination to God, humanism presents an anthropocentric worldview premised wholly on human dignity and freedom. Modern theology likewise acknowledges the new, anthropocentric worldview. Humanism assumes that the deeper purpose of human life can be found only in this world. Human beings form part of an intramundane order; they are links in the totality of ﬁnite reality. The world functions without any empirically or scientiﬁcally demonstrable goal; in itself it does not reveal any particular meaning. For the sake of completeness: such an accent on assigning meaning, as opposed to ﬁnding it in the real world, also features in religions. “Humanists regard the universe as self-existing and not created. Humanism asserts that the nature of the universe depicted by modern science makes unacceptable any supernatural or cosmic guarantees of human values” (Humanist Manifesto). A minority of humanists leave some leeway for a kind of transcendence, but it is certainly not focal in their

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thinking about ultimate reality. Thus one hears about horizontal transcendence; this refers to experiences that put people in contact both with the here and now and with a future that surpasses it: transcendence is a horizon towards which people could evolve (Van den Ende, 2005, 396– 398). Thirdly, humanism implies people’s personal and collective responsibility to think for themselves and coexist. Here the signiﬁcance and coherence of autonomous decisions are decisive. Through the inspiration of normative narratives and texts from the cultural tradition of humankind values such as equality and tolerance will hopefully be fostered (Boelaars, 1997, 18–31, 54–82; Duyndam, 2005, 163–166; Kuijlman, 2001, 18–31; Kunneman, 1997, 284–288; Ten Kate, 2005, 143–146). Finally there are atheistic meanings. This should not be confused with anti-theism, which can mean combative, militant a-theism. In modern times atheism was initiated by Comte and Feuerbach, but it became inﬂuential mainly through the circulation of the writings of Marx, Freud and Nietzsche. Atheism has three features in common with humanism: rejection of the authority of the Bible and other revelational books, in which respect it also concurs with deism; a focus on human beings and this world as the ultimate reality; and an emphasis on personal and social responsibility. Atheism rejects God in favour of human beings: atheism is humanism (Dalferth, 2003, 267).5 A peculiarity of atheism is its emphasis on arguments for repudiating God’s existence and, concomitantly, any created order or connection between religion and morality. Arguments for denying God’s existence may range from rejection of the God concept prevalent in the atheist’s own culture to denial of any form of extramundane reality. The ﬁrst variant entails rejection of cultural representations of God: what is presented as God does not meet the philosophical criteria one could set for such a term. Thus some Greek philosophers were branded atheists by their contemporaries because of their rejection of polytheism, and more recently people like Spinoza, who also propounded a version of God that did not conform to an ultimate reality. But rejecting the God of monotheistic religions does not imply outright rejection of ultimate reality—a reality that explains why there is something rather than nothing and why everything is 5 In the Netherlands humanism used to be predominantly atheistic; in recent times it has come to include an agnostic trend and even a religious one (cf. Glastra van Loon, 1995; Kuijlman, 2001; Ringoet, 1998, 41–43).

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the way it is (Hoheisel, 1993, 1132; Honnefelder, 1993, 1133–1135). The second variant of atheism, which rejects any form of extramundane reality, maintains that assigning ultimate reality to a symbolic world is a projection by an individual or a community. It denies the existence of any reality that cannot be scientiﬁcally proved or observed. To these atheists the philosophical proofs of God’s existence advanced by theism and deism are not scientiﬁc (which, strictly speaking, they never were in Christian theology either), hence they dismiss the very notion of God as a metaphysical abstraction. Radical atheism implies both godlessness in the sense of the absence of any notion of God in the sciences, and denial of God in everyday life. It does not deny that people can have so-called religious experiences but rejects the possibility of any supernatural cause of such experience. Belief in God is considered mythological, belonging to some more or less primitive stage of human evolution. The idea of God is a projection of human possibilities: God is assigned qualiﬁcations that actually apply to human beings. Belief in God is an excuse to dodge personal freedom and responsibility. God symbolises an almighty father who protects his children against the contingency of life. Research has shown that atheists are particularly opposed to the authoritative and legal functions of God as a father (Seckler, 1993, 1135–1137; Vergote, 1984, 207–209). This leads to an appeal to human beings to rise from the dead and become truly human.6 Instead of taking refuge in religion they should join the battle against oppressive economic and social structures; human beings are accountable for their own ethical ideals and moral norms and cannot evoke eternal norms and values, for these do not exist in their own right. Denial of the existence of God the supreme being and of a created order in the world go hand in hand; its concomitant is aﬃrmation of the presence of inexplicable evil and innocent suﬀering in the world, which is our next topic (Dalferth, 1994, 27–28; Dethier, 1995, 27–30, 37–38; Stroeken, 2005; Thiry, 1997, 94–107; Van der Ven, 1998b, 174–175). Suﬀering Geertz’s conception of a general order of existence includes beliefs, moods and motivations in the face of boundary situations. 6 “Croire en Dieu ce serait péché d’orgueil ; l’athéisme est une forme d’humilité. Cest se prendre pour un animal, comme nous sommes en eﬀet, et nous laisser la charge de devenir humains” (Comte-Sponville, 1999).

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Sooner or later every human life is marked by suﬀering. This experience contrasts with the notion that humans can save themselves, curb misfortune and always have happiness within reach. Suﬀering is an existential problem that confronts people with the question of the meaning of life. At the same time it challenges them to alleviate or eliminate suﬀering wherever possible (De Roest, 2004; De Visscher, 1992, 78; Luther, 1992, 168). Geertz considers it a distinctive feature of worldviews that they can make experiences of suﬀering meaningful, which is not the same as denying their reality. Geertz sees suﬀering pre-eminently as a problem for worldviews. It challenges worldviews to teach people “not how to avoid suﬀering but how to suﬀer, how to make of physical pain, personal loss, worldly defeat, or the helpless contemplation of others’ agony something bearable, supportable—something, as we say, suﬀerable” (Geertz, 1973, 104). Depending on what worldview one espouses one can speak of theodicy, anthropodicy or cosmodicy. Theodicy relates suﬀering to a God concept, anthropodicy to a concept of human beings and cosmodicy to a perception of the cosmos. At this stage systematic theorising on anthropodicy and cosmodicy is limited (cf. Van der Ven, 1998b, 214), hence our discussion is conﬁned to theodicy. Among religious worldviews the experience of suﬀering is the topic of what is known as the theodicy debate: how can belief in God be justiﬁed in the face of suﬀering, or how can the experience of suﬀering be reconciled with belief in an omnipotent, benevolent creator? Various religious traditions have pondered the possibility of associating the experience of suﬀering with God. Van der Ven deﬁnes theodicy as an enlightened attempt to account for God’s existence in the context of evil and suﬀering in the world (Van der Ven, 1989, 5–27; 1994a, 227). Van der Ven identiﬁes seven theodicy models in the literature: an apathy model, a retribution model, a plan model, a developmental model, a solidarity model, a substitution model and a mystical model. Each model has a particular slant on God’s existence in the face of suﬀering. The seven models can be ranged on a continuum, with one pole accentuating God’s transcendence and the other his immanence. Three models may be located at the transcendent pole: apathy, retaliation and plan. Three may be located at the immanent pole: solidarity, substitution and mysticism. The developmental model occupies a position midway between the extremes (Van der Ven, 1994a,

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198–200; 1987; 1998b, 212–214; cf. Vermeer, 1999, 22–52; Vossen & Van der Ven, 1995, 13–19; cf. Depoortere, 2000). Let us ﬁrst consider the three models at the pole of God’s transcendence. The apathy model is based on the view that God keeps aloof from suﬀering. He neither invented it nor brought it about. He is not aﬀected by suﬀering and lets it take its course. God and suﬀering have nothing to do with each other. Pondering the meaning of suﬀering and reﬂecting on God’s existence are separate, unrelated exercises. This model presents God as perennially unmoved. This means that he does not actively will suﬀering: God contemplates human suﬀering from a distance. In that suﬀering he is the one ﬁxed point. The retribution model rests on the assumption that suﬀering is divine retribution for people’s sins. God wills or permits human suﬀering. Evil is requited with evil, a law of cause and eﬀect. Retribution aﬄicts individuals, groups and generations. It may strike here and now, or at the end of time. God’s image is that of an allpowerful, righteous judge. Augustine laid the foundation for this model with his accent on the image of God as a judge. In his omnipotence God remains strictly separate from the world. People abuse their freedom and therefore they have to suﬀer. This is not necessarily a matter of individual sins but could imply the original sinfulness of all humankind. With reference to this model Weber distinguishes between direct retribution in this world and retribution at the end of time (Weber, 1972, 314–319). The plan model is based on the notion that suﬀering has a place in God’s design for history. A hallmark of this model is its teleological orientation. Depending on the perspective, the plan could be for the whole world or for an individual. At the end of time it will become clear that all suﬀering was for the good and helped to perfect creation. The images of God in this model are those of omnipotence and love, as well as the image of divine providence. Suﬀering is put in a broader context of time and space. A prominent exponent of the plan model is Leibniz. In his view God created the best of all worlds and countenances the suﬀering happening in it as a consequence of human free will. Where the aim of all living beings is to achieve harmony, one could say that what in fact exists is the best or most harmonious (Leibniz, 2004, 67; 1996, 119–130, 165–175). Thus the model safeguards God’s goodness by accentuating the goodness of his creation. The Protestant tradition in particular followed

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this model with its doctrine of predestination: God provides everything, including the meaning of the suﬀering of his elect. Next we consider three models at the pole of God’s immanence. The solidarity model rests on the premise that God has compassion with suﬀerers and in this closeness comforts them. There is no relation between sin and suﬀering; suﬀering in itself is meaningless and remains an enigma. But the presence of God’s love makes it more bearable. The image of God is that of loving, defenceless supremacy— helplessness in the face of suﬀering and supremacy in love. This God concept is also known as that of the guiding suﬀerer. One could say that because of his love for human beings God needs humankind in order to exist; people that respond to his love contribute to his reality here and now. This God image is associated with the ﬁgure of Jesus. He severed the connection between suﬀering and sin and in his preaching depicted God’s kingdom as a way of life that brings salvation and healing to suﬀerers. Despite biblical texts that substantiate this model, Christian theology has been loath to tackle it. The main proponents are Moltmann and the process theologians. According to Moltmann Jesus’ passion is the crux of Christianity; the emphasis should not be on God’s absoluteness and freedom as much as on his Leidenschaft and concern for people, interpreted in terms of the biblical history of the covenant. In that sense one could speak of God’s pathos and a form of divine self-humiliation (Moltmann, 1981, 136–146; 1972, 255–267). The process theologian Surin (1989, 59–68) points out that divine omnipotence is not the only power in the world, hence there is scope for the use (and abuse) of human freedom in regard to suﬀering. The substitution model assumes that God has solidarity with suﬀering humans and presents self-sacriﬁce as a way to salvation. This inspires people to sacriﬁce themselves for others. The innocent suﬀerer takes the place of a solidary God through her self-surrender to other suﬀerers. The God concept is that of omnipotence and love enacted in an eschatological perspective—that of liberation from suﬀering and death as manifested in the death and resurrection of Jesus Christ. The God concept is linked with the image of the suﬀering servant (Deutero-Isaiah) and Jesus Christ’s vicarious suﬀering. Love is expressed in solidarity with others who suﬀer or with suﬀering humankind as a whole. A proponent of this approach to suﬀering is Sölle. If suﬀering and the concomitant dependence on others are accepted, it creates scope for someone who will stand in for the

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suﬀerer. That is one side of substitution, from the perspective of those at the receiving end. The other side is people’s responsibility for each other. That is substitution from the perspective of those who stand in for others. In this sense Sölle’s substitution model could be called a social approach (Sölle, 1983, 35–49; cf. Depoortere, 2000, 33–36). Thirdly, the mystical model rests on the assumption that suﬀering establishes an intimate relationship between God and human beings. Suﬀering remains an enigma; in their suﬀering people experience remoteness from a loving God and long to be united with him. Suﬀering in all its many forms is transformed into a kind of mystical suﬀering caused by separation from God. The God concept is that of intimate love for human beings. God does not use human suﬀering. Like the previous model, this one has been highlighted in recent times in the work of Sölle. She emphasises that it is not a form of ‘dolour-ism’ but rather a being-in-God, as manifested, for instance, in the story of Job, the work of St John of the Cross and that of Edith Stein. Contemplation of innocent suﬀerers addresses an appeal to remain in some sort of inconsolable state that only God can resolve (Sölle, 1997, 174–201). Finally we turn to the model that occupies an intermediate position on the continuum between God’s transcendence and his immanence: the developmental model. Here the premise is that God sees suﬀering as a means of puriﬁcation, in other words, an educative tool. For this reason it is also called the therapeutic model. The God concept is that of a loving parent chastising her or his children. The positive eﬀects are usually experienced only after the suﬀering is over; while they are suﬀering people feel more or less cut oﬀ from God. Sometimes the parent is perceived as cruel, particularly in the case of innocent victims like small children or handicapped persons. On these grounds process theologians reject the notion that people are perfected through suﬀering; at the same time they hold that God inspires people to use all experience, including suﬀering, as opportunities for growth: suﬀering can contribute to a greater sense of identity, more communication with others, and healing (Whitney, 1985, 168; McWilliams, 1985, 131–132). Death According to Geertz the contingency of life, and with it mortality, is one of the boundary situations that challenge people to symbolisation by way of a worldview. The boundary of time, partly

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conditioned by mortality, raises the question: is death really the end? As in the case of suﬀering, we conﬁne ourselves to attitudes towards death; hence we leave out of account such questions as how caregivers’ actions can postpone, palliate or hasten death (Schwemmer, 1997, 15–29). All worldviews oﬀer one or more answers to questions about death. In contrast to the approach to suﬀering, nonreligious worldviews also present systematic approaches to death (cf. Plantier, 1996, 806–810; Spiro, Curnen & Wandel, 1996, 111–183). Ideas about death have evolved in the course of Western history (Wandel, 1996, 1–15). Ariès found that the cosmological perspective on an end-time gradually became individualised to personal destiny. And life after death is conceptualised less and less in spatial terms as a heaven; instead there is a growing tendency to anticipate some sort of future in the temporal dimension. Like the belief in purgatory, belief in hell is also declining, and with it the feelings of guilt and fear that dominated the experience of death in the Middle Ages (Ariès, 1977). In present-day Western cultures there are mainly four attitudes to death: Judaeo-Christian, reincarnationist, agnostic and immanentist attitudes (Schreiber & Siemons, 2003; Van ’t Spijker, 1999). Judaism presents several approaches to death. The Old Testament view of death is by no means uniform. Some texts mention Sheol, a nether world from which no-one returns (e.g. Gen. 37:35; Ps. 30:4; Job 11:8). The dead who dwell there have left life behind; there is no hope of salvation. Elsewhere in the Old Testament Sheol is not depicted in spatial terms but as death’s encroachment on life (e.g. Ps. 30:4; Ps. 55:16); when aﬄicted by illness, calamity or persecution people imagine they are in Sheol. The New Testament, too, still speaks about the realm of death, whose denizens have no active life (e.g. Acts 2:27; cf. Schwemmer, 1997, 78–79). The last books of the Old Testament—written in the time of the second temple—cautiously hint at life after death, more especially at a resurrection and concomitant hope of an afterlife; in Hellenistic circles one also ﬁnds occasional references to an immortal soul. People started speculating about the fate of the righteous dead in anticipation of their resurrection, known as a ‘state between’ (e.g. Is. 26: 19; Ps. 88:11–13; Ps. 6:6; Bar. 2:17; Dan. 12:2; even earlier in 2 Kings 2:22). Judaic belief in the phenomenon of life after death can only be understood in terms of the belief expressed in the Old Testament writings that Yahweh was active in salvation history, which distinguishes it from

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mythical images of a repetitive cycle of life and death (Haag, 1993, 1191–1193; cf. Werlitz, 2003, 41–61). Thus Judaism provides a basis for four diﬀerent views to be found in the New Testament and the history of Christianity: a physical view entailing belief in bodily resurrection; a spiritual view entailing belief in the immortal soul; what is known as an urban model entailing belief in the new Jerusalem; and a cosmological model entailing belief in a new heaven and a new earth (Schillebeeckx, 1990, 132–134). First there is the physical view with its belief in a bodily resurrection. It relates to perfect salvation and bliss for individuals. In the New Testament it ﬁnds expression in such texts as Mark 16:1–8; Matthew 28:1–10; Luke 12:1–12; and 1 Corinthians 15:35–57. The ﬁrst three texts recount the tradition that arose about the grave in Jerusalem. The fourth text, written by Paul, is the earliest testimony to the resurrection. It is a succinct testimony, which—unlike the evangelists’ accounts—makes no mention of the empty tomb; the accent is on the fact that Jesus comes to his disciples as a living Lord. The crux of this earliest tradition is actually seeing the risen Jesus (Dunn, 2003, 864–874). The diﬀerence from the Judaic conception is that this is not just a future prospect for all people, but that in one person that future has already commenced: that gives Jesus’ resurrection eschatological signiﬁcance, with salvation as victory over death. To Christians Jesus’ resurrection has transformed death. In keeping with Jewish anthropology the resurrection does not imply continuity in a bodily sense but a new creation of the selfsame person, along with his history and relationships formed in his lifetime. Paul speaks about being raised to a spiritual body. Individual existence continues in life after death. The reference to bodily resurrection indicates that this existence has a communal basis. During the Enlightenment the notion of bodily resurrection came under pressure, partly as a result of Lessing’s publication of a text that exposed the contradictions in the relevant Easter narratives. This ruled out earlier attempts at harmonisation and made it quite evident that these are religious narratives (Dunn, 2003, 870f.; Schillebeeckx, 1970, 437–444; 1990, 133). Secondly, there is the spiritual view entailing belief in an immortal soul. Like the notion of a bodily resurrection, the perspective is that of the individual, but translated in the context of Hellenistic philosophy. Belief in an immortal soul is expressed to some extent in texts such as 1 Peter 1:9 and 2 Peter 1:4. In this respect early

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Christianity is imbedded in the religions of antiquity. The belief in the immortality of the soul developed further in dialogue with the Graeco-Roman conception of death, which makes a more radical distinction between body and soul than Judaism does. This is reﬂected in the Pauline letters, which operate in Hellenistic culture (Dunn, 2003, 839–841). In this view the emphasis is very much on Jesus’ divine nature. As a result Jesus—and, so it was believed, all human beings—share in God’s immortality and intransience. At death the soul goes to God and reaches consummation. The spiritual notion of an immortal soul and the physical concept of a bodily resurrection go hand in hand. In the course of history attention shifted from the communal concept of a body to the strictly individual concept of soul (anima separata). The critical tension between the two is expressed in the early Christian belief that the continued life of the soul is a ﬁrst step (dimidia resurrectio) in anticipation of the body’s resurrection (Greshake, 1993, 1199–1200; Kremer, 1993, 1197–1198). Nowadays the notion of the immortality of the soul is subject to criticism, since it is said to reduce the soul to a dehumanised relic (Schillebeeckx, 1970, 441–444). Thirdly, there is the urban view with its belief in the new Jerusalem. It relates to the ﬁnal salvation or radical liberation of humankind— in the future—to a community of love. This view is articulated in, for example, Revelation 21:24. The urban vision is associated with a key concept of salvation in the Old Testament. The resurrection is seen as a collective, eschatological event. Just as death cannot disrupt Jesus’ communion with God, so the believer’s communion with God will ﬁnally vanquish death. In this regard the individual and collective aspects are inseparable. Hence one cannot divorce individual resurrection from the traditional visio beata of communion with God and those who have died before. The Christian belief in life after death cannot be reduced to an individual event. Life after death is not complete while earthly history continues. Although life after death is a new creation by God, its indispensable concomitant is the anticipated achievement of salvation and liberation by the community of believers in earthly history (Greshake, 1993, 1202; Schillebeeckx, 1970, 445; 1990, 130–132). Fourthly, there is the cosmological view with its belief in a new heaven and a new earth. It relates to the eschatological consummation of the whole of creation, expressed in such texts as Revelation 14:13 and Revelation 21 and 22. The cosmological approach stems

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from the writings of the later Old Testament prophets, Trito-Isaiah, Jeremiah and Ezekiel. These books contain typical apocalyptic images of a new creation coming to humankind from God instead of the completion of history through human endeavour. This will be the blissful home of all humankind. The glory of that creation is totally new, unimagined and incomprehensible. The cosmological age should not be seen as an era that starts at the end of history. It speaks about history in an evocative sense, expressing the belief that the dead will be incorporated into the body of Christ along with many brothers and sisters in the perspective of Christus totus, the universal centre of all reality (Greshake, 1993, 1205–1206). Early Christianity focused primarily on collective resurrection and the last judgment at the end of time. As the perspective on death became increasingly individual, the urban and cosmological approaches moved into the background, although they have been taken up anew by Third World theologies and what is known as political theology. These theologies raise the Christian hope that the new life in an urban and cosmological perspective can already be realised in the structures of this world (Schillebeeckx, 1970, 445; 1990, 131–133; cf. Heyde, 2000, 134–188; Noordegraaf, 1999, 118–121). The four views described above are on the borderline between imagery and conceptual reason. They are inseparably linked with people’s religious experience as expressed in Judaeo-Christian revelational writings. In the course of history these metaphors became more focused as a result of further reﬂection (Küng, 1983, 241–242). The common denominator is belief in life after death, although this does not modify either death or earthly life. Death in itself contains no hint of a promise, but its absurdity does not have the last word. Faith in a benevolent God makes people hope for the perpetuation of the good in earthly life, of which Jesus’ resurrection is a hopeful portent. Thus the four approaches do not focus purely on what happens after this life but also incline the conduct of their exponents in a speciﬁc direction: that of caring for the human body and human health, of caring for people who have lost all hope (Schillebeeckx, 1970, 448– 450; 1990, 134). The second angle on life after death is that of reincarnation. According to this approach it is assumed that after death life continues on earth in a diﬀerent guise. It could be that of a human being or another, possibly non-human body. The interim between death and reincarnation may be brief or protracted. Actually one cannot speak

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of a reincarnationist belief, since Hinduism, Buddhism and Western trends have highly divergent views on the subject. We conﬁne ourselves to tenets in Hinduism and the modern concept of reincarnation. The doctrine of reincarnation arose quite late in the history of Hinduism, in the age of the Upanishads and the Bhagavad Gita. It derived, ﬁrstly, from a new conception of karma and, secondly, from the notion of samsara. The new conception of karma was that people’s future depended not only on bringing ritual oﬀerings—as laid down by Vedic religion—but also on their behaviour as individuals. That gave the concept of karma anthropological purport. Individuals are governed by their past, but their present behaviour co-determines their future. The aggregate of their actions determines the karma they accrue in their lifetime. “Among them, those who have good residual results of action here—earned in this world and left as residue after the enjoyment in the region of the moon—quickly reach a good womb, the womb of a Brahmana, or of a Ksatriya or of a Vaisya. But those who have bad residual results of action quickly reach an evil womb, the womb of a dog or of a hog or of a Candala” (Swahananda, 1980, 374–375). Karma is regarded as energy that continues to exist after the person’s death. This energy is not just a spiritual force but has material features. Secondly, there is the cyclic concept of samsara, the seemingly endless succession of births and deaths. Karma and samsara are closely linked. Karma manifests itself in the perpetual cycle of rebirth, resulting in a deterministic view of human life. Ordinary people aspire to happier forms of rebirth. But the sage has a diﬀerent aim: liberation from samsara. Such liberation can be achieved through union with the absolute. There are various ways of accomplishing it—detachment, studying the Vedic traditions, meditation. Release from reincarnation is not a gift from God but an immanent soteriology; the sage attains personal insight into the essence of life (Domergue, 1997, 41–48). The reincarnationist approach commonly encountered in the West these days diﬀers greatly from the Hindu conception described above. The diﬀerences concern knowledge of past lives, the concept of individuality and the experience of reincarnation as such. The premise of the modern notion of reincarnation is the belief that people have had past lives. They try to get in touch with their past lives by various means, from so-called altered states of consciousness to regression therapies and hypnosis. Thus they gain knowledge not only about their personal history but also, they maintain, about the history

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of humankind. In other words, this modern approach looks primarily to the past and past lives—an orientation of which there is little or no trace in Hinduism. Secondly, this modern approach sees reincarnation as assuring the retention of individuality and human identity. Accordingly critics claim that Western reincarnationist approaches are primarily a denial of the reality of death, based on fear of the loss of personal identity. In Hinduism, on the other hand, the cardinal aim is to merge individuality with the absolute. Finally, from the knowledge gained about past lives the modern approach concludes that people will continue to reincarnate indeﬁnitely. Viewed thus, life looks like an exciting serial. This contrasts with the Hindu approach, which is not intent on achieving reincarnation but much rather on liberation from the wheel of rebirth, which is experienced as a form of suﬀering (Domergue, 1997, 73–89; Schwemmer, 1997, 38–42; Van Kampen, 1994, 25–71). Agnosticism has two main elements: abandoning all speculation on life after death, on the basis of human beings’ limited cognitive powers. To start with the second element: agnosticism proceeds from the assumption that human cognition is limited and that people are incapable of giving exact answers to major existential questions. Human knowledge is conﬁned to the sensory domain and logic. Each experience is unique and cannot produce truth claims about the essence of things. That is the view of strict agnosticism: nobody can attain to metaphysical knowledge. This contrasts with the view of proponents of what is known as moderate agnosticism: they merely say that they themselves have no such knowledge, but do not exclude the possibility that others may achieve it (Splett, 1993, 242; Thiry, 1997, 27–73). Following from the notion of our cognitive limitations, any statement about what happens after death must acknowledge that it is an impenetrable mystery. Strict agnosticism propounds no view on the meaning of death or what happens after death, simply because it cannot be known for sure. The belief in another life after death is seen as a projection of the desire to retain a personal identity. Getting rid of that desire sets one free. Hence its proponents insist that we abandon all speculations about life hereafter; instead we should make the world here and now more liveable—in this respect agnosticism concurs with immanentism, to be discussed below. Acceptance of death sets people free. That is the thesis of existentialist philosophy, with which some theologians agree (Weger, 1993, 242–243; cf. Kuitert, 2002, 207–216, 222).

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Immanentism makes no assertions about death other than what people can experience and know about it here and now. Human sense perception and reason are undeniably limited, but the world they experience through these is the only one we have and people have to deal with it (Boelaars, 1997, 30). Immanentism has both a rational and a non-rational form. We conﬁne ourselves to the former, which has been expounded mainly since the Enlightenment. Philosophers like Feuerbach want to abolish the age-old dichotomy between Diesseits and Jenseits: the focus should be on life here and now, not on life after death. Believing in life after death is simply to live in a mirror of fantasy. The future of the human race depends entirely on scientiﬁc knowledge and expertise. In a sense human beings have become the creators of their own future. Instead of the belief in life after death, which merely seeks to obviate the limit of mortality, scientiﬁc and technological achievements can gradually extend the boundaries of life. Ideally death should be a gracious conclusion to a life well lived (Den Hertog, 1999, 316–337). Ritual dimension of worldviews The last dimension of worldviews that we identiﬁed in Geertz’s deﬁnition is the ritual dimension. He describes it as ‘clothing the conceptions with an aura of factuality’. That is precisely the function of ritual. It imparts a uniquely realistic quality to the symbols of worldviews. Rituals enable people to pass from everyday to symbolic reality, and vice versa. In rituals the everyday world is perceived as part of ultimate reality, which corrects and completes its perspective. It interrelates the model-for and the modelof reality. Rituals sustain and stimulate the symbolisation process in worldviews. Geertz cites ritual feasts—following Singer, he calls them cultural performances—as a prime example. Viewed thus worldviews are more than just interpretations of reality: they constitute the world in which we live (Geertz, 1960; 1966, 26; 1968, 92, 100, 111; 1973, 112–118, 393–394). Geertz’s approach has greatly inﬂuenced theories of ritual that adopt a cultural and symbolic approach. Rituals create a framework for the conduct of symbolic communication. In and via the ritual participants can share in the reality it evokes (Bell, 1992, 25–26; Lukken, 1999, 50–53, 86–87; Rappaport, 1999, 107–129). Rituals occupy a key position in the culture of a worldview. They both articulate and help to constitute it. As a result rituals have a great impact on the worldview-related meanings assigned by groups and individuals. For groups who adhere to a particular worldview

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rituals consolidate social relations and promote cohesion of the community; they enhance conformity and reduce cognitive and behavioural ambivalence. Particularly in times of crisis and stress rituals reinforce the common values of a worldview community and underscore the members’ commitment to each other (Bell, 1997, 27–29, 177–180; Menken-Bekius, 1998, 43–44). At the level of individual interpretation rituals engender a conviction that the beliefs of the particular worldview are credible and the behaviour they entail is good. In performing rituals individuals accept the perspective of the worldview concerned. Rituals bridge the gap between their inner and external reality. The beliefs arising from, and aﬃrmed by, rituals encompass the entire person; they experience and share them with others in everyday life (Bell, 1992, 71; Heimbrock, 1988, 10–13; cf. Lukken, 1999, 60–64). Thus rituals decisively inﬂuence people’s cognitive, emotional and social experience (McCauley, 2001, 123–133). They are a major means of coping with existential problems. When confronted with chaos and when other avenues lead nowhere—when nothing remains to be said, done or thought—there is still ritual ( Janssen, 1997, 75). Rituals often function as events marking the transition to a new social role or phase of life. These are known as rites of passage, such as those accompanying birth, conﬁrmation of a life partnership, illness and death. The term is associated with Van Gennep, who showed how what he called the ‘processual’ form of ritual epitomises experiences in social life as a sequence of changes in space and time, involving transitions in state and status for individuals and the society. Changes in individuals’ status in society are perceived as crises for both the individuals and their environment. For individuals these transitions are unique: they are born only once and certainly die only once. For societies the transitions are recurrent: they go through them countless times. To sustain these constant crises they are ritualised in rites of passage (Van Gennep, 1961, 1–25, 65). In spiritual care two kinds of rites of passage are particularly pertinent: rites of separation (e.g. funerals) and rites of transition (e.g. baptism, extreme unction). As a key dimension of worldviews rituals feature most prominently in religions. Humanistic worldviews have a long anti-ritual tradition so as to set themselves apart from religions. Rituals are the primordial language of religion. They are pre-eminently capable of evoking and establishing religious experiences. In ritual religion touches

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people. In this sense religious rituals include more than just the traditional ones; at this level, too, new rituals are invented. Religious rituals are often performed in boundary situations, such as the beginning and end of life. They have been described as religion’s ultimate answer to the experience of life’s contingency (Lukken, 1999, 101–103; Menken-Bekius, 1998, 23–25). 4.2.2

Worldview-related dimension of identity: research ﬁndings

Having explored the worldview-related dimension of identity in a theoretical perspective, let us see how spiritual caregivers perceive and assess this dimension. We analyse three umbrella concepts: the culture of worldviews, meanings assigned in worldviews, and ritualism. We identify four terms in the culture of worldviews: collective worldview, worldview-related institutions, the tradition of worldviews and multiple worldview. Under meanings assigned in worldviews we look at three terms: ultimate reality, suﬀering and death. Ritualism in worldviews yields two terms: the ritual dimension generally, and rites of passage. Worldview-related culture Within this culture we distinguish between four aspects: collective world view, worldview-related institutions, the traditions of worldviews and multiple worldview. We formulated three items for each aspect, giving us twelve items altogether. Collective worldview The culture of a worldview forms a framework in which individuals and groups interpret the world in terms of that worldview. This culture is collective, since it originates in people’s and groups’ communication with each other. We wanted to know in how far spiritual caregivers endorse the collective character of worldviews. To this end two items (f and k) were taken over, in somewhat amended form, from the study by Van der Slik (1992, 162; cf. 3.2.2). Here is an example: f. Only by discussing my beliefs with others can I discover their meaning.

Worldview institutions Social institutions are losing inﬂuence, also in the sphere of worldviews. This is known as de-institutionalisation. What are spiritual caregivers’ attitudes towards their own denomination?

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To operationalise the concept ‘worldview institution’ we adopted somewhat modiﬁed versions of items in a study of socio-cultural developments in the Netherlands (Eisinga et al., 1995, scale 2.15): g. The leadership of my world view association are perfectly equal to their task.

Traditions of worldviews People evolve their worldview in time, that is, within a particular tradition. In our ‘high modern’ society the importance of tradition is declining. What does tradition mean to spiritual caregivers? Here is an example of our operationalisation of the concept ‘tradition of worldviews’: h. Drawing strength from one’s own tradition is of fundamental signiﬁcance.

Multiple worldview Traditions can continue to be meaningful in the form of communicative self-substantiation in open dialogue with other traditions and worldviews. In view of the plurality of worldviews in society we see a multiple worldview as openness to other worldviews on the assumption that it is possible to interact with other worldviews and their traditions by adopting diﬀerent perspectives. Here is an example of our operationalisation of the concept of multiple worldview. d. Dealing with other worldviews gives me more insight into my own tradition.

The responses to these items were subjected to factor analysis. This yielded four factors, on the basis of which we constructed four scales (ﬁgure 4.2; cf. appendix 2, instrument 6 and appendix 3, table 9 and 10). The theoretical classiﬁcation into four aspects was empirically conﬁrmed. As is evident in ﬁgure 4.2, spiritual caregivers endorse Figure 4.2 Worldview-related culture Worldview-related culture

collective worldview

worldview institution

worldview tradition

multiple worldview

items: f, k mean: 2.9

items: g, l mean: 2.6

items: a, h, j mean: 3.8

items: b, d, e mean: 3.8

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the signiﬁcance of their own worldview’s tradition and the relevance of other traditions to their own worldview. They are fairly negative about their own worldview institution and are dubious about the collective character of worldviews generally.7 Finally we describe the social location of the scales based on the ﬁve personal characteristics and the institutional characteristic described in 1.3: gender, training, denomination, ministerial approval, professional association and care institution. Roman Catholic spiritual caregivers assign their own denomination a low rating (mean: 2.3); the rating of pastoral workers in their ranks is particularly low (mean: 2.1). Dutch Reformed (Nederlands Hervormde) and Reformed (Gereformeerde) spiritual caregivers rate their own denomination more highly (mean for both: 2.8). Members of the Association of Pastoral Workers (Vereniging voor Pastoraal Werkenden, VPW ) adopt a more negative attitude towards their own denomination (mean: 2.3). Spiritual caregivers who do not belong to any worldview association are ambivalent about worldview traditions (mean: 3.0). In the case of collective world view and multiple worldview we found no diﬀerentiation that met our criterion of signiﬁcance. Meanings assigned in worldviews Among the meanings assigned in worldviews we distinguish between three themes: ultimate reality, suﬀering and death. Ultimate reality According to Geertz attitudes towards ultimate reality are the crux of all worldviews. Under this theme we distinguish between religious and nonreligious meanings, and in each category we identify two types of interpretation: a panentheistic and a deistic religious interpretation, and an immanentist and an atheistic nonreligious interpretation. To measure these attitudes we used items from the study of socio-cultural developments in the Netherlands (Eisinga et al., 1995, scale 2.12.1). For each of the ﬁrst three aspects we choose two items and for the atheistic aspect we used four, hence ten items in all.

7 Openness to other traditions appears to correlate positively with a client-oriented approach discussed in chapter 2, namely the attitudes of compassion and symmetry (respectively .14 en .27; signiﬁcant at .001 level). There is no signiﬁcant relation between the multiple worldview and tradition-oriented attitudes (-, 04).

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– Panentheistic interpretation. Panentheism is a transcendent-immanent approach that seeks to link transcendence and immanence in God. God is not a wholly supernatural omnipotence but an immanent energy in all living beings and the driving force in human history. Example: e. According to my belief or thinking there is a God who wants to be our God.

– Deistic interpretation. Deism rejects any form of divine revelation and salviﬁc involvement in creation. Deism entails a kind of natural religion: God is the ultimate hypothesis at the root of reality. Example: b. According to my belief or thinking there is something like a supreme being who controls life.

– Immanentist interpretation. According to the immanentist approach the meaning of life lies wholly in this world. Good and evil reside in human beings, who have to ﬁnd a way of making the best of things. Example: a. According to my belief or thinking the divine is nothing but the valuable in humankind.

– Atheistic interpretation. Atheism focuses on arguments for repudiating God’s existence and, concomitantly, any created order or connection between religion and morality. This world is the ultimate reality. Example: d. According to my belief or thinking life is merely an evolutionary process.

The responses to these items were subjected to factor analysis. This yielded three factors, on the basis of which we constructed three scales (ﬁgure 4.3; cf. appendix 2, instrument 7 and appendix 3, table 11 and 12). The theoretical classiﬁcation into religious and nonreligious interpretations was conﬁrmed, but the classiﬁcation into four subcategories was not. Factor analysis of the subcategories of religious interpretations revealed a merging of the panentheistic and deistic interpretations. We classiﬁed our ﬁndings into two sets: those for spiritual caregivers from religious traditions and those for spiritual caregivers from the humanistic tradition. Figure 4.3 shows that spiritual

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Figure 4.3 Ultimate reality Ultimate reality religious

nonreligious

panentheism

deism

immanentism

atheism

items: e, g mean: mean religious: mean humanist:

b, i 3.7 3.8 1.8

items: a, f mean: 2.4 mean religious: 2.3 mean humanist: 3.4

items: c, d, h mean: 2.0 mean religious: 1.9 mean humanist: 3.2

caregivers from religious traditions believe in the existence of a transcendent reality; they reject immanentism and atheism. Spiritual caregivers from the humanistic tradition are negative about religious belief. They endorse an immanentist approach and are ambivalent about the atheistic view. Finally we describe the social location of the various interpretations. Again we ﬁrst give the results for spiritual caregivers from religious traditions and then those for spiritual caregivers from the humanistic tradition. The ﬁndings for respondents from religious traditions are as follows. Among spiritual caregivers from religious traditions respondents with theological training disagree more with an immanentist approach than those without theological training (means respectively: 2.3 and 2.6). In comparison with college educated caregivers those with a university education reject an immanentist approach more strongly (mean: 2.3 vs 2.6). The disagreement with an immanentist approach is strongest among Reformed (Gereformeerde) spiritual caregivers, Protestant ministers and members of the Union of Dutch Clergy (Bond voor Nederlandse Predikanten, BNP ) (means respectively 2.1, 2.1 and 2.0). Rejection of atheism is more marked among Dutch Reformed (Nederlands Hervormde) spiritual caregivers, Protestant ministers and BNP members (means respectively 1.7, 1.8 and 1.7). As for respondents from the humanistic tradition, it appears that in comparison with college educated caregivers those with a university education rate ultimate reality more highly (mean: 2.2 vs 1.5). Suﬀering Suﬀering confronts thinking religious people with the theodicy problem: how does one reconcile suﬀering with belief in an omnipotent, benevolent God? Under this theme we distinguish between

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theodicy models that emphasise God’s transcendence and those that accentuate his immanence. Among transcendence-oriented models we distinguish between the apathy, retribution and plan models. Among immanence-oriented models we distinguish between the solidarity, substitution and mystical models. Midway on the continuum, on the borderline between transcendence and immanence, we locate the developmental model. For each of these seven aspects we chose three items from the study by Van der Ven (1996c; Van der Ven & Vossen, 1995), giving us a total of 21 items. Here is an example from each category: – Apathy theodicee. The apathy model assumes that God keeps aloof from suﬀering. He neither invented it nor brought it about. He is not aﬀected by suﬀering and lets it take its course. Example: t. When suﬀering happens, God is not aﬀected by it.

– Retribution theodicee. The retribution model assumes hat suﬀering is divine retribution for people’s sins. God wills or permits human suﬀering. Retribution aﬄicts individuals, groups and generations. It may strike here and now, or at the end of time. Example: n. Suﬀering is a punishment from God.

– Plan theodicee. The plan model assumes that suﬀering has a place in God’s design for history. Depending on the perspective, the plan could be for the whole world or for an individual. At the end of time it will become clear that all suﬀering was for the good. Example: l. Suﬀering is part of God’s plan.

– Development theodicee. The development model assumes that God sees suﬀering as a means of puriﬁcation. The positive eﬀects are usually experienced only after the suﬀering is over; while they are suﬀering people feel more or less cut oﬀ from God. Example: b. God calls suﬀerers to learn from their suﬀering.

– Solidarity theodicee. The solidarity model assumes that God has compassion with suﬀerers and in this closeness comforts them. There is no relation between

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sin and suﬀering; suﬀering in itself is meaningless and remains an enigma. Example: o. God suﬀers with those who suﬀer.

– Substitution theodicee. The substitution model assumes that God presents self-sacriﬁce as a way to salvation. The innocent suﬀerer takes the place of God through her self-surrender to other suﬀerers. Example: h. Through suﬀering God stimulates us to serve others.

– Mysticism theodicee. The mystical model assumes that suﬀering establishes an intimate relationship between God and human beings. Suﬀering remains an enigma, but is transformed into a kind of mystical suﬀering caused by separation from God. Example: k. Suﬀering puts humans in direct contact with God.

The responses to these items were subjected to factor analysis. This yielded seven factors, on the basis of which we constructed seven scales (ﬁgure 4.4; cf. appendix 2, instrument 8 and appendix 3, table 13 and 14). The empirical ﬁndings conﬁrm our theoretical classiﬁcation into transcendence- and immanence-oriented theodicy models, as well as the subcategories in each dimension. We classiﬁed the ﬁndings between those for spiritual caregivers from religious traditions and those for spiritual caregivers from the humanistic tradition. Figure 4.4 shows that spiritual caregivers from religious traditions subscribe to one Figure 4.4 Suﬀering Suﬀering transcendence

transc. imman.

immanence

apathy

retribution

plan

development

solidarity

substitution

mysticism

items: f, r, t

items: i, n, s

items: e, l, u

items: b, c

items: j, o

items: h, p, q

items: d, k, m

mean: 1.7

mean: 1.4

mean: 2.2

mean: 2.7

mean: 4.1

mean: 2.5

mean: 2.6

relig.: 1.6 hum.: 2.4

relig.: 1.4 hum.: 1.2

relig.: 2.2 hum.: 1.7

relig.: 2.7 hum.: 2.2

relig.: 4.1 hum.: 2.5

relig.: 2.5 hum.: 2.1

relig.: 2.6 hum.: 2.2

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theodicy model—that of solidarity. The others are either rejected or evoke negative ambivalence. Spiritual caregivers from religious traditions are extremely negative about the retribution and apathy models and negative about the plan and substitution models. The mystical and developmental models evoke negative ambivalence. In short: transcendence-oriented theodicy models are largely rejected. Spiritual caregivers who hold a humanistic worldview reject all theodicy models, especially the retribution and plan models. They are least negative about the solidarity and apathy models. Finally we describe the social location of the various theodicy models. Again we ﬁrst present the ﬁndings for spiritual caregivers from religious traditions and then those for spiritual caregivers from the humanistic tradition. Among respondents from religious traditions Catholic spiritual caregivers are least negative about the apathy model (mean: 1.8) and Protestant ministers most negative (mean: 1.5). Female spiritual caregivers are more negative about the substitution model than males (means respectively 2.3 and 2.6). As for respondents from the humanistic tradition, we found that graduates of the Humanistic Training Institute (Humanistisch Opleidingsinstituut) reject more the solidarity model (mean: 2.3). In regard to the retribution, plan, developmental and mystical models we found no diﬀerentiation that met our criterion. Death All worldviews oﬀer some approach to the question of what happens after this life: is death really the end of life? And how do spiritual caregivers feel about it? In the case of death we distinguish between Christian, alternative religious and nonreligious interpretations. Among Christian interpretations we distinguish between panentheistic and deistic approaches, and among nonreligious interpretations between immanentist and agnostic approaches. Among alternative religious worldviews we restricted ourselves to the belief in reincarnation. To operationalise these ﬁve concepts we took a number of items from the study of socio-cultural developments in the Netherlands (Eisinga et al., 1995, scale 2.12.4). Here is one example from each category: – Panentheism. Panentheism assumes that there is life after death. Faith in a benevolent God makes people hope for the perpetuation of the good in earthly life, of which Jesus’ resurrection is a hopeful portent. Example:

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f. In death God holds on to me.

– Deism. Deism assumes that there is life after death, not on the basis of divine revelation and salvic involvement in creation, but on the basis of the laws of nature. Example: d. Death is the passage to another life.

– Reincarnation. Reincarnation assumes that after death life continues on earth in a diﬀerent guise. It could be that of a human being or another, nonhuman body. The interim between death and reincarnation may be brief or protracted. Example: g. All creatures return to earth after death.

– Immanentism. Immanentism makes no assertions about death other than what people can experience and know about it here and now. The world people experience through their sense perception and reason is the only one they have. In this sense death belongs to life. Example: e. Death is part of the natural order.

– Agnosticism. Agnosticism abandons all speculation on life after death, on the basis of human beings’ limited cognitive powers. Example: c. It is impossible to say what happens after death.

The responses to these items were subjected to factor analysis. This yielded three factors, on the basis of which we constructed three scales (ﬁgure 4.5; cf. appendix 2, instrument 9 and appendix 3, table 15 and 16). The empirical ﬁndings conﬁrmed our theoretical classiﬁcation into Christian, alternative religious and nonreligious interpretations. Factor analysis revealed a combination of the panentheistic and deistic approaches under Christian interpretations. We classiﬁed our ﬁndings into those for spiritual caregivers from religious traditions and those from the humanistic tradition. Figure 4.5 shows that spiritual caregivers from a religious tradition endorse traditional Christian views on life after death, and especially the immanentist approach. They are dubious about the agnostic view of death and explicitly renounce

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Figure 4.5 Death Death

Christian

alternative religious

nonreligious

panentheism

deism

reincarnation

immanentism

agnosticism

items: f, l mean: 3.8 religious: 3.9 humanist: 2.3

d, k, n

items: g, i, m mean: 1.9 religious: 1.9 humanist: 1.9

items: a, e mean: 4.1 religious: 4.0 humanist: 4.5

items: c, h, o mean: 3.1 religious: 3.0 humanist: 3.5

the notion of reincarnation. Figure 4.5 shows that spiritual caregivers from the humanistic tradition agree with the agnostic and—very strongly—with the immanentist approaches to life after death. They reject the notion of reincarnation and the Christian view of life after death. Finally we describe the social location of the various approaches to death. Once again we ﬁrst present the ﬁndings for spiritual caregivers from religious traditions and then those for spiritual caregivers from the humanistic tradition. Among respondents from a religious tradition those with theological training are most in agreement with the Christian notion that there is life after death (mean: 3.9). Among Catholic spiritual caregivers there is a proportionately higher rating of the immanentist approach (mean: 4.3). Durch Reformed (Nederlands Hervormde) spiritual caregivers and Protestant church workers are less explicitly positive towards this approach (means respectively 3.8 and 3.3). As for respondents from the humanistic tradition, university graduates are more in agreement with the Christian view of life after death than respondents with a college education (means respectively 2.7 and 2.0). Rituals and worldviews The third and last dimension of worldviews we classiﬁed into rituals generally and rites of passage relating to death. We formulated three items for each of the two concepts, giving us a total of six items. Rituals in general The performance of rituals, says Geertz, gives the symbolic reality of worldviews an aura of factuality. Rituals are a key feature of worldviews generally, and probably of most reli-

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gions. We want to ﬁnd out in how far spiritual caregivers are conscious of the focal position of rituals in worldviews. Here is an example of the operationalisation of this concept: a. Rituals are the most vital element of a religion.

Rites of passage relating to death Ritual has been called religion’s ﬁnal answer to the contingency of life. Rites of passage can be meaningful in health care when other forms of guidance and help run out. We want to determine in how far spiritual caregivers are aware of the signiﬁcance of rites of passage, especially the rites of passage relating to death. Here is an example of our operationalisation of this concept: d. When there is nothing more to be done about aﬄiction, one can still resort to ritual communication.

The responses to these items were subjected to factor analysis. This yielded two factors, on the basis of which we constructed two scales (ﬁgure 4.6; cf. appendix 2, instrument 10 and appendix 3, table 17 and 18). The empirical ﬁndings conﬁrmed the theoretical classiﬁcation into the ritual dimension of worldviews generally and rites of passage relating to death. We classiﬁed our ﬁndings into those for spiritual caregivers from religious traditions and those from the humanistic tradition. Figure 4.6 shows that those from a religious tradition largely endorse the importance of the ritual dimension generally and express positive ambivalence about the speciﬁc meaning of rites of passage relating to death. Figure 4.6 also reveals that spiritual caregivers from the humanistic tradition are ambivalent about the importance of the ritual dimension generally and negative about the speciﬁc meaning of rites of passage relating to death. Figure 4.6 Rituals and worldviews Rituals and worldviews Rituals in general

rites of passage relating to death

items: a, c mean: 3.3 religious: 3.4 humanist: 3.0

items: d, f mean: 3.1 religious: 3.2 humanist: 2.4

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As for the social location of the scales we investigated, we found that the negative attitude of humanistic spiritual caregivers towards the speciﬁc meaning of rites of passage relating to death applies mainly to those employed as humanistic counsellors (mean: 2.3). Regarding the ritual dimension of worldviews generally we found no diﬀerentiation that met our criterion of relevance. 4.3

Résumé

The key question in this chapter is: what is the worldview-related dimension of spiritual caregivers’ identity like? Ricoeur sees identity as a narrative process, in which symbols feature prominently. Symbolisation is also the focal point of Geertz’s approach to worldviews. A person’s identity is shaped by the stories she tells about herself and the stories told about her by others. The plot of the narrative connects past actions and events with the current story and possible actions, events and stories about them in the future. Personal identity comprises various aspects: historicity, sociality and praxis. Historicity has to with the idem and ipse dialectic, that is the dialectic between continuity and discontinuity, which shapes the person’s uniqueness. Sociality concerns the dialectic between self and others, which entails attestation in the sense of an individual’s fragile, contingent testimony to others. As for praxis, it relates to the dialectic between activity and passivity, in which tragedy and suﬀering—being pathic elements of the life story—play a special role. We found that spiritual caregivers agree on the importance of narrative for their identity, the uniqueness of the human person in the narrative context and the pathic nature of human identity. They also tend to agree with the attestatory nature of personal statements in the encounter with others. Table 4.1 summarises these results. Table 4.1 Narrative identity Mean Uniqueness Attestation Passivity Narrative identity

3.8 3.3 3.6 3.6

Standard deviation .67 .62 .71 .64

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The worldview-related dimension of identity involves symbols that people use to interpret reality, especially in life’s boundary situations. The process of symbolisation has three dimensions: the culture of a worldview, meanings assigned in worldviews and ritualism in worldviews. The culture of a worldview pertains to worldview-related elements that people ﬁnd in their environment and in their social relations with others in time. It includes communication with others about symbolisation, in which the context of the culture with its speciﬁc worldview institutions and traditions plays a role. The meanings attributed in worldviews have to do with people’s symbolisation, mainly in regard to the following three themes: ultimate reality, which can be either religious or nonreligious; suﬀering, in which religious meaning is assigned according to more or less transcendent and immanent theodicy models; and death, which can be viewed in a Christian, alternative religious or nonreligious perspective. Ritualism in worldviews expresses the link between everyday and symbolic reality, which also helps to shape the worldview. Empirical measurement reveals the following picture. Spiritual caregivers are negatively ambivalent about a collective worldview. They agree about the signiﬁcance of their own worldview tradition and that of other traditions for their own worldview. They are fairly negative towards their own denominations. Spiritual caregivers from religious traditions believe in the existence of a transcendent reality and reject the immanentist and atheistic views. Spiritual caregivers from the humanistic tradition reject belief in a transcendent reality, concur with an immanentist approach and are ambivalent about the atheistic view. Those from religious traditions agree with the theodicy model of solidarity; they reject or are negatively ambivalent about the other models, especially transcendence-oriented ones. Spiritual caregivers with a humanistic worldview reject all theodicy models. Those from a religious tradition agree with traditional Christian notions about life after death, and especially with an immanentist approach to death; they are ambivalent about an agnostic view of death and explicitly reject reincarnation. Spiritual caregivers from the humanistic tradition endorse the agnostic and, to some extent, the immanentist conception of life after death, but reject both the Christian and reincarnationist views. Those from a religious tradition largely agree with the signiﬁcance of the ritual dimension generally and are positively ambivalent about the speciﬁc meaning of

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rites of passage. Spiritual caregivers from the humanistic tradition are ambivalent about the signiﬁcance of the ritual dimension generally and are negative about the speciﬁc meaning of rites of passage. We conclude that in some ways deinstitutionalisation holds good for spiritual caregivers, but de-traditionalisation less so (cf. Bernts & Peters, 1999, 38–39). Table 4.2 summarises these ﬁndings. Table 4.2 Worldview Culture Collective worldview Worldview tradition Worldview institution Multiple worldview

Mean

Standard deviation

2.9 3.8 2.6 3.8

.69 .53 .77 .52

Religious

Humanistic

Relig.

Hum.

3.8 2.3 1.9

1.8 3.4 3.2

.69 .83 .68

.80 .98 .94

Suﬀering Apathy Retribution Plan Development Solidarity Substitution Mysticism

1.6 1.4 2.2 2.7 4.1 2.5 2.6

2.4 1.2 1.7 2.2 2.5 2.1 2.2

.67 .55 .74 .76 .70 .66 .60

.95 .37 .34 .51 .56 .58 .52

Death Belief in life after death Reincarnation Death—immanentist Death—agnostic

3.9 1.9 4.0 3.0

2.3 1.9 4.5 3.5

.57 .69 .73 .68

.75 .73 .44 .56

Ritual dimension Ritual dimension generally Rites of passage

3.4 3.2

3.0 2.4

.69 .71

.56 .84

Meanings assigned Ultimate reality Religious belief Immanentism Atheism

The ﬁndings in regard to social location appear in table 4.3. Remarkably, denomination and, to a lesser extent, training and professional association play a major role in spiritual caregivers’ per-

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ception of their identity and its worldview-related dimension. Ministerial approval and type of care institution have no diﬀerentiating eﬀect. Table 4.3 Worldview: social location M/F training denomination approval uniqueness attestation passivity narrativity

*

collective worldview tradition worldview institution multiple worldview belief immanentism atheism apathy retribution plan development solidarity substitution mysticism life after death reincarnation death—immanentist death—agnostic ritual dimension generally rites of passage

prof. care association institution

* *

*

* * *

* * * *

* *

*

*

*

* * * *

*

*

*

5 LEGITIMACY AND POSITION OF SPIRITUAL CARE IN HEALTH CARE In chapter 3 we examined the function of worldview in health care and in chapter 4 we focused on the personal worldviews of spiritual caregivers. In this chapter we explore what the function of worldview in health care implies for the professional discipline of spiritual care. We do so by looking at two aspects: the legitimacy of spiritual care, and its position in health care. That brings us to our fourth research question: how do spiritual caregivers view the legitimacy and position of spiritual care as a professional discipline in health care? Legitimacy relates to the question whether spiritual care has a place in health care, and its position to whether its role, if any, is on the periphery or forms an integral component of health care. We probe these two questions from both a health care and a worldview perspective (5.1). In this discussion ‘ministry’ and ‘sanctuary’ are key terms, so we deal with them in a separate section (5.2). The chapter concludes with a résumé (5.3). 5.1

Legitimacy and Position of Spiritual Care as a Professional Discipline in Health Care

In this ﬁrst section we examine the legitimacy and position of spiritual care as a professional discipline, ﬁrst theoretically (5.1.1), then according to the perceptions of spiritual caregivers as reﬂected in our research ﬁndings (5.1.2). 5.1.1

Legitimacy and Position of Spiritual Care as a Professional Discipline

Legitimacy of spiritual care Our ﬁrst question, we have said, is whether spiritual care in fact has a place in health care. The question pertains to its legitimacy as a professional discipline in health care or, as it is sometimes called, the right and necessity of spiritual care (Hirsch Ballin et al., 1998; Van Tuijl, 1994; Weiher, 1999, 87–88). The legitimacy of spiritual care has three aspects: its legitimacy in terms of health care, in terms of worldviews, and in terms of its own domain—that of spiritual care.

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Its legitimacy in terms of health care has two facets: statutory legitimacy, and what is laid down in policy. Its statutory legitimacy depends mainly on the enabling Quality Care Institutions Act of 1996. The relevant clause reads: “Inasmuch as the relevant care entails the patient’s or client’s accommodation in an institution for at least 24 hours, the caregiver is responsible for ensuring that spiritual care which accords maximally with the religion or worldview of the patients or clients is available in the institution” (chapter II, article 3; our translation).1 Legitimacy in terms of policy likewise has two facets: its legitimacy according to the institutional management’s perception of care, and from the patient’s point of view. The ﬁrst is contained in the board’s policy documents, which are based on scientiﬁc notions of health care. Management’s conception of care may underscore the importance of worldviews per se, as well as the contribution of communication on worldviews to patients’ health (Gribnau & Pijnenburg, 2004; Pijnenburg & Ten Have, 2004). Legitimacy in terms of policy from the patient’s point of view pertains to the value the patient attaches to the worldview as such, and the usefulness of the worldview for dealing with health problems as perceived by the patient. This type of legitimacy stems from the patient’s autonomy and patient-oriented demand-driven care in the interaction between caregiver and patient (cf. 2.2). Viewed thus, patients’ councils in care institutions may advocate the availability of spiritual care in the institution and satisfaction polls among patients can corroborate the right and necessity of spiritual care (Van der Loo et al., 1998). In addition the legitimacy of spiritual care may be viewed from the angle of actual worldviews. By this we mean the various worldviews’ conceptions regarding the worldview-related dimension of care and its contribution to the health of patients in care institutions.

1

With a view to the statutory legitimacy of spiritual care the Lower House considered a draft Spiritual Care in Care and Judicial Institutions Act. The bill was aimed at explicitly ensuring the accessibility and availability of spiritual care according to choice in care and judicial institutions. In the end the bill was rejected by the Upper House: old age homes in particular would require a massive (costly) operation to catch up. In addition some political parties thought it would be better to regulate spiritual care by means of general legislation on health care and justice than by means of a separate act (Oﬃciële Publicaties van de Overheid, 07.02.1996 and 11.11.1997; Rebel, 2004, 10–13).

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Worldviews include beliefs about the meaning of life, suﬀering and death which aﬀect people, arouse emotions and express them; they also have rituals that enable people to experience their emotions and reconcile them. These beliefs, emotions and rituals create order in the chaos of life. In a health care context worldviews can have intrinsic value, as well as an extrinsic function in the assimilation and healing of illness. The professional group of spiritual caregivers also substantiates its legitimacy with reference to article 6 of the Constitution, which regulates freedom of religion and worldview. The relevant section reads as follows: “Everyone has the right to confess their religion or worldview freely, either individually or collectively, subject to each person’s responsibility under the law” (Constitution, article 6, section 1; our translation). This article permits advocacy of the right to practise a worldview in health care, hence allows scope for spiritual care. If people are admitted to a care institution for longer than 24 hours, the institution has to ensure that they can demand spiritual care for free confession of their worldview, as stipulated in the Quality Care Institutions Act. Spiritual caregivers, either individually or as members of a spiritual care service, can advocate the right and necessity of spiritual care within the institution. One could call this domain-related thematic legitimacy. Spiritual caregivers’ personal beliefs play a major role in the legitimacy of the profession. In policy making management often asks them to explain the signiﬁcance of their discipline in the institution as a whole. In multidisciplinary collaboration, too, spiritual caregivers may be asked to explain to fellow caregivers the value, according to their own beliefs, of spiritual care in patient care. Such explanation calls for a personal view on the right and necessity of spiritual care, as well as a modest form of internal public relations without exceeding the bounds of decorum and integrity (cf. Oranje, 1996, 867–869). Position of spiritual care Having considered whether spiritual care has a place in health care at all (legitimacy), we turn to its position: is it peripheral or does it form an integral part of health care? Thus there are two possibilities: isolation and integration. Isolation is a situation where spiritual care takes up a position separate from other disciplines and claims a special place in the institutional organisation. Integration is a sit-

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uation where spiritual care neither takes up a separate position nor adapts so fully to the institution that it forfeits its independence altogether. There are three kinds of integration. The ﬁrst is organisational integration: the institution creates conditions for substantively free spiritual care. Secondly, there is integration in terms of policy: spiritual care is positioned in the vicinity of the board or management. Finally there is process integration: spiritual care is positioned in the vicinity of care teams (Van Gerwen, 1992, 467f.). In the ﬁrst case spiritual care is a separate department alongside others in the organisation, in the second case it is seen as contributing to institutional policy at meso level, and in the third as contributing to the care process at micro level. It goes without saying that these three forms of integration are by no means mutually exclusive. Process integration is considered the most thoroughgoing form. It presupposes organisational and policy integration: incorporation into the care process implies that spiritual care plays a role at the organisational and policy levels as well. Policy integration enables it to have a signiﬁcant hand in the setting of institutional goals (Rebel, 1993, 16). Process integration means that spiritual care can do justice to the pivotal role of the care process at micro level (De Groot, 1994, 142, 145; Liégois, 2000). A combination of policy and process integration permits spiritual care to contribute its rightful share to both the care process at micro level and institutional goals (Rooijakkers, 1991, 10; 2000, 389–390). An isolated position is advocated by those who set great store by the distinctiveness of spiritual care and its essential diﬀerence from the medical approach. Patients beneﬁt by a discipline that pursues an entirely diﬀerent goal from the therapeutic disciplines. The rationale of spiritual care is said to be that spiritual caregivers are ‘there’ for patients, are ‘present’ at their bedside, are ‘at hand’ when patients hover on the fringes of contingency, and thus share with them the fellowship of the weak, of which the caregiver, too, forms a part. Such a commitment sets spiritual caregivers ‘apart’ from the therapeutic disciplines: it obliges them to occupy an isolated position. This approach is averse to adopting methods from other disciplines. Spiritual care should be particularly careful to maintain its own language and orientation in dealing with patients. Its ‘own language’ is the linguistic level of worldviews, which is said to be expressive and evocative (Bach, 1996, 642–644). Its special orientation is that patients are human beings rather than sick people, dialogue partners whose

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subjective deﬁnition of their health problems is adopted. The relationship calls for attentiveness and dedication; only then can one determine what care the patient requires (Baart, 2004, 405f.; cf. Molenaar, 2004). Proponents of this position tend to attach great importance to the spiritual caregiver’s ministry, which will be discussed in due course. They also point out the great weight assigned to the medical approach in care institutions, from which—it is felt—spiritual care should distance itself (Klessmann, 1997, 31–34; cf. Van Loenen, 1996, 610). 5.1.2

Legitimacy and Position of Spiritual Care as a Professional Discipline: Research Findings

Having examined the legitimacy and position of spiritual care as a professional discipline in a theoretical perspective, we turn to the question of how spiritual caregivers view and assess these aspects of their profession. Again we ﬁrst deal with the legitimacy of spiritual care and then with its position in health care. Legitimacy of spiritual care We distinguish between three aspects of legitimacy: legitimacy from the angles of health care, worldviews, and the special domain of spiritual care respectively. Under legitimacy from the angle of health care we diﬀerentiate between statutory legitimacy and legitimacy laid down in policy, and under the latter we make a further distinction between the caregiver’s point of view and that of the patient. As for legitimacy from the perspective of worldviews, the relevant issues are notions about the worldview-related dimension of care and the contribution of worldviews to the health of patients in care institutions. Finally, spiritual caregivers can legitimise their profession with reference to domain-related themes such as the value of a worldview for patients. We formulated three items for each of these ﬁve aspects, giving us 15 items in all. Statutory legitimacy Statutory legitimacy has to do with the legal justiﬁcation of spiritual care. Here is an example from the three items in which the term was operationalised: e. In the legitimation of spiritual care (in my care institution) I rate statutory guarantee by a future Spiritual Care Act (‘totally unimportant’ to ‘very important’).

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Legitimacy from the institutional approach to care Policy legitimation may be based on the institution’s approach to care, especially the importance attached to spiritual care in institutional policy. Here is an example from the three items in which the term was operationalised: f. In the legitimation of spiritual care (in my care institution) I rate institutional boards speaking out in favour of spiritual care (‘totally unimportant’ to ‘very important’).

Legitimacy from the patient’s point of view Policy legitimation may stem from the patient’s demand for spiritual care. Here is an example from the three items in which the term was operationalised: g. In the legitimation of spiritual care (in my care institution) I rate heeding patients’ requests for guidance in worldview-related problems (‘totally unimportant’ to ‘very important’).

Denominational legitimacy Legitimacy from the angle of worldviews has to do with worldview associations’ approach to the importance of spiritual care in health care. Here is an example from the three items in which the term was operationalised: n. In the legitimation of spiritual care (in my care institution) I rate the attention devoted to spiritual care by worldview associations in their policy documents (‘totally unimportant’ to ‘very important’).

Domain-related thematic legitimation by spiritual caregivers Spiritual caregivers can legitimise their discipline by invoking themes peculiar to their domain, such as the importance of worldviews to patients. Here is an example from the three items in which the term was operationalised: m. In the legitimation of spiritual care (in my care institution) I rate my focus on worldview-related themes when providing care (‘totally unimportant’ to ‘very important’).

The quantitative data yielded by spiritual caregivers responses to these items were subjected to factor analysis. This resulted in ﬁve factors, on the basis of which we constructed ﬁve scales (ﬁgure 5.1; cf. appendix 2, instrument 11 and appendix 3, table 19 and 20). Our theoretical classiﬁcation regarding legitimacy was empirically conﬁrmed. As is evident in ﬁgure 5.1, spiritual caregivers ﬁnd all the investigated forms of professional legitimacy important, especially

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Figure 5.1 Legitimacy of spiritual care Legitimacy of spiritual care health care-related

worldviewrelated

spiritual caregiverrelated

policy statutory

institutional approach to care

patient

denomination

domain-related thematic

items: e, i, k mean: 4.0

items: f, h, l mean: 4.2

items: b, g, o mean: 4.6

items: c, j, n mean: 3.5

items: a, d, m mean: 3.8

legitimacy based on patient demand. We also give the social location of the scales in terms of the ﬁve personal characteristics and the institutional characteristic described in 1.3: gender, training, denomination, ministerial approval, professional association and care institution. Women attach greater value to statutory legitimacy than men (means respectively 4.2 and 3.9). Spiritual caregivers employed in psychiatric centres attach less value to denominational legitimacy (mean: 3.1). Position of spiritual care From a health care perspective spiritual care can occupy one of two positions: isolation and integration. Among the various forms of integration we settled for process integration. This is the most thoroughgoing form of integration, presupposing integration at both an organisational and a policy level. For each position of spiritual care from a health care perspective—isolation and process integration— we formulated three items. That gave us six items altogether. Isolation Isolation is when spiritual care adopts a separate position from other discipline and claims independent status in the organisation. Here is an example from the three items in which the term was operationalised: b. Spiritual caregivers should position themselves quite separately from social workers, psychologists and remedial educationists.

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Process integration Integration is when the care institution creates conditions for spiritual care at an organisational and policy level, as well as at the level of care in interaction with patients. This is known as process integration. Here is an example from the three items in which the term was operationalised: a. In the interest of optimal patient care spiritual caregivers should cooperate closely with other caregivers.

The quantitative data yielded by spiritual caregivers’ responses to these items were subjected to factor analysis. This resulted in two factors, on the basis of which we constructed two scales (ﬁgure 5.2; cf. appendix 2, instrument 12 and appendix 3, table 21 and 22). Figure 5.2 Position of spiritual care Position of spiritual care

isolation items: b, d, e mean: 1.8

process integration items: a, c, f mean: 4.0

The theoretical classiﬁcation of the position of spiritual care from a health care perspective was empirically conﬁrmed. As is evident in ﬁgure 5.2, spiritual caregivers reject an isolated position and opt for integration. We also give the social location of the scales in terms of the ﬁve personal characteristics and the institutional characteristic described in 1.3: gender, training, denomination, ministerial approval, professional association and care institution. Spiritual caregivers employed in psychiatric centres assign process integration a lower positive rating (mean: 3.6); the rating of colleagues in nursing homes is higher (mean: 4.1). 5.2

Ministry and Sanctuary of Spiritual Care

The legitimacy and position of spiritual care can also be put in a worldview perspective. We ﬁrst examine this perspective theoretically (5.2.1), whereupon we analyse spiritual caregivers’ attitudes in this regard (5.2.2).

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Ministry and sanctuary in a theoretical perspective

Spiritual care as a professional discipline is also understood in terms of a ministry and a sanctuary. The two terms express a worldviewrelated angle on its legitimacy. Let us consider the arguments for and against the notion of spiritual care as a ministry and entailing a sanctuary. A decision on this score has implications for its organisational mode of operation and its relations with other worldviews. Ministry Describing the function of spiritual care as a ministry is not conﬁned to church-aﬃliated spiritual caregivers; the term is also used by their humanistic colleagues. Spiritual caregivers are assigned their ministry by worldview associations. By this we mean that the worldview association approves or sanctions the appointment of the spiritual caregiver at a given institution. Often such approval is expressed in a missionary mandate, either accompanied by a ritual or not. This procedure is attributable to the separation of church and state according to the so-called accommodation model (Van der Ven, 2005). The state does not intervene directly in the church but ‘accommodates’ it, in this instance by providing scope and support for spiritual care by worldview associations in health care. Hence the ministry of spiritual caregiver is a judicial and institutional matter. We locate the ministry of spiritual care at three levels: the macro level of health care and society, the meso level of the care organisation and the micro level of relations with patients. Some authors consider the notion of spiritual care as a ministry largely advantageous, others emphasise the drawbacks. We consider the arguments for and against at each level. At macro level representation of a worldview association is adduced as an argument in favour of a ministry. Research shows that society still regards worldview associations as authoritative: they are seen as ‘moral beacons’ and ‘counsellors’ when social problems arise (Dekker, De Hart & Peters, 1997, 122; Becker & De Wit, 2000). Via the ministry this social signiﬁcance of worldview associations can have positive implications for spiritual caregivers’ authority and the contribution of spiritual care to health care (as evidenced, e.g., by the activities of organisations like Landelijk Platform Kerk en Zorg [National Church and Care Forum] and Reliëf ).

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As an argument against the ministry at macro level we cite the phenomena of de-institutionalisation, de-traditionalisation and the declining inﬂuence of worldviews as a result of pluralism and secularisation (cf. 4.2.1). The ministry of spiritual caregivers is also subject to these developments. In health care, moreover, the phenomenon of medicalisation leads to marginalisation of worldviews. In earlier times the charitable organisation of health care meant that churches/ worldview associations had considerable inﬂuence. But the charitable basis of health care has largely been superseded by medical science. In mergers of care institutions their denominational, worldviewrelated character is increasingly discarded. In conjunction with the aforementioned social trends this diminishes the impact that worldview associations can have on health care. As a result ministry in a worldview association has less inﬂuence and authority. At the meso level the allegedly desirable, even necessary, dissociation from institutional goals and interests is adduced as an argument in favour of the ministry. The aims and substance of spiritual care are not determined by health care organisations. In this respect the worldview associations’ responsibility is recognised. The ministry expresses the connection with worldview associations and their distinctive goals (cf. 6.1.1). The link with a worldview association means that spiritual caregivers are under less pressure to account for their particular counselling approach, as distinct from other helping services in the institution (cf. Van Loenen, 1996, 606–610). Nor do they have to accept co-responsibility for institutional policy. This relative uninvolvement in the interests of the care organisation is a priceless advantage over other disciplines: greater involvement in institutional interests could make them vulnerable when individual patients’ interests conﬂict with those of the institution. Spiritual care is less exposed to that risk (cf. Klessmann, 1997, 31–34). An argument against the ministry at meso level is isolation as a result of dissociation from institutional goals and interests. A care institution is a bureaucratic organisation, in which professionals perform their tasks according to ﬁxed rules and account for it to management. A major factor in this regard is standardisation, in the sense of rules and regulations for activities, and formalisation, such as written procedures and protocols (cf. 2.1.1). Because spiritual care cannot be called to account for the extent to which institutional goals are achieved and is usually not called upon to observe organisational

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procedures and protocols, the profession is cut oﬀ from other disciplines. The ministry of spiritual care is an odd man out in care institutions. The result is a position of isolation, which makes it vulnerable in that institutional management and other disciplines may experience it as invisible and hence largely irrelevant. At micro level the ministry’s function in facilitating dialogue with patients is adduced as an argument for the ministry. This function pertains to communication on worldviews between spiritual caregiver and patient, which is characterised by exchange of information, exchange of perspectives and coordination of perspectives (cf. 6.1.1). Talking to people about religion and worldview requires more than detached, professional expertise; it demands personal involvement (Nieuwenhuis, 2004, 22–24). Such dialogue, it is said, presupposes considerable correspondence between patient and spiritual caregiver’s worldview-related ideas, as well as profound knowledge and adroitness on the part of caregivers in handling their own worldview tradition. It is argued that this makes explicit aﬃliation to a worldview association a great advantage for spiritual caregivers (Kromhout, 1994, 27–38; Van Straten, 2002, 15–21). Viewed thus the ministry is extremely valuable to spiritual caregivers. They are both inwardly and outwardly involved with what the ministry indicates: their own worldview tradition. According to this argument, then, categorical spiritual care is preferable. An argument against the merits of the ministry at micro level is its limited relevance to the various tasks of spiritual care in interaction with patients. Its signiﬁcance is said to be conﬁned to ritual tasks. The ministry, it is argued, is only necessary for sacramental activities. Oﬃciating in non-sacramental rituals oﬀers great scope for individual style. As for the ethical task, commitment to the moral views of a worldview association is not vital. Individual dialogue with patients mainly invokes the partners’ personal experience in the sphere of worldviews; while this experience may be informed by the worldview association, it does not necessarily coincide with the association’s notions in that regard. Spiritual caregivers are not only concerned about the professional signiﬁcance attached to the ministry, but also about its signiﬁcance in their own worldview. They may attach great value to the ministry because of their personal beliefs. To their mind it forms part of a system of symbols referring to an all-embracing order of cosmos, nature and society that imparts meaning to individual lives. In

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that case the ministry embodies that which transcends the individual. On the other hand spiritual caregivers may experience the ministry as a straitjacket, an undesirable dependence on a worldview association. In that case their relation to the worldview institution will have secondary, even negative meaning (Nieuwenhuis, 2004, 23–26). Sanctuary The sanctuary of spiritual care stems from freedom of religion and belief. As mentioned already, this is the freedom of individual citizens vis-à-vis the state. At the level of their worldviews citizens are protected against interference by the state and public institutions, as well as by private law agencies which fulﬁl analogous functions, such as care institutions. The sanctuary of spiritual care derives from this protection of citizens against inﬂuencing. While the ministry is a prerogative of spiritual care based on the separation of church and state, its sanctuary is primarily a prerogative of patients and only secondarily of spiritual care, and then only to safeguard the patients’ prerogative—their inviolable right. This sanctuary, located at a judicially individual level, has no macro implications; it is meaningful only at the meso and micro levels. Again we look at the arguments for and against. First we brieﬂy consider the relation between sanctuary and ministry. Spiritual caregivers’ incumbency of a ministry is often used as an argument for a sanctuary in care institutions. As indicated already, however, there are two diﬀerent issues at stake. The ministry of spiritual care is an institutional issue, associated with the separation of church and state. Sanctuary, on the other hand, derives from individual citizens’ freedom in regard to religion and belief. Opting for the ministry does not automatically imply opting for a sanctuary, and vice versa. One could advocate a sanctuary irrespective of whether the spiritual caregiver has an oﬃcial ministry or not. Thus there are those who advocate assigning every patient a similarly privileged oﬃcial, who could come from any discipline (Bokslag, 1988, 9). It is also possible to attach value to the ministry without demanding a sanctuary for spiritual care. An argument for a sanctuary at micro level is unconstrained professional communication with patients. Both patient and spiritual caregiver are free in their communication about worldviews. Spiritual caregivers have a civil right to discuss worldview-related themes with patients, which gives them scope to realise the goals of their worldview

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associations in the care institution. On the strength of this argument some authors link a sanctuary with the spiritual caregiver’s oﬃcial connection with a worldview association. An argument against a sanctuary at micro level is the integration of spiritual care in care institutions. In terms of religious freedom spiritual caregivers’ dialogue with patients on worldview-related matters indeed occupies a sanctuary. But this privilege is exercised in the context of a care institution. That means that spiritual caregivers’ contact with patients can never be totally divorced from the institution’s plan for patient care. Unconstrained discussion of worldviews has to be integrated with the common focus of all care disciplines on promoting the patient’s health. An argument in favour of a sanctuary at meso level is exemption from accountability for contacts with patients in multidisciplinary collaboration, and the concomitant conﬁdentiality. The sanctuary of spiritual care implies a form of autonomy. Its only accountability relates to the stipulations of the CAO (Collective Labour Agreement). Exemption from accountability pertains to the spiritual caregiver’s ministerial conﬁdentiality, it is argued, rather than professional conﬁdentiality. Professional conﬁdentiality is always shared, requiring an account to colleagues. Ministerial conﬁdentiality is another matter. In team consultations with fellow caregivers spiritual caregivers need only state that they are in communication with a patient, but need not divulge the contents of the communication. Ministerial conﬁdentiality safeguards not only the privacy of patients’ disclosures about their worldviews but also their perception of the treatment provided by the institution. Thus they are able to speak their minds without any implications for their treatment. As a result the spiritual caregiver becomes a champion of individual patients’ interests (Bach, 1996, 640). This argument does not altogether hold water: ministerial and professional conﬁdentiality are much the same thing when it comes to nondisclosure; the main diﬀerence lies in the way patients perceive conﬁdentiality in terms of their frame of reference, or that of worldview associations—the secret of the confessional comes to mind most readily—and ‘profane’ professions in health care. An argument against a sanctuary at meso level is the danger that spiritual care will be marginalised in care institutions. A sanctuary hinders spiritual care from conforming to institutionally accepted ideas and practices. By insisting on exemption from accountability

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and the concomitant autonomy spiritual care runs a risk of isolation. From the point of view of a sanctuary, organisational integration appears to be the most viable option: the organisation merely creates the conditions for substantively unconstrained spiritual care. A sanctuary impedes policy and process integration. From an institutional perspective, the distinctive input from a sanctuary may be perceived as a marginal voice. From this point of view the idea that spiritual caregivers’ sanctuary makes them a champion of individual patients’ interests is considered inconsistent: one cannot advocate critical aloofness and isolation from multidisciplinary care and still claim a role as the patient’s ‘champion’ in one’s dealings with other disciplines. Territorial and categorical modes of operation The decision regarding the legitimacy of spiritual care in health care has implications for the organisational mode of operation of spiritual care and relations with the various worldviews. There are two organisational modes of operation—a territorial and a categorical approach. The ﬁrst is associated with a preference for an integrated position from the perspective of health care. The second is associated with a preference for the ministry from a worldview perspective. The territorial approach entails a substantive preference for multiple worldview counselling to patients, while the categorical approach favours counselling in terms of only one worldview (we shall use the term ‘mono-worldview counselling’). Opting for integration almost automatically entails a departmental or ‘territorial’ mode of operation. This means that spiritual caregivers are assigned to speciﬁc departments in the care institution, whereupon they visit all patients qualifying for spiritual care in these departments. The VGVZ professional association has advocated this approach since its inception (cf. Snelder, 1996, 65). A territorial mode of operation means that spiritual caregivers also have to deal with patients who espouse worldviews diﬀerent from their own. Counselling patients from a diﬀerent worldview association than the spiritual caregiver’s, or who belong to no denomination, may be termed ‘multiple worldview counselling’. In this sense the territorial approach accommodates the dialogue partners’ personal worldviews in a special way. Firstly, it is said that familiarity with the same worldview-related codes is not prerequisite for successful

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communication (Van der Ven 1996c, 46–62). Secondly, it is said that whereas people’s personal worldviews are determined to some extent by a particular worldview tradition, they do not necessarily coincide with it. Thirdly, this approach allows for pluralism among worldviews and within a particular worldview. Spiritual caregivers are supposed to be able to deal with this pluralism, implying respect for the diversity of beliefs irrespective of their own convictions. It is possible to adopt a pluralistic approach to worldviews, which implies some detachment from one’s own worldview as well (Van der Ven, 2004, 165–176). The question is in how far it is possible to combine diﬀerent worldview perspectives. It is impossible to apply a neutral phenomenology in the face of diverse worldviews: one always proceeds from the presuppositions of a particular worldview (D’Costa, 1996, 344–345). It makes sense to switch from one’s own perspective to that of other individuals, groups, institutions—even between diﬀerent perspectives within oneself (Van der Ven, 2001a, 8–9, 22–23). This implies that ‘generalised spiritual care’, which pretends that all worldviews are the same, and that all worldviews are the same to the individual spiritual caregiver, is neither feasible nor meaningful. The territorial approach proceeds from the principle of ‘egalitarian inclusion’, which is far more typical of care organisations than of churches and other worldview associations. Basically care organisations cater for all potential patients. Worldview associations, on the other hand, are primarily oriented to their members; that orientation is more appropriate to a categorical mode of operation, to be discussed below. By adopting the principle of egalitarian inclusion spiritual care accommodates itself to the health care mode of service delivery (Van der Ven, 1996b, 229–230). Heavy emphasis on the ministry of spiritual care results in a ‘categorical’ or denominational mode of operation. This implies selection on a denominational basis: spiritual caregivers counsel only patients from the worldview association that gave them a mission. Membership of the same denomination facilitates communication with patients. In such a participatory framework it is easier to reach understanding and agreement. When spiritual caregivers communicate with patients who espouse the same worldview some sort of likeminded approach to the search for truth can be assumed (Van der Ven 1996c, 46–62).

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To what extent do patients want a categorical mode of operation in practice? Native Dutch patients, it has been established, are more or less accustomed to the territorial approach. Over the past few decades they have become receptive to counselling from spiritual caregivers from diﬀerent denominations to their own. Often the spiritual caregivers’ own worldview orientation matters less than their ability to transpose themselves to the patient’s situation and her worldview-related experience. Among the native Dutch population some minority groups in conservative denominations or communities do set store by a categorical method of operation: they would rather talk to a spiritual caregiver from their own denomination or community. Among immigrant patients one also discerns a preference for a categorical mode of operation, for instance among Islamic and Hindu patients, for whom special spiritual caregivers are duly appointed. The drawback of the categorical method of operation is that spiritual care runs a risk of becoming restricted and fragmented. It becomes restricted because not all patients are members of a denomination; besides, their membership of a worldview association ranges from active, core membership through passive membership to peripheral, past membership that has since lapsed, either tacitly or formally. It becomes fragmented because the patient population of present-day care institutions is heterogeneous when it comes to worldview. Compartmentalising that population for purposes of spiritual care leads to the fragmented presence of diverse worldview representatives in diﬀerent departments, which in its turn can lead to isolation. Thus the categorical and territorial operational methods are antithetical. Under either system spiritual caregivers can operate more or less independently as regards the content of care, or they can collaborate closely. When an institution’s spiritual care is organised entirely on the basis of a particular worldview association one could describe it as mono-worldview spiritual care. When spiritual caregivers from related worldview associations cooperate one could describe it as ecumenical cooperation. This can be broadened even further when there is cooperation between spiritual caregivers from diﬀerent worldview traditions—what we call multiple worldview cooperation.

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Ministry and sanctuary: research ﬁndings

Having examined ministry and sanctuary in a theoretical perspective, we shall now establish how spiritual caregivers perceive and assess the ministry, a sanctuary and their mode of operation. Ministry and sanctuary The legitimacy and position of spiritual care in a worldview perspective relate, ﬁrstly, to a worldview-related ministry, more particularly formal appointment to, or conﬁrmation in, the position of spiritual caregiver in a care institution by a recognised worldview association. We locate the ministry at the macro, meso and micro levels. Our study is conﬁned to the macro and micro levels, because the arguments at meso level—especially dissociation from the institution and the risk of marginalisation—also apply to sanctuary. At both macro and micro level we operationalised one argument for and one argument against. At micro level the issues are the ministry’s facilitation of dialogue and its limited relevance to the various tasks at this level. At macro level the issues are representation of a denomination and its limited signiﬁcance or even total insigniﬁcance. Finally we examine how spiritual caregivers evaluate the ministry in terms of their own worldview. Secondly, the legitimacy and position of spiritual care from a worldview perspective relates to its sanctuary. This derives from the individual’s freedom of religion and worldview from interference by the state, state organs and organisations with analogous functions. We conﬁne our study to the meso level, because in practice that is where the debate on a sanctuary is conducted. Again we operationalised one argument for and one against. We formulated three items for each of these seven aspects, giving us a total of 21 items. Ministry at micro level. Argument for: facilitation of dialogue It is said that at micro level the ministry helps to promote agreement in worldview-related communication with patients. It is a matter of facilitating such dialogue, particularly with a view to exchange of information, exchange of perspectives and coordination of perspectives. Here is an example from the three items in which the term was operationalised: o. When the spiritual caregiver has the same aﬃliation as the patient it facilitates discussion of worldview-related themes.

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Ministry at micro level. Argument against: limited signiﬁcance The ministry is said to have limited signiﬁcance for the tasks in interaction with patients, its signiﬁcance being restricted to ritual tasks in spiritual care. Here is an example from the three items in which we operationalised the limited signiﬁcance of the ministry at micro level: p. The ministry is only important when it comes to the performance of ritual tasks.

Ministry at macro level. Argument for: denominational representation The ministry’s signiﬁcance is said to lie in its connection with a macro level worldview denomination, more particularly in the social signiﬁcance of the association sanctioning the appointment. Here is an example from the three items in which the term was operationalised: e. The ministry gives the spiritual caregiver a symbolic function, in that it refers to a particular worldview association.

Ministry at macro level. Argument against: limited signiﬁcance The ministry is subject to such processes as de-institutionalisation and de-traditionalisation. In health care there is also the phenomenon of medicalisation. As a result the ministry has only limited, if not zero, signiﬁcance. Here is an example from the three items in which we operationalised the dwindling signiﬁcance of the ministry at macro level: k. As a result of pluralism and individualisation in the ﬁeld of worldviews the ministry of spiritual care has lost its importance.

Personal value of the ministry Apart from the professional meaning assigned to ministry and sanctuary we want to know what the ministry means to spiritual caregivers in terms of their own worldview. Here is an example from the three items in which the term was operationalised: j. At present the ministry has great personal value for me.

Sanctuary at meso level. Argument for: exemption from accountability At meso level a sanctuary assures the autonomy of spiritual care. It entails exemption from accountability to other disciplines and management. Here is an example from the three items in which the term was operationalised:

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Sanctuary at meso level. Argument against: marginal position At meso level a sanctuary puts spiritual care at risk of marginalisation in the organisation—that of having little impact on institutional policy and the multidisciplinary approach to care. Here is an example from the three items in which the term was operationalised: t. An oﬃcial connection with a worldview association reduces the inﬂuence of spiritual care on institutional policy.

The quantitative data yielded by spiritual caregivers’ responses to the relevant items were subjected to factor analysis. This resulted in six factors, on the basis of which we constructed six scales (ﬁgure 5.3; cf. appendix 2, instrument 13 and appendix 3, table 23 and 24). The theoretical classiﬁcation for the ministry and sanctuary is largely conﬁrmed by the empirical ﬁndings. Factor analysis resulted in a fusion of the limited signiﬁcance of the ministry at macro and micro level. As may be seen in ﬁgure 5.3, spiritual caregivers disagree with views that stress the limited signiﬁcance of the ministry, and with those that stress the marginal position in the care institution entailed by a sanctuary. They agree with views that accentuate the value of the ministry and sanctuary, such as those on the ministry’s representation of a worldview association and the exemption from accountability as a result of a sanctuary. They also assign the ministry positive personal value. The only view that met with ambivalence is that of the ministry facilitating dialogue with patients. Finally we give the social location of the investigated scales in terms of the ﬁve personal characteristics and the institutional characteristic described in 1.3: gender, training, denomination, ministerial approval, professional association and care institution. For the sake of convenience we conﬁne ourselves to ﬁndings with an eta >.30. In the case of the argument for the ministry at macro level (denominational representation), spiritual caregivers with no denominational status are ambivalent (mean: 3.1). Respondents who have ministerial approval rate the argument more highly (mean: 3.7). In the case of the argument against the ministry at micro and meso level (its limited signiﬁcance), respondents with no denominational status are again ambivalent (mean: 3.1). Those who have minister-

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Figure 5.3 Ministry and sanctuary of spiritual care Ministry and sanctuary of spiritual care

ministry

facilitation of dialogue (microargument for)

denominational representation (macroargument for)

personal value of ministry

items: l, o mean: 2.9

items: b, e, f mean: 3.6

items: a, j, q mean: 3.6

sanctuary

restricted limited signiﬁcance (microargument against)

meaning limited signiﬁcance (macroargument against)

exemption from accountability (mesoargument for)

g, p, s mean:

k, r 2.5

items: d, i, m items: c, t, u mean: 3.4 mean: 2.4

marginal position (mesoargument against)

ial approval disagree more strongly (mean: 2.4). As for the value of the ministry in terms of personal worldview, spiritual caregivers with no status in a worldview association are negatively ambivalent (mean: 2.8). Those with ministerial approval rate it more highly (mean: 3.8). Territorial and categorical spiritual care There are various ways of dealing with the plurality of worldviews in health care. Each approach has an impact on the way spiritual care is provided, aﬀecting both relations with fellow spiritual caregivers and relations with patients. It is reﬂected in the organisation and content of the mode of operation. The decision to counsel patients from the same worldview association separately results in denominational or categorical spiritual care. The choice of nondenominational or territorial spiritual care entails openness to providing spiritual care for patients from another (or no) worldview association. In addition to the organisational distinction between a categorical and a territorial mode of operation, there is the substantive choice between multiple or mono-worldview cooperation with other spiritual caregivers and multiple or mono-worldview counselling for patients. In each case we operationalised only the multiple worldview perspective, since agreement or disagreement with this perspective indicates the attitude towards the alternative—mono-worldview cooperation and counselling—as well. Thus we operationalised four aspects: categorical and territorial modes of operation at an organ-

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isational level, and multiple worldview cooperation and multiple worldview counselling at a substantive level. For each aspect we formulated three items, giving us twelve items in all. Categorical spiritual care The categorical mode of operation entails denominational spiritual care. Here is an example from the three items in which we operationalised this organisational mode of operation: b. I am a proponent of organising spiritual care categorically, that is classifying and allocating patients according to worldview.

Territorial spiritual care The territorial mode of operation implies departmentalised spiritual care. Here is an example from the three items in which we operationalised this organisational mode of operation: h. I am a proponent of territorial organisation of spiritual care.

Multiple worldview cooperation Multiple worldview cooperation implies substantive openness to, and cooperation with, spiritual caregivers who espouse other worldviews. Here is an example from the three items in which the term was operationalised: j. Cooperation between non-Christian and Christian spiritual caregivers is essential.

Multiple worldview counselling for patients Multiple worldview counselling for patients means that there is no substantive diﬀerence in the counselling provided for patients with diverse worldviews. This kind of counselling is associated with a territorial mode of operation. Here is an example from the three items in which the term was operationalised: e. Spiritual caregivers can guide patients holding diverse religious and nonreligious worldviews.

The quantitative data yielded by spiritual caregivers’ responses to these items were subjected to two factor analyses, one for the categorical items and one for the other items. The ﬁrst factor analysis yielded one factor, on the basis of which we constructed one scale; the second factor analysis resulted in three factors, on the basis of which we constructed three scales (ﬁgure 5.4; cf. appendix 2, instrument 14 and appendix 3, table 25 and 26). As is evident in ﬁgure 5.4, spiritual caregivers reject a categorical mode of operation and opt for a territorial mode of operation; they

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Figure 5.4 Categorical and territorial spiritual care Categorical and territorial spiritual care categorical

territorial

categorical spiritual care

territorial spiritual care

multiple worldview cooperation

multiple worldview counselling

items: b, c, i mean: 2.3

items: g, h mean: 3.9

items: j, l mean: 4.4

items: d, e, f mean: 3.9

agree fully with multiple worldview cooperation in spiritual care and are positive about multiple worldview counselling of patients. Finally we give the social location of the investigated scales in terms of the ﬁve personal characteristics and the institutional characteristic described in 1.3: gender, training, denomination, ministerial approval, professional association and care institution. The categorical mode of operation is rated positively by Jewish spiritual caregivers (mean: 4.7) and less negatively by spiritual caregivers employed in nursing homes (mean: 2.4). The territorial mode of operation is rated negatively by Jewish spiritual caregivers (mean: 1.9). This mode of operation is less strongly supported by respondents who do not belong to a professional association (mean: 3.5), although VGVZ members are more in favour of a territorial mode of operation (mean: 4.0). Spiritual caregivers employed in general hospitals are even more positive about the territorial mode of operation (mean: 4.1), while those in nursing and old age homes rate it less positively (means respectively 3.7 and 3.4). As for multiple worldview patient counselling, it is rated less positively by humanistic spiritual caregivers, especially those who studied at the HOI (mean: 3.2), are members of the Humanistisch Verbond and hold a position as humanistic counsellor (means for both: 3.4). In the case of multiple worldview cooperation we found no diﬀerentiation that met our criteria. 5.3

Résumé

The key question in this chapter concerns the importance of worldviews as a function in health care for spiritual care as a professional discipline. We have already deﬁned the distinctive function of

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worldviews in health care as symbolisation of the contingency of life. Spiritual caregivers are employed in health care where they deal with worldview-related issues, among which contingency is a cardinal theme. We concentrated on two aspects of spiritual care as a professional discipline: its legitimacy and its position. These aspects have to be located in relation to both health care and worldview. Legitimacy concerns the justiﬁcation of the existence of spiritual care in health care; position refers to the formal relation of spiritual care to other health care disciplines and to institutional management. We identiﬁed ﬁve forms of legitimacy: statutory legitimacy; legitimacy according to the respective perceptions of the institution, the patient and the denomination, and domain-related thematic legitimacy. In a health care perspective there are two possible positions: isolation and integration. Spiritual care is often conceived of in terms of ministry and sanctuary, implying that its legitimacy and position are based on worldview-related considerations. The choice made in regard to the legitimacy and position of spiritual care has implications for its organisational and substantive modes of operation. A territorial mode of operation is associated with a preference for integration, while a categorical mode of operation implies a choice for the ministry. The territorial mode of operation entails multiple worldview patient counselling, whereas a categorical mode entails mono-worldview counselling. Our research revealed the following picture. Spiritual caregivers consider all types of legitimacy that we investigated important, especially legitimacy based on patient demand. They reject an isolated position in the institution, opting instead for integration. They disagree with notions of the limited signiﬁcance of the ministry, either socially or in regard to the various tasks in interaction with patients. Neither do they agree with the idea of the limitations of a sanctuary, especially that it is said to marginalise the profession in care institutions. Instead they endorse the idea of the ministry representing a worldview association. They also agree with the value of a sanctuary in the care institution: this exempts spiritual caregivers from accounting for the contents of their dealings with patients in multidisciplinary cooperation. They assign the ministry positive signiﬁcance in their personal worldview. They are ambivalent about the view that sharing the patient’s worldview tradition facilitates dialogue. The respondents favour a territorial mode of operation, fully

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endorse multiple worldview cooperation in spiritual care and are positive about multiple worldview patient counselling. These results indicate that the legitimacy that spiritual caregivers rate most highly is at the level of individual relations with patients. They value the ministry, but are ambivalent about its role in relations with patients. They also value the sanctuary of spiritual care. In their relations with patients spiritual caregivers advocate a multiple worldview, in keeping with their preference for a territorial mode of operation and an integrated position. These results are summarised in table 5.1. Table 5.1 Legitimacy and position of spiritual care

mean Legitimacy Statutory legitimacy Care-related legitimacy Patient-related legitimacy Denomination-related legitimacy Domain-related thematic legitimacy

standard deviation

4.0 4.2 4.6 3.5 3.8

.76 .59 .44 .76 .62

Position Isolation Integration

1.8

.57

Arguments for spiritual care as ministry Ministry—facilitation of dialogue Ministry—denominational representation Ministry—personal evaluation

4.0 2.9 3.6 3.6

.59 .87 .74 .87

Arguments against spiritual care as ministry Ministry—limited signiﬁcance

2.5

.73

3.4 2.4

.82 .73

2.3 3.9 4.4 3.9

.73 .91 .55 .62

Arguments for spiritual care as sanctuary Sanctuary—exemption from accountability (positive argument) Sanctuary—marginal position (negative argument) Categorical and territorial spiritual care Categorical spiritual care Territorial spiritual care Multiple worldview cooperation Multiple worldview counselling

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Agreement is greatest in the cases of legitimacy from the patient’s point of view and multiple worldview cooperation. An isolated position evokes least agreement. As for social location, we found the greatest diﬀerentiation in views on the ministry and sanctuary. The strongest diﬀerentiating factors are respondents’ denomination, followed by membership of a professional association and the care institution where they are employed; training received and ministerial approval came last. We conclude that personal characteristics and the institutional characteristic play an important role in spiritual caregivers’ views on the legitimacy and position of their occupation as a professional discipline. Table 5.2 summarises the relevant diﬀerentiation in regard to social location. Table 5.2 Legitimacy and position of spiritual care in health care: social location variables

M/F training denomi- approval prof. care nation association institution

statutory legitimacy * care related legitimacy patient-related legitimacy denominational-related legitimacy domain-related thematic legitimacy isolation integration ministry/ facilitation of dialogue ministry/denominational representation ministry/personal evaluation ministry/limited signiﬁcance sanctuary/exemption sanctuary/marginal position categorical spiritual care territorial spiritual care multiple worldview cooperation multiple worldview/ patient counselling

*

* * *

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

* *

*

*

*

*

* *

6 GOALS AND TASKS OF SPIRITUAL CARE Having considered the personal identity of spiritual caregivers as professionals in chapter 4 and the legitimacy and position of spiritual care as a professional discipline in chapter 5, we now direct our attention more speciﬁcally to the goals and tasks of spiritual care. This is in response to our ﬁfth research question: how do spiritual caregivers see the goals and tasks of their profession? The goals of spiritual care are the results that spiritual caregivers hope to achieve with their activities. Here one can distinguish between desirability and feasibility. We conﬁne ourselves to the former, but with due regard to the fact that the goals pursued should be attainable in a general sense. The tasks of spiritual care are the activities performed in pursuit of the goals. Hence we ﬁrst look at the goals (6.1), then the tasks (6.2), each time presenting both the theoretical background followed by an account of the empirical ﬁndings. The chapter concludes with a résumé (6.3). 6.1

Goals

The goals of spiritual care, which distinguish the profession from other health care disciplines, comprise a number of immediate goals and an ultimate goal (6.1.1). Then we examine some approaches to these goals (6.1.2). Finally we consider spiritual caregivers’ own perception of goals and goal orientations as reﬂected in our research results (6.1.3). 6.1.1

Immediate goals and ultimate goal

The goals of spiritual care give the profession a distinctive orientation and structure in health care. In 1.1.3 we located the profession of spiritual care in a hospital setting in the area where worldview and health care overlap. Hence the goal of spiritual care should relate to the respective goals of worldviews and health care. Following Geertz, the general goal of worldviews can be deﬁned as the development of symbolic meanings, which are both cognitive and aﬀective and are expressed in rituals. In a worldview perspective, then, the

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goal of spiritual care may be deﬁned as communication on worldviews (Van der Ven, 2000, 92–98). Spiritual care seeks to promote insight into and knowledge about people’s attitudes to life by stimulating such communication. The overall goal of health care is to promote people’s health. The World Health Organisation (1948; 1986) deﬁnes health as “a state of complete physical, mental and social well-being and not merely the absence of disease or inﬁrmity”. The goal of spiritual care lies in the area where these two goals overlap. Thus the broadest deﬁnition of the goal of spiritual care in health care is as follows: promoting the physical, mental and social well-being of people by means of communication on worldviews; or: worldview-related communication as a contribution to physical, mental and social well-being. According to this deﬁnition communication on worldviews is the immediate goal and the contribution to health is the ultimate goal. Let us consider both goals. Immediate goals at micro level We have said that the immediate goal of spiritual care is to promote communication on worldviews. This communication has three aspects: exchange of information, exchange of pserspectives and coordination of perspectives, all in relation to worldviews. The ﬁrst aspect concerns information in a broad sense: an exchange of insights, feelings and behaviour. Many of spiritual caregivers’ conversations with patients are conducted at this basic level. Spiritual caregiver and patient give each other an opportunity to talk about important experiences, feelings, beliefs, values, norms and rituals. They also give each other information to interpret this testimony in the context of their respective worldviews. This provides a basis for patient and spiritual caregiver to exchange perspectives. The two dialogue partners don’t merely communicate from their own perspectives but endeavour to adopt the other’s perspective as well; in other words, the aim is reciprocal participation. Such an exchange of perspectives can lead to understanding. The aim is not to adopt the other’s perspective permanently but to adopt it temporarily in order to understand the person. The third phase is to coordinate these perspectives in dialogue with the partner. On the basis of the exchange of perspectives that has been achieved the dialogue between spiritual caregiver and patient can deepen into a search for truth in the area of worldviews (Van der Ven, 1998d, 266–278; 2004, 168–175). Three

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kinds of truth are at issue: the truth in an objective sense, the good and just in an intersubjective sense, and the authentic in a subjective sense. Unlike scientiﬁc propositions, the criterion of propositions about worldviews is reasonableness, not reason. The propositions should meet the criterion of pragmatic coherence: they have to manifest unity and order, and be conﬁrmed by everyday life. Such worldview-related truth is attestatory (Van Kessel, 1989, 75–85; Van der Ven, 1996c, 48–51; Taylor, 1991, 16–29). Communication about worldviews has an individual and a collective dimension. The individual dimension has an experiential, an aﬀective and a cognitive aspect. This dimension has to do with the meaning the worldview has for individual patients: their experience, feelings and ideas. Patients’ experience comprises their personal perception of life in the health care context; that includes their perception in terms of their worldview, for instance the experience of contingency. Feelings are moods and motivations, including those associated with the patient’s worldview. Ideas are patients’ more or less systematic knowledge, beliefs and notions, also at the level of their outlook on life. The collective dimension has a social, a moral and a ritual aspect. It concerns patients’ participation in communities, which is where their worldview-related ideas are exchanged, shaped and celebrated. Worldview-related ideas are exchanged in social relationships, hence we speak of a social aspect. Within the community models for reality assume concrete shape as speciﬁc norms and values, thus constituting a moral aspect. And in that community adherence to a particular worldview is celebrated, giving it a ritual aspect. In all major worldviews the collective dimension has a prominent place. Judaism is a typical example of a religion that originally possessed and still possesses all the attributes of a community religion. In the Christian worldview the common perception of the kingdom of God has assumed new expressions throughout the history of Christianity. The Islamic ideal is the umma, the community of the faithful; Buddhism has the social organisation of the sangha, the religious community that inﬂuences society around it. In Hinduism the importance of the community is reﬂected upon and practised in sampradaya. Humanism, too, attaches great value to the community; its moral sense of human beings’ solidarity and interrelationship extends to all humankind (Ward, 2000, 9–127). We shall now look more

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closely at the three aspects of each dimension in the perspective of worldview-related communication. Individual communication on worldviews has, as indicated already, an experiential, an aﬀective and a cognitive aspect. Its experiential aspect pertains to worldview-related experience. These are crucial experiences, which make people feel that they are touching or being touched by the very core of life. Examples are experiences of the holy or numinous, of contingency or fear, of the unrepeatability of events, of the irreversibility of actions, and the experience of the meaning of life and existence (cf. Hermans, 2001, 170–180; Van der Lans, 1998, 8–16; Van Saane, 1998). As a result of such experiences in the present past experiences of the same kind are reinterpreted and restructured, thus giving the person’s future outlook new meaning. The experiences are generated by stimuli that patients receive; dominant stimuli may become impressions and experiences in themselves. Experience, including worldview-related experience, is often physically perceptible. More speciﬁcally neuropsychologists have established that meditational states of experience correspond with distinct brainwave pattern activity and that transitions into more advanced stages of meditation correspond with brainwave changes (Peterson, 2003, 105–113). However, that does not tell us what the experiences are based on: subjective experience, including those relating to a worldview, cannot be reduced to, or fully explained at, a biological level (Moleman, 2004, 18–19). As for the aﬀective aspect, communication on worldviews pertains to worldview-related emotions—what Geertz calls moods and motivations. These are powerful, profound and permanent and have a certain intensity (moods) and orientation (motivations). They give worldview-related activity a permanent ‘ﬂow’ (Geertz, 1973, 94–97, 104, 122). The feelings could be positive, like joy, peace and warmth, or negative, like helplessness, fear or loneliness. In addition they may be directed to the self, other people or God. Examples of self-directed feelings are energy, self-assurance and self-esteem. Other-directed or God-directed feelings include love, intimacy and security. The literature also refers to feelings that are particularly inclined to be coloured by worldview by virtue of their focus, for example the longing for a perspective on the deeper meaning of life or a longing to resolve doubts about the possibility of such meaning (cf. Nauta, 1995, 36–37; Van Saane, 1998, 235).

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In the case of the cognitive aspect, communication about worldviews pertains to worldview-related beliefs—what Geertz calls symbolic transformations of reality. They are beliefs in the sense that people ‘believe’ in their reality. Beliefs provide a model of reality, answers to existential questions and the meaning of life generally (Geertz, 1960, 28–29; 1968, 97–98; 1973, 93–94). They include both speciﬁc images and concepts, as well as ideas and thoughts. As noted already, key ideas in worldviews relate to the nature of ultimate reality, and to suﬀering and death. These beliefs are expressed in the narratives of worldview traditions and in people’s stories about their lives. Collective communication on worldviews has, we have said, a social, a moral and a ritual aspect. The social aspect of communication on worldviews pertains to relations with others. It could entail analysis and stimulation of these relations and meta-reﬂection on them. Analysing relations occurs when the spiritual caregiver uses the dialogue to explore the patient’s relationships and their pertinence to the health care context. Relations are stimulated when the spiritual caregiver assists a patient to invoke certain relationships or helps the person to handle relational problems, all in a framework of physical, mental and social well-being. Meta-reﬂection on relations occurs when spiritual caregiver and patient together look for the meaning of relationships in a worldview perspective. Worldviews regard friendship and love generally as a supreme good. As for the moral aspect, communication on worldviews relates to moral behaviour and is aimed at ethical, good conduct in real-life situations (cf. Van der Ven, 1998d, 154–176). It concerns worldview-related models for reality. In their dealings with patients spiritual caregivers discuss values and norms in the patient’s personal life as well as those applicable to the health care context. Values and norms have always been crucial in worldviews. They apply to individual life, coexistence with others and society at large. Examples of cardinal values in most worldviews are love of one’s neighbour, charity, justice and honesty. The ritual aspect relates to the expression of worldview-related beliefs in either spontaneous or formalised symbolic activities (Lukken, 1999, 97–99). Above, following Geertz, we underscored the focal signiﬁcance of ritual communication in worldviews. Rituals express and help to shape the worldviews of individuals and groups. Participation in rituals is an important part of patients’ worldviews

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in that it concretises them (cf. Hermans, 2001, 203–214; 2002, 327–331). Rituals enable people to make the transition from their reality as patients in a care institution to a symbolised, ultimate reality, and vice versa. According to Geertz the performance of rituals gives the worldview an ‘aura’ of objectivity. Beliefs reinforce the plausibility of the ultimate reality and give the action orientations a mandatory character. Rituals strengthen the bond with others and reduce ambivalence at a cognitive and behavioural level (Bell, 1997, 27–29,177–180). Ultimate goal at micro level The ultimate goal of spiritual care is to make a speciﬁc contribution to patients’ health. We have mentioned the three aspects of health identiﬁed by the World Health Organisation: physical, mental and social. A direct focus on promoting physical health is the prerogative of doctors, nurses and other paramedical professionals. Psychologists, social workers and (remedial) educationists concentrate mainly on the mental and social aspects of health. Spiritual caregivers are concerned with the spiritual aspect of mental health. They belong to the category known as peri-medical professionals (Nationale Ziekenhuisraad, 1987). The substance and criteria of mental health are not clear. Sometimes mental health is deﬁned negatively as the absence of psychiatric disorders. Elsewhere it is described positively as positive well-being, quality of life, contentment and integration (Boot & Knapen, 1996, 27; Corveleyn, 2003; Loewenthal, 1995, 7–8). Fortmann points out that mental health in a positive sense is located at two levels: the psychological level and that of worldview. The psychological level relates to mental health or illness, which is the domain of psychologists and psychiatrists. The worldview level relates to the ultimate meaning of life. In boundary situations, when people reach the limits of their capacity to assign meaning, endure suﬀering and pass a moral judgment on good and evil, a common sense approach is inadequate. Through worldview-related symbolisation the world and the boundary situations are put in an ultimate context. Fortmann explains that there is a diﬀerence between neurotic conﬂict and existential conﬂict in regard to life’s boundaries. Worldviews always pertain to what Fortmann calls inner health and to dealing with profound questions triggered by existential conﬂict. The same criteria are given

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for both the psychological and worldview levels, for instance ego strength, autonomy, integration, realistic perception of the world and creativity; but it is important to distinguish between neurotic and existential aspects (Fortmann, 1974, 351–359). In our approach to spiritual care and health we have in mind the existential, worldviewrelated or spiritual aspect of mental health. That is the special domain of spiritual care: other disciplines undoubtedly delve into the psyche but not into the patient’s soul (Corveleyn, 2003, 27–31). Spiritual care invokes worldviews so as to activate powers in people that enable them to form an optimally autonomous perception of life, which helps them to discern coherence in their experiences and thus enhances their existential problem solving (Kromhout, 1990). In this sense the spiritual aspect of mental health is linked to the other aspects of human health (Naurath, 2000, 20–43). Goals at meso level The two kinds of goals at the micro level also feature at meso level: a worldview-related goal and a health goal. At meso level spiritual care seeks partly to create scope for worldviews and partly to make a speciﬁc contribution to health care. These goals play a role in both professional deliberations and deliberations on policy. Fellow caregivers meet with spiritual caregivers at a departmental level and in departmental groups or clusters. They also have more or less regular consultations with management. Hence the ﬁrst meso level goal is to focus attention on worldviews as an element of care, for instance by clarifying the speciﬁc implications of worldviews for the care of diﬀerent patient groups. Spiritual care can also draw attention to the role of worldviews in the care activities of other disciplines; especially in nursing care attempts are being made to establish standards for worldview-related care (MacSherry, 2000). In dealings with the management of care institutions spiritual caregivers can highlight the importance of worldviews for the institution as a whole. Sometimes such policy communication relates to the identity and inspiration of the institution (Gribnau & Pijnenburg, 2004; Schepens, 1997, 66–98). The second goal at meso level is to focus on care in the broad sense of the word. Caring for human beings—their physical, mental and social well-being—is a major concern in worldviews. They emphasise that people are destined to live in freedom and love, and to experience reconciliation and forgiveness when evil in the form

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of guilt enters their lives. In worldview traditions this concern for human health and healing is expressed in the organisation of health care, as well as in pilgrimages and various other rituals such as religious healing practices (Gribnau & Pijnenburg, 2000; Pieper, Post & Van Uden, 1999; Vellenga, 1998). Spiritual care aims at ensuring that good care is provided. To this end it participates in deliberations with other disciplines in the various departments. It shares this orientation with management as well. 6.1.2

Goal orientations

In the literature one ﬁnds distinctions between orientations or approaches to goals. These stem from the basic model for the provision of spiritual care and applies to both micro level goals for interaction with patients and the meso level goals discussed above. We shall take a closer look at ﬁve goal orientations. Firstly, spiritual care focuses on patients’ experience by listening to and sharing it. The main thing is to allow maximum scope for patients to articulate that experience. This is known as a participatory orientation. Hiltner—who, inspired by humanistic psychology, pioneered this approach—considers helping patients in their selfexploration a necessary condition for a sound approach to their problems. In so doing spiritual caregivers can help patients to accept, understand and clarify their inner and interpersonal conﬂicts. A prerequisite is to create a trust relationship, which enables patients to learn to help themselves and perceive the situation not merely as a tribulation but also as a challenge to growth (Hiltner, 1959, 19–33; 1969, 99–111). By maintaining a close presence, showing respect and appealing to patients’ maturity spiritual caregivers help them to ﬁnd the strength to help themselves (cf. Taylor, 1991, 15–60; Worsley, 2002, 162–177). A second aim of this orientation to patients’ experience is to oﬀer comfort and encouragement. In this context comfort is synonymous with what Hiltner calls sustaining. At ﬁrst glance merely oﬀering comfort appears contrary to the rationality that marks modern health care (Van der Ven, 2003, 26f.). But oﬀering comfort could be a considered choice if the accent is not so much on strictly goal-oriented rationality and the concomitant control and stability, but rather on communication between all parties involved in the care programme to ensure an integrated approach to patients’ problems (cf.

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2.1.1). Spiritual caregivers and pastors are expected to be able to oﬀer comfort, with the caveat that it must not be facile comfort in the sense of disregarding the patient’s actual experience (Veltkamp, 1990, 11; cf. Ganzevoort, 1996, 123–130; Van der Wal, 1997). This refutes the argument that the comfort orientation has no real substance; on the contrary, images from worldviews that transcend everyday meanings can be tested by determining whether they are able to create order in people’s existential chaos and thus oﬀer comfort in the experience of suﬀering (Vossen, 1990, 24; cf. Aden & Ellens, 1990, 193–195; Stilma, 1991). In addition to the participatory and comfort approaches’ orientation to patients’ experience, spiritual care seeks to guide their evaluation of that experience. This is known as the challenge orientation. Present experience forms a basis for eﬀecting changes in the future. The challenge orientation is often adopted when dealing with negative experience. Spiritual caregivers challenge patients to take a fresh look at their situation and view it from a distance. They focus patients on the tasks they have set themselves or that they face as a result of their admission to health care. They challenge patients to re-deﬁne their situation and look for possible ways to change it (cf. Cobb & Robshaw, 1998; Denys, 1992). Proponents of this approach see the crisis that accompanies health problems as an opportunity for growth. In concrete terms the challenge may consist in guiding patients to look critically at things like loyalties and conﬂicting loyalties or the balance between giving and taking in their biographies, and to face up to faults and merits (Boszormenyi-Nagy, 2000, 80–141; Van den Blink, 2002). Others use Bible readings to give patients a fresh perspective on their experience (Louw, 1994, 88–108; 2000). That brings us to the next orientation. Apart from an orientation to patients’ experience and their evaluation of it, spiritual care can focus on its own mission or message and try to get patients to accept it. This is what happens in the charismatic orientation. In a psychosocial sense this orientation stems from Weber. He was the ﬁrst to describe the charismatic orientation in detail with reference to the supernormal powers ascribed to wizards, priests and prophets in religious communities. Charismatic authority arises mainly in times when people need inspiration and enthusiasm. Examples of charismatic personalities are the founders of the world religions, who had an extraordinary inﬂuence on human

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history. But after their death the product of their charisma became an object of trivialisation (Veralltäglichung) (Weber, 1972, 140–147; 2001, 442–444). Under certain cultural conditions charismatic leadership can still be exercised eﬀectively today (Wilson, 1978, 13–22, 96–100). In addition to the special charisms peculiar to the founders of the world religions there are ordinary charisms, which include faith, hope and love as well as testimony, help and spiritual guidance (Küng, 1985, 212–222). Whereas the kerygmatic orientation, to be discussed below, accentuates the objective contents of the message, the charismatic orientation stresses the personal manner in which the spiritual caregiver experiences the message and conveys it to patients. The premise of the charismatic orientation is the spirit at work in people, including spiritual caregivers, which gives them power to act towards others in a liberating way. According to some authors this inspiration is at least as important as professional expertise (Csordas, 1994, 25–73; Van Heyst, 2003, 427–430; Sonnberger, 1996, 74–78). Finally spiritual care can focus on its own mission or message by adopting a kerygmatic approach. The point of reference in this orientation is kerygma, that is, the beliefs of the worldview association. Spiritual caregivers adopt this kerygma as their personal perspective and seek to convey the message to patients with a view to their appropriating it. Theologically this orientation derives from the work of Thurneysen, who was inspired by dialectical theology. Thurneysen sees dialogue as human encounters in the presence of God and in the context of the church. The focal point is the (sacramental) Word, more especially the proclamation of God’s reconciliation. Spiritual caregivers legitimise the substance of their message by referring to the Bible, Christian tradition and/or contemporary religious life in the church. Ultimately the kerygmatic approach seeks to oﬀer hope to people in distress (Thurneysen, 1968, 36–57, 157–240). Spiritual care based on this model often invokes ecclesiastic ministry (cf. Eschmann, 2000, 10–13; De Korte, 1994, 255). The sequence in which we discussed the various orientations is not fortuitous: they range from orientations that operate wholly within the patient’s frame of reference to approaches based on an extraneous frame of reference. Spiritual caregivers with a participatory orientation adhere most strictly to the experience that patients present to them. Those with a comfort orientation oﬀer some form of support and solace as well, but they maintain the focus on the

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patient’s experience. Spiritual caregivers with a challenge orientation distance themselves somewhat from the patients’ frame of reference so as to facilitate evaluation of their experience. Those with a charismatic orientation oﬀer an extraneous message in the form of their own inspiration. And spiritual caregivers with a kerygmatic orientation also operate from outside the patient’s frame of reference by presenting the message of their worldview association. 6.1.3

Goals and goal orientations: research ﬁndings

Having explored the goals and goal orientations of spiritual care in a theoretical perspective, we turn to spiritual caregivers’ appraisal of these. We analysed four umbrella concepts: the immediate goals of spiritual care at micro level, the ultimate goal at micro level, the goals of spiritual care at meso level and the goal orientations of spiritual care. The immediate goals and the ultimate goal at micro level In the relations between spiritual caregivers and patients we distinguished between an immediate and an ultimate goal. The immediate goal—that of promoting communication on worldviews—has an individual and a collective dimension. The individual dimension has an experiential, an aﬀective and a cognitive aspect; the collective dimension has a social, a moral and a ritual aspect. The ultimate goal is to promote patients’ health, more especially the spiritual dimension of mental health. We formulated three items for each of these seven aspects, giving us 21 items in all. Experiential aspect of communication on worldviews The immediate goal of spiritual care in dealings with patients has an experiential aspect. In their interaction with patients spiritual caregivers focus inter alia on experiences and questions relating to worldviews. How important do they consider this goal to be in their interaction with patients? Here is an example from the three items in which we operationalised the experiential aspect: p. In my dealings with patients I consider the goal of guidance regarding experiences in the sphere of meaning (‘totally unimportant’ to ‘very important’).

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Aﬀective aspect of communication on worldviews The immediate goal of spiritual care in dealings with patients has an aﬀective aspect. In their interaction with patients spiritual caregivers also focus on their existential feelings. How important do they consider this goal to be in their interaction with patients? Here is an example from the three items in which we operationalised the aﬀective aspect: l. In my dealings with patients I consider the goal of dealing with existential feelings (‘totally unimportant’ to ‘very important’).

Cognitive aspect of communication on worldviews The immediate goal of spiritual care in dealings with patients has a cognitive aspect. In their interaction with patients spiritual caregivers focus partly on exchanging worldview-related beliefs. How important do they consider this goal to be in their interaction with patients? Here is an example from the three items in which we operationalised this aspect: r. In my dealings with patients I consider the goal of focusing on their opinions in regard to worldview (‘totally unimportant’ to ‘very important’).

Social aspect of communication on worldviews The immediate goal of spiritual care in dealings with patients has a social aspect. In their interaction with patients spiritual caregivers also focus on the signiﬁcance of their relationships. How important do they consider this goal to be in their interaction with patients? Here is an example from the three items in which we operationalised the social aspect: c. In my dealings with patients I consider the goal of examining possible conﬂicts with others about their outlook on life (‘totally unimportant’ to ‘very important’).

Moral aspect of communication on worldviews The immediate goal of spiritual care in dealings with patients has a moral aspect. In their interaction with patients spiritual caregivers also deal with moral themes. How important do they consider this goal to be in their interaction with patients? Here is an example from the three items in which we operationalised the moral aspect: d. In my dealings with patients I consider the goal of reviewing their past at a moral level (e.g. guilt problems) (‘totally unimportant’ to ‘very important’).

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Ritual aspect of communication on worldviews The immediate goal of spiritual care in dealings with patients has a ritual aspect. In their interaction with patients spiritual caregivers focus partly on their expression of their worldview by way of rituals. How important do they consider this goal to be in their interaction with patients? Here is an example from the three items in which we operationalised this aspect: n. In my dealings with patients I consider the goal of coping with their existential experience by way of rituals (‘totally unimportant’ to ‘very important’).

Ultimate goal: promotion of mental health The ultimate goal of spiritual care is to contribute to patients’ health, especially the spiritual dimension of mental health. How important do spiritual caregivers consider this goal to be in their interaction with patients? Here is an example from the three items in which we operationalised this goal: u. In my dealings with patients I consider the goal of contributing to their mental health (‘totally unimportant’ to ‘very important’).

Spiritual caregivers’ responses to these items were subjected to factor analysis. This yielded ﬁve factors, on the basis of which we constructed ﬁve scales (ﬁgure 6.1; cf. appendix 2, instrument 15 and appendix 3, table 27 and 28). Figure 6.1 Immediate goals and ultimate goal of spiritual care Goals of spiritual care at micro level

immediate goals

ultimate goal

individual

collective

experiential-aﬀective

social-moral

experiential

aﬀective

cognitive

social

moral

ritual

items: e, g, p

l

items: f, m, r

items: b, c

d

items: a, i, n

mean: 3.6

mean: 3.8

mean: 4.3

mean: 3.7 humanist: 3.1 religious: 3.7

promotion of mental health items: s, u mean: 4.3

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The empirical ﬁndings conﬁrm our theoretical classiﬁcation into immediate goals and an ultimate goal. They also conﬁrm the subdivision of the immediate goals into an individual and a collective dimension. But they don’t conﬁrm the distinctions we made earlier between the diﬀerent immediate goals, distinctions we derived from the literature (cf. Glock & Stark, 1968, 14–18). Factor analysis combined the experiential and aﬀective goals as well as the social and moral goals. In regard to the experiential and aﬀective aspects, this ﬁnding of the factor analysis accords with new insights in cognitive science of religion, which indicate a conjunction of the experiential and aﬀective aspects (Boyer, 1994, 23–27, 174–184; Peterson, 2003, 85–95; Pyysiäinen, 2001, 80–89). As for the social and moral aspects: the moral aspect of a worldview may be located at both an individual and a social level; it would seem that spiritual caregivers have concentrated on this second level, relegating the connection between individual and moral aspects to the background. On the basis of the factor loadings we called the combination of the ﬁrst two aspects experiential-aﬀective and that of the other two aspects social-moral. As is evident in ﬁgure 6.1 spiritual caregivers endorse all the goals we investigated at micro level. They attach greatest importance to experiential-aﬀective communication on worldviews and promotion of mental health; cognitive, social-moral and ritual communication about worldviews is rated as less important, although the ratings are still clearly positive. Finally we give the social location of the scales in terms of the ﬁve personal characteristics and the institutional characteristic described in 1.3: gender, training, denomination, ministerial approval, professional association and care institution. The only relevant diﬀerentiation concerns the ritual aspect of communication on worldviews. We only present the ﬁndings for spiritual caregivers from religious traditions, because those for spiritual caregivers from the humanistic tradition did not show any diﬀerentiation. Second-grade college educated respondents are more explicitly positive in their evaluation of this goal (mean: 4.0). Compared to colleagues without ministerial approval, spiritual caregivers with ministerial approval from a religious association put less emphasis on this goal (means respectively 3.9 and 3.7), while respondents with no position in a religious worldview association rate it more highly (mean: 3.9). Ministers in a protestant church put less emphasis on this goal (mean: 3.6). VGVZ-members from

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religious traditions are less explicitly positive about it (mean: 3.6), while non-members of a professional association give it an explicitly positive rating (mean: 4.0). ‘Religious’ spiritual caregivers employed in a general hospital attach less importance to the ritual goal (mean: 3.6), while their colleagues in nursing homes rate it more highly (mean: 3.9). Goals at meso level In their deliberations with other disciplines at a departmental and cluster level, and in deliberations with management, the primary goal of spiritual care is to highlight the theme of worldviews and, secondly, to contribute to health care generally. For each of these two goals— focus on the worldview-related dimension of care and focus on care generally—we formulated three items, giving us six items in all. Focus on worldview-related dimension of care Spiritual care is intent on creating scope for worldviews not only at micro level but also at the meso level of care institutions. The idea is to explain the signiﬁcance of worldviews for the care provided. How important do spiritual caregivers consider this orientation to be in their relations with other caregivers and management? Here is an example from the three items in which we operationalised this goal: c. In my work I rate discussion of the role of worldviews in multidisciplinary cooperation (‘totally unimportant’ to ‘very important’).

Focus on care at meso level Spiritual care is intent on contributing to health care as a whole. After all, caring for people in distress is a cardinal concern in worldviews. Spiritual care seeks to ensure that good care is provided. How important do spiritual caregivers consider this orientation to be? Here is an example from the three items in which we operationalised this goal: f. In my work I rate contributing to quality of care (‘totally unimportant’ to ‘very important’).

Spiritual caregivers’ responses to these items were subjected to factor analysis. This yielded two factors, on the basis of which we constructed two scales (ﬁgure 6.2.; cf. appendix 2, instrument 16 and appendix 3, table 29).

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Figure 6.2 Goals at meso level Goals at meso level

focus on worldview-related dimension of care

focus on care

items: a, c mean: 4.1

items: d, e, f mean: 4.2

The theoretical classiﬁcation of meso level goals is conﬁrmed. As is evident in ﬁgure 6.2, spiritual caregivers ﬁnd both goals important— both clariﬁcation of the role of worldviews and contributing to care generally. There is no relevant diﬀerentiation in regard to the social location of the scales we investigated. Goal orientations of spiritual care We have described ﬁve orientations to spiritual care. In the participation and comfort orientations spiritual care focuses on patients’ experience; the former aims at clarifying the experience, the latter at encouraging patients to assimilate it. The challenge orientation focuses on evaluation of patients’ experience. The charismatic and kerygmatic orientations focus on the mission of spiritual care or of the spiritual caregiver. We formulated three items for each of these ﬁve orientations, giving us ﬁfteen items in all. Participation orientation In an orientation which centres on patients’ experience spiritual care seeks to facilitate self-discovery. The premise is patients’ ability to help themselves. How important do our respondents consider this orientation to be? Here is an example from the three items in which we operationalised the participation orientation: f. For good spiritual care I consider allowing scope for patients’ inner experience (‘totally unimportant’ to ‘very important’).

Comfort orientation In an orientation centring on patients’ experience spiritual care can also oﬀer them comfort and encouragement. The comfort is directed to the patient’s present situation and experience. How important do our respondents consider this orientation

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to be? Here is an example from the three items in which we operationalised the comfort orientation: e. For good spiritual care I consider searching with patients for possible sources of comfort (‘totally unimportant’ to ‘very important’).

Challenge orientation In a challenge orientation spiritual care aims at evaluating patients’ experience. The spiritual caregiver challenges patients to view their experience from a detached position. The aim is possible change in the future based on this evaluation. How important do our respondents consider this orientation to spiritual care? Here is an example from the three items in which we operationalised it: k. For good spiritual care I consider calling on patients’ to take personal responsibility (‘totally unimportant’ to ‘very important’).

Charismatic orientation In contrast to a focus on patients’ experience and their evaluation of it, spiritual care can concentrate mainly on its own mission or message. A charismatic orientation proceeds from the subjective, personal inspiration of the spiritual caregiver. How important do spiritual caregivers consider this orientation to be? Here is an example from the three items in which we operationalised the charismatic orientation: d. For good spiritual care I consider witnessing to my own belief in my behaviour as a spiritual caregiver (‘totally unimportant’ to ‘very important’).

Kerygmatic orientation In the kerygmatic orientation the accent is on the objective beliefs of the spiritual caregiver’s worldview association. That association’s message is the point of departure. How important do spiritual caregivers consider this orientation to be? Here is an example from the three items in which we operationalised the kerygmatic orientation: b. For good spiritual care I consider referring patients to the tradition of my own worldview (‘totally unimportant’ to ‘very important’).

Spiritual caregivers’ responses to these items were subjected to factor analysis. This yielded three factors, on the basis of which we constructed three scales (ﬁgure 6.3; cf. appendix 2, instrument 17 and appendix 3, table 30 and 31).

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Figure 6.3 Goal orientations of spiritual care Goal orientations of spiritual care

experience

evaluation of experience

mission

participatory

comfort

challenge

charismatic

kerygmatic

items: f, h, m

e, j, l

items: c, k

items: a, d, i

b, g, o

mean: 4.0

mean: 2.7

mean: 4.5

The empirical ﬁndings conﬁrm the theoretical classiﬁcation into orientations to experience, evaluation of experience and mission. At the level of the subdivisions within these categories factor analysis combined the participation and comfort orientations and the charismatic and kerygmatic orientations. On the basis of the factor loadings of items we labelled the combination of the ﬁrst two aspects ‘orientation to experience’ and the combination of the other two ‘orientation to mission’. As is evident in ﬁgure 6.3 spiritual caregivers rate an orientation to patients’ experience as very important and a challenge orientation as important; they are negatively ambivalent about a mission orientation. Finally we give the social location of the scales in terms of the ﬁve personal characteristics and the institutional characteristic described in 1.3: gender, training, denomination, ministerial approval, professional association and care institution. Protestant church workers are less explicitly in favour of the challenge orientation (mean: 3.5). Protestant ministers reject the mission orientation (mean: 2.5). We found no relevant diﬀerentiation regarding orientation to experience. 6.2

Tasks

Spiritual caregivers’ tasks are the activities required to achieve their goals. A properly deﬁned set of tasks helps to diﬀerentiate spiritual care as a specialist ﬁeld from other health care professions. The

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responsibilities attached to these tasks need to be deﬁned in a professional code for the service. In this section we ﬁrst describe these tasks from a theoretical perspective (6.2.1) and then from an empirical perspective on the basis of our research ﬁndings (6.2.2). 6.2.1

Tasks from a theoretical perspective

The National Hospital Council’s memoranda for 1983 and 1987 contain the ﬁrst draft outline of eight tasks of spiritual caregivers. On the basis of this early list the VGVZ compiled a professional proﬁle in 1995. The association’s aim is to have this proﬁle accepted as a quality norm for institutions (Doolaard, 1996, 188). The subsequent professional code of the VGVZ (2002) elaborates on this proﬁle (cfr. Hekking, 2003). The professional proﬁle identiﬁes fourteen tasks, in which the inﬂuence of the National Hospital Council’s original list is clearly discernible. These fourteen tasks are classiﬁed into four categories: patient-oriented tasks, tasks oriented to interdisciplinary cooperation, externally oriented tasks and tasks oriented to the discipline of spiritual care. Patient-oriented tasks include oﬀering patients the spiritual care they need, oﬀering spiritual care to the family and people in the patient’s social network, and performing liturgical, ritual and related tasks. Tasks oriented to interdisciplinary cooperation involve actual interdisciplinary cooperation and assistance, conﬁdentiality in relation to other professionals, ethical and worldview-related opinion forming, teaching and training tasks, and consultation with institutional management and other services. Externally oriented tasks are coaching and supervision of volunteers, guidance within the institution and contacts outside the institution. Finally, tasks oriented to the discipline of spiritual care include tasks in extra-institutional care, tasks within the spiritual care service or individual care unit, and personal professional training (Doolaard, 1996, 887–911). We explore only three tasks as an extension of the three goals that we investigated: individual counselling and performance of rituals at micro level (6.2.1.1) and supra-disciplinary consultations at meso level (6.2.1.2). 6.2.1.1 Tasks at micro level First we discuss some aspects of a counselling conversation, followed by some aspects of the performance of rituals.

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chapter six Aspects of counselling conversations

In terms of time investment patient counselling is the spiritual caregiver’s principal task. We consider three aspects of this task: its human fellowship character, its demand/supply structure and the initiation of counselling conversations (cf. Stevens, 1990, 14–32). The ﬁrst aspect of spiritual caregivers’ counselling task is their relationship with the patient. Is it a functional or a non-functional relationship? The interaction between spiritual caregiver and patient involves a relationship between two unique individuals. Both parties have their own ideas and values, biography and life world, current worries and outlook on the future. Their relationship is marked by mutual observation and aﬃnity (sympathy or antipathy). Every dialogue displays a polarity of giving and receiving, in varying proportions. Viewed from this basic angle, the way spiritual caregiver and patient approach each other determines their relationship (Stevens, 1990, 14–25). Some authors see the relationship as mainly functional. After all, it is ephemeral, asymmetrical and geared to an extraneous purpose. It is not a friendship but is aimed at the aforementioned experiential-aﬀective, cognitive, social-moral or ritual goal. That is why it is ephemeral: once the goal has been more or less achieved, the relationship ends. Even in care institutions where patients stay for relatively long periods the counselling relationship has a time limit. By asymmetrical we mean that the counsellor engages as a helper: helpers have to introduce their own thoughts and feelings appropriately, for the good of the patient. Hence they themselves and their life world enter into the relationship selectively (cf. Stevens, 1990, 14–15; 30–31). Other authors prefer to see the relationship between spiritual caregiver and patient as predominantly non-functional. Both parties engage personally in the relationship. Spiritual caregiver and patient are equals. This equality is at a human level: spiritual caregivers also reﬂect on themselves and on existential problems (cf. Van Beinum, 1996, 303; Hoogeveen, 1994, 88–89). Spiritual caregivers’ task is to be there for the patient without undue emphasis on their counselling objectives and their own frame of reference. Indeed, what sets spiritual caregivers apart from other helpers and caregivers is that they push these things aside. This person-to-person relationship is geared to human fellowship, for instance in the form of personal closeness, encouragement and comfort without any intentional oﬀer of help.

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The patient feels addressed as a human being (hence experiences herself as a person with her own responsibility) and also feels that the spiritual caregiver engages as a human being rather than as the possessor of speciﬁc professional knowledge and expertise (Firet, 1974, 203–222). This quality of the relationship is emphasised particularly in presence-oriented spiritual care, which is primarily aimed at providing an attentive presence and resonating and identifying with the patient’s life world and history. Such an unhurried, caring relationship is eﬀective even if it does not culminate in actual problem solving: at all events patients will have had an experience of self-worth that will counteract any sense of wounded dignity or social redundancy. Thus this form of spiritual care focuses on the patient’s personal identity. The spiritual caregiver operates primarily from a sense of human fellowship, a reciprocity that is crucial for the eﬀectiveness of this approach. In earlier chapters we associated an awareness of the ‘fellowship of the weak’ with the contingency of human life as such (Baart, 2003a, 11–14; 2004, 876–881; cf. Van der Ven, 2003, 32). The second aspect of spiritual caregivers’ counselling task is the extent to which spiritual care is directed to patients’ demand for help and to supplying the kind of help that is requested. Some authors would like spiritual care, like other disciplines, to focus purposively on meeting patients’ demand for help. To this end spiritual care develops a distinctive, worldview-related diagnostics (cf. Fitchett, 1993). Worldview-related diagnostics can be deﬁned as collecting, selecting and organising data on the patient and identifying the problem with a view to intervention by a spiritual caregiver. The accent in problem identiﬁcation varies depending on the caregiver’s approach, for instance a narrative, psychoanalytic or systems theory approach (Bouwer, 1997, 23–25; 2000a; 2003b, 75–87). With a view to the eﬀectiveness of care, management, too, requires spiritual caregivers to justify their patient care in terms of a demand-supply structure. In the case of demand-oriented supply spiritual caregiver and patient may enter into a formal or informal agreement, sometimes called a counselling contract (Stevens, 1990, 30; Andriessen, 1996, 132–135), on things like the nature, duration and frequency of counselling, mutual expectations and interim and ﬁnal evaluation of the counselling. Other authors feel that spiritual care is not and should not be characterised by a problem intervention structure. In institutions for mentally handicapped people, for example, spiritual care is not

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directed to counselling in problem situations but rather to reading and interpreting the patient’s life story (Van Oosterhout et al., 1996, 730–733). Yet others, concurring with this view, maintain that in spiritual care the term ‘demand for help’ should be interpreted very broadly as indicating the patient’s existential (need) situation (cf. Taylor, 1991, 45–57). There are also authors who feel that spiritual care should avoid the potential power mechanisms that diagnostic classiﬁcation may entail (Bach, 1996, 643–645). The third aspect of spiritual caregivers’ counselling task concerns the initiator of the contact between spiritual caregiver and patient. There are two possibilities: the contact may be initiated by the patient or the attendant doctor or nurse acting on the patient’s behalf by referring him to the spiritual caregiver; or it may be initiated by the spiritual caregiver. The argument in favour of the ﬁrst option—initiation by patients or their therapists/caregivers—is that it respects patients’ self-determination. Patients themselves declare their need for spiritual care, thus obviating any risk that spiritual care will be foisted on them. Inasmuch as patients may not be suﬃciently aware of their worldview-related problems and needs, the doctors and nurses who treat them and care for them are willing and able to refer them to a spiritual caregiver. In a framework of patient-oriented demanddriven care, in which interaction is geared to the patient’s need(s), this is the best approach. The ﬁrst argument against this approach is that many patients have only a vague or distorted image of spiritual care, for instance that it is conﬁned to ecclesiastic pastoral work. In addition existential problems tend to remain unspoken for a long time and are often hard to articulate. At such a time patients may resist the idea that they need someone who will understand and assist them. Quite often, too, existential problems are translated into psycho-physiological or psychosocial complaints. As a result even the attending doctor and nurses may fail to spot the patient’s existential problems or may misinterpret them (Bodson, 1982, 1544–1547). This means that the patients do not ask for spiritual help, neither does the attending doctor or nurse refer them to a spiritual caregiver. Secondly, those dispensing treatment and care may themselves have a negative picture of spiritual care, which militates against referral (cf. 6.2.1.2). There are three argument for spiritual caregivers initiating dialogue with patients. The ﬁrst is that spiritual caregivers are not therapists. They do not form part of the organisation of medical and

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other therapies, which are based on speciﬁc medical grounds, although interdisciplinary consultation may lead to the recommendation of an interview with a spiritual caregiver. In most cases, however, this is not done on strictly medical or therapeutic grounds. Even so spiritual caregivers can evolve a practice of having an introductory conversation with patients, in which they assess in how far they actually are in need of spiritual care. The second argument is at the level of society and social institutions, which are subject to individualisation and privatisation (cf. Felling, 2004). Patients increasingly indicate that they are not aﬃliated to any institutionalised worldview. Their worldviews are highly individualised. This leads one to expect that they are less in need of counselling by a representative of a worldview association. The same individualisation and privatisation apply to the helpers with whom spiritual caregivers collaborate and on whom they mostly have to depend for referral of patients. In this context spiritual caregivers’ personal initiative is called for to counteract possible risks and damage from leaving patients to cope with their existential needs on their own as a result of individualisation and privatisation. The third argument concerns the position of spiritual caregivers who fulﬁl their task as a ministry on behalf of a worldview association. In the past ministers were fully entitled to visit patients at their own initiative, an outcome of the tradition of parish visiting in churches and other worldview associations. The argument underscores the character of spiritual care as a discipline occupying a special place in health care. Historically this last argument has always taken ﬁrst place; many spiritual caregivers still see it as the basis for their initiating behaviour and their special position in care institutions. In this context spiritual care is sometimes said to have a sanctuary in health care (see e.g. Van Loenen, 1996, 605; Smeets, 2000b, 437–441). Against the initiation of counselling dialogue by spiritual caregivers one could argue that it is a case of safeguarding their own profession rather than of caring for patients in existential need. Spiritual caregivers’ personal initiative, it is said, is aimed at preventing any loss of professional importance in a secularising, individualised context. Besides, the reference to the tradition of parish visitation by ministers and pastors is inappropriate. A care institution is not a parish or congregation. Spiritual caregivers work in a diﬀerent context, where diﬀerent rules apply. Finally the invocation of the special

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position of spiritual caregivers is not always presented accurately. Their ministry means that their employment in the institution is based on an agreement between the worldview association and the management of the care institution; this does not by deﬁnition include the right to visit patients on their own initiative. We have already pointed out, moreover, that the sanctuary pertains to patients’ rights in terms of freedom of religion and worldview, not to spiritual caregivers’ rights, in terms of which they could claim some sort of ‘right to personal initiative’. Aspects of ritual practice Rituals are once-only or recurrent symbolic actions, in which human beings relate to an ultimate reality that these activities represent. The hallmarks of rituals are their stylised, repetitive, traditional, multilayered, dramatic and spiritual character (Grimes, 1990, 13–14). In spiritual care one encounters individual, group and collective rituals. Individual rites usually mark a transition, for instance the beginning or end of life. In the Christian tradition they take the form of baptism, extreme unction or benediction (Collins, 1991, 11–24). In recent times attempts have been made to ﬁnd innovative rituals for these transitions and for coping with radical existential experiences (Bell, 1997, 93f., 223–241). By group rituals we mean ceremonies speciﬁcally geared to groups of patients in care institutions. They occur mainly in institutions for the mentally handicapped (e.g. so-called ‘sensory integration’ rituals) and in nursing and old age homes (e.g. group singing) (Van Oosterhout et al., 1996, 741–742; cf. Bell, 1997, 93f.). By collective rituals we mean services conducted regularly at ﬁxed times for all patients in the care institution, often for their relatives, staﬀ members and outsiders as well. The most typical example is the Sunday liturgy in the Christian tradition. These may be oﬀered by just one denomination, or they may be conducted ecumenically by, for instance, Protestant and Catholic churches (Oskamp & Schuman, 1998, 154–279). There are formal diﬀerences in emphasis in diﬀerent types of care institutions. Thus the liturgy in institutions for the mentally handicapped will focus more on experiential content than on cognitive intelligibility (Van Oosterhout et al., 1996, 740).1 1 There are arguments in favour of caregivers rather than outside clergy conducting the rituals in the institution. These relate to organisational clarity, speciﬁc

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The individual, group and collective rituals outlined above have two dimensions that we shall now explore: an individual and an interactive dimension. The individual dimension has three aspects: an experiential, an expressive and a cognitive aspect. The interactive dimension has two aspects: a moral and a social aspect (cf. Bell, 1997, 93–137; Hekking, 1996, 484–486; Menken-Bekius,1998, 39–70; Witjes, 1996, 538–541). Firstly, the experiential aspect: it relates to what participants in a ritual may experience. Rituals typically address the senses, such as smell (e.g. the use of incense) and taste (e.g. in the Christian eucharist and the Islamic sugar feast). Rituals entail a symbolised experience of entering a diﬀerent temporal and spatial realm. In experiences of discontinuity rituals symbolise an experience of discontinuity as opposed to continuity; conversely, in experiences of continuity they symbolise the experience of continuity as opposed to discontinuity. The ritual gives the symbolised ultimate reality an ‘aura’ of being true reality, thus enabling people to experience life’s boundary situations in a diﬀerent light. Rituals address people emotionally, protecting them against alienation brought on by a crisis situation such as admission to a care institution (Bruggeman, 1990, 33). This is often based on an experience of security, healing and inner change. The expressive aspect pertains to actual symbolic expression as the key component of ritual. It is not conﬁned to the spoken word, but also and more particularly takes the form of singing, music, posture and movement. Four natural elements can also be used in ritual expression: water (e.g. in baptism), ﬁre (e.g. in the ritual of the Paschal candle, cremation), soil (e.g. in funerals) and air (e.g. ritual breathing). Worldviews have a long tradition of diverse ritual expressions. Religious art, for example, is also regarded as ritual expression. Rituals symbolically express the feelings of a worldview and seek to make these ‘palpable’ to participants. The assumption is that ritual expression contributes to religious and worldview-related identity construction (cf. 4.2.1). Thus Christian rituals express a personal bond with God.

professional competence, continuity in these rituals and the connection between visiting patients and oﬃciating in rituals. External worldview associations can demonstrate their involvement through choir singing and voluntary workers from the local worldview association, and in consultations of the ministers and management of these associations with spiritual caregivers (Oranje, 1996, 389–391).

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The cognitive aspect pertains to the worldview-related beliefs communicated by the ritual. This takes the form of performance rather than discourse, in the sense that rituals enact rather than describe ultimate reality. In and through the ritual people share in the ultimate reality that the ritual evokes (Lukken, 1999, 50–53, 86–87; Rappaport, 1999, 107–129). We are reminded of Geertz’s view that worldview-related beliefs are symbolic transformations of reality. These beliefs are not simply inferences from experience, neither do they antecede experience; the two relate dialectically. The symbolised ultimate reality is celebrated as true reality. This is how we interpret ritual communication of worldview-related beliefs in rituals: they are in the nature of confession or testimony. Ricoeur’s notion of personal attestation is also applicable to ritual testimony. It entails commitment before a forum of fellow humans and, in religious terms, also to God. This happens—as Ricoeur points out—pre-eminently in evocative, poetic language. The interactive dimension, we have said, has a moral and a social aspect. The moral aspect refers to the ritually established connection with the norms and values of the relevant worldview. The use of performative language addresses an appeal to act accordingly. As Geertz points out, the symbolised ultimate reality is not merely a model of reality but also a model for reality. Thus rituals refer to values and norms that a particular worldview seeks to realise. Religions have puriﬁcatory rituals with a moral function (e.g. fasting in monotheistic religions, bathing in the Ganges in Hinduism) and humanistic contemplation sessions usually have a moral dimension of human solidarity (Blokland & Van Straten, 1996, 649–651).2 The moral climate of a worldview ﬁnds expression in ritual. The social aspect refers to the bond between individuals who aﬃrm and enact the ritual. Rituals help to reinforce the religious or worldview group through a common deﬁnition of life (Bell, 1997, 59; Ganzevoort, 2000, 27–30). They strengthen community cohesion,

2 The signiﬁcance of the ritual task for humanistic spiritual caregivers is a debate in its own right. Humanism has no prescribed rituals. Its historical aversion to this task was based on two arguments: it did not want to be a church alongside other churches, and it set great store by individual freedom. More recently the trend has been changing. Humanistic spiritual caregivers now recognise the importance of this task on the basis of the functions that rituals could fulﬁl for patients (Witjes, 1996, 538–541).

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enhance conformity and reduce ambivalences at the level of collective behaviour (Bell, 1997, 27–29, 177–180; Menken-Bekius, 1998, 43–44). This function of rituals was more pronounced in the past, when society was organised on a more worldview-related—especially religious—basis than it is today. Liturgy and sacraments had a great impact on community life. They also helped people to make the transition between seasons and diﬀerent phases of life (known as rites of passage). Examples include ritual feasts (e.g. the Jewish Passover and Christian Easter) and the ritual calendar (e.g. Ramadan in Islam). 6.2.1.2 Aspects of supra-disciplinary consultation at meso level Relations with fellow caregivers can be subdivided into two dimensions: a multidisciplinary consultation dimension and a managerial dimension. The ﬁrst refers to consultations with other caregivers and helpers, the second to consultation with institutional policy. In our discussion of these dimensions we concentrate on problems experienced by spiritual caregivers: competition problems, division problems and image problems, and problems of support at the managerial level (cf. Meulink, 1996, 555–557; Bach, 1996, 642–645). First we look at the dimension of multidisciplinary consultations with other caregivers and helpers. These consultations assume three forms: written reports in a care ﬁle, individual consultation with a caregiver or therapist in charge of a case, and participation in multidisciplinary team consultations. Disciplines with which spiritual caregivers consult vary from one ﬁeld of operation and even one institution to the next (Sneep, 1996, 509–512; Van den Berg, 1996, 518). The main argument in favour of such consultations is the integration of spiritual care in health care and highlighting spiritual care themes in consultations (Sneep, 1996, 509). The distinctive angle of spiritual care in such consultations is to link the worldview-related component of the patient’s life world to the care and treatment provided. The aim is to make this concern a shared responsibility (cf. Van der Leur, 1996, 629). Problems could arise in demarcating the respective provinces of spiritual care and other professional disciplines. If the boundaries are determined unilaterally by one discipline only, there is a risk of competition, if not division, between other disciplines and spiritual care. And in their dealings with other disciplines spiritual caregivers may encounter problems in establishing their image. Competition means that the other care disciplines and spiritual care become rivals. Other professionals may lay claim to treatment

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of patients’ ‘inner world’ in the sense of their existential problems and interpretation of life. This factor is particularly pertinent in psychiatric care, where most caregivers operate in the sphere of mental health. According to Fortmann (1974, 351–359) psychologists, psychiatrists and pastors all use the term ‘mental health’ and sometimes apply the same criteria to its psychological and spiritual aspects. Psychotherapists, too, operate in the ﬁeld of existential meaning (Rebel, 1996a, 17–29; Van Kalmthout, 2001, 23–26). All this can cause competition (cf. Voestermans, 1998, 238–244), arising from the aforementioned specialised diﬀerentiation and autonomy of professions, with the concomitant striving for power. Specialised diﬀerentiation does not mean that the spheres of concern of diﬀerent disciplines no longer overlap (cf. Van der Ven, 1996a, 47f.). Autonomy plays a major role, in that each profession wants to retain and strengthen control over its own activities as well as heighten its inﬂuence over others (Van der Krogt, 1981, 107–113). Division means that cooperation between spiritual care and other disciplines is undermined by mutual diﬀerences on issues like goals, paradigms, concepts and methods. Diﬀerences in goals were discussed in 6.1: spiritual care is the only discipline that focuses systematically and methodically on worldview-related communication and the spiritual aspect of mental health. Many of the concepts used in my research—for instance those from scientiﬁc theology, religious studies and humanistic studies—diﬀer from those of other disciplines, evidenced by diﬀerences in the idiom used. Spiritual care often makes use of performative language, while other disciplines rely mainly on the diagnostic and consultative idiom of medical science. Following Ricoeur, we have pointed out that in the sphere of worldviews poetic language is commonly used, since it seeks to ‘open up’ symbolic reality. As a result communication between spiritual caregiver and patient is more in the nature of worldview-related and religious attestation (Ricoeur, 1995a, 38–43, 65–71, 215–235; cf. Thomasset, 1996, 251–260). These diﬀerences can impede communication between spiritual and other caregivers, which entails a risk that each discipline will conﬁne itself to its own domain and consultation does not get oﬀ the ground.3 3

Spiritual caregivers are by no means unanimous in their positive appraisal of multidisciplinary consultation. Critics among them cite the time taken up by consultations at the expense of direct patient care. Secondly, they maintain that spir-

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Image problems mean that other disciplines have a biased or negative image of spiritual care. Competition and division entail a risk of biased or negative images on both sides. A biased image of spiritual care may be a result of insuﬃcient information. Research shows that other disciplines know little about spiritual care, which may well lead to infrequent referral to this discipline (Pieper & Van Uden, 2000, 32–33). The profession’s image may also be distorted by negative associations. In conventional helping professions people are often wary of the worldview-related themes that spiritual caregivers deal in (Pieper & Van Uden, 1998, 71–72; 2002, 368–372). In addition biased or negative images may be caused by spiritual caregivers’ own behaviour. Often they create an impression of acting in isolation (Berkhout-Dhondt, 1996, 262), an image commonly associated with ministers and pastors in territorial pastoral work (Körver, 1999, 21–34). Such problematic images can be overcome through regular contact with other caregivers and helpers, information and education, and participating in joint projects (Meulink, 1996, 558–560; Van Oosterhout, Peeters, & Snelder, 1996, 179; Zuidgeest & Roosjen, 1996, 680–682). In extra-institutional activities supra-disciplinary consultation with caregivers and other parties is increasing (cf. Kemper, 2004, 4–7; Nusselder, 1996, 776–777). Here, too, spiritual caregivers face a problem of mutual demarcation of their domain and that of other professional disciplines, and the risk of biased or negative images. Deﬁnition of their own domain and possible competition with other caregivers are particularly knotty problems in this regard (Arends, 2003, 127–146; Henstra, 2002, 20–24). Next we consider the managerial dimension, that is consultation with institutional management and the support given to spiritual caregivers at this level. Consultation with policy organs—that is management and cluster and departmental heads—is aimed at integrating a worldview perspective with the policy of the institution, cluster or department. Participation in the institutional council and patientrelated committees is also important. Whether and how policy tasks are tackled depends partly on the position of spiritual care in the

itual care has no responsibility for treatment. Proponents of consultation in their turn want to see spiritual care at least as a supporting discipline in treatment (cf. Bach, 1996, 639–640; Sneep, 1996; Zuidgeest & Roosjen, 1996, 681–682).

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institution and on the spiritual caregiver personally. There are various ways of accomplishing this through positioning at staﬀ level or directly with management. Depending on how individualistically they have been trained, spiritual caregivers may neglect this aspect of their task (Huizing & Koolwijk, 1996, 580–585; Körver, 1999, 21–34; Van der Ven, 1998a, 40). The main themes of policy consultations are the policy of the spiritual care service, ethical policy, institutional climate and the worldview-related identity of the care institution ( Jaques, 1988, 33–34; Koolwijk, 1996, 568–569; Prummel, 1996, 532–535). Here support of spiritual care by the management of the care institution is an issue. In how far is it prepared to integrate spiritual care in the institution and allow it adequate staﬃng and ﬁnancial resources? As a discipline with, by and large, limited staﬃng spiritual care depends to some extent on the scope provided by management, including the position it is assigned in the care institution’s organisational structure. If spiritual care is positioned directly under management, it stands a better chance of direct consultation and support from management. If it is positioned in the institution’s cluster structure it has a better chance of being integrated into the primary care process, but it runs a risk of being overlooked at managerial level. Another important factor is the institution’s mission statement. If it contains an explicit reference to the signiﬁcance of worldviews, there is a better chance that the speciﬁc approach of spiritual care will be acknowledged at managerial level (VGVZ, 1997; Meulink, 1996, 558–560; Zuidgeest & Roosjen, 1996, 680–682). 6.2.2

Tasks: research ﬁndings

Having explored the tasks of spiritual care in a theoretical perspective, we turn to spiritual caregivers’ appraisal of these tasks. On the basis of the immediate goals and ultimate goal of spiritual care we identiﬁed certain aspects that have a direct bearing on tasks in interaction with patients: counselling conversations, ritual tasks and consultation with fellow caregivers and management. Aspects of counselling In this ﬁrst task of spiritual care we identiﬁed three aspects: the functional or non-functional nature of conversations, especially the human

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fellowship character of the relationship; the demand/supply structure; and initiation of counselling by spiritual caregivers. We formulated three items for each of the three aspects, giving us nine items in all. Human fellowship character From a non-functional point of view both spiritual caregiver and patient engage personally in the relationship between them. As human beings they are equal. The spiritual caregiver’s task is to be there for the patient, without prioritising her own counselling goals and frame of reference. The patient is treated with a sense of human fellowship. Presence-oriented spiritual care in particular accentuates the fellowship nature of the counselling relationship. How do spiritual caregivers interpret this attitude in their dealings with patients? Here is an example from the three items in which this aspect was operationalised: e. In listening to the patient’s story I must suspend my own humanistic or theological frame of reference.

Demand/supply structure The counselling conversation proceeds from patients’ worldview-related questions and needs. To this end spiritual care develops its own worldview-related diagnostics. The supply is aimed at communication on worldviews, ultimately at the spiritual aspect of patients’ mental health. In such a perspective the counselling conversation is functional and asymmetrical. How do spiritual caregivers interpret this demand/supply structure? Here is an example from the three items in which this aspect was operationalised: b. My primary task is to focus on the question: ‘What does the patient expect from me and what can I oﬀer?’

Initiation of counselling Counselling can be initiated by the patients themselves—possibly via referral by the attending doctor or nurse— or by the spiritual caregiver. Traditionally it was typical for caregivers to visit patients on their own initiative. There are three arguments in regard to this approach: the fact that spiritual caregivers are not therapists, the individualisation of society and the link with a worldview association. The danger of the approach is that the aim may be to safeguard the profession rather than to care for patients in their existential need. How do spiritual caregivers interpret

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this orientation to initiative? Here is an example from the three items in which this aspect was operationalised: c. I should also take the initiative in approaching patients.

Spiritual caregivers’ responses to these items were subjected to factor analysis. This yielded three factors, on the basis of which we constructed three scales (ﬁgure 6.4; cf. appendix 2, instrument 18 and appendix 3, table 32 and 33). Figure 6.4 Aspects of the counselling Aspects of counselling

human fellowship

demand/supply structure

initiation by spiritual caregiver

items: e, f mean: 2.3

items: a, b, d mean: 4.1

items: c, g, i mean: 4.0

The empirical ﬁndings conﬁrm the theoretical breakdown into three aspects.4 As is evident in ﬁgure 6.4 spiritual caregivers concur with a demand/supply structure and an initiative-oriented approach to the counselling conversation; they reject a purely ‘human fellowship’ approach to the relationship. Finally we give the social location of the scales in terms of the ﬁve personal characteristics and the institutional characteristic described in 1.3: gender, training, denomination, ministerial approval, professional association and care institution. The human fellowship approach is roundly rejected by spiritual caregivers with ministerial approval (mean: 2.2). VGVZ-members are also quite strongly opposed to this approach (mean: 2.2), whereas non-members of a professional association are less so (mean: 2.6). Spiritual caregivers employed in gen-

4 The empirical scale construction reveals some weaknesses in two of the three scales: item (a) of the demand-supply structure scale and item (e) of the ‘human fellowship’ scale have fairly low communality (.17 and .18 respectively); the reliability of the demand-supply structure scale is somewhat low (.47), as is the correlation between the two items of the human fellowship scale (r .24). Nevertheless we settled for this empirical solution, since otherwise it would have impaired the picture of spiritual caregivers’ perception of two important aspects of their dealings with patients.

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eral hospitals are more strongly opposed to a human fellowship approach (mean: 2.0) than those in nursing homes (mean: 2.4). In the case of demand/supply structure and the initiation of counselling by spiritual caregivers there is no diﬀerentiation that meets our criterion of relevance. Aspects of rituals Rituals are a major component in spiritual caregivers work. To account for the importance assigned to this task one has to examine the dimensions and aspects of these rituals. We identiﬁed two dimensions: an individual and an interactive dimension. We subdivided the individual dimension into an experiential, an expressive and a cognitive aspect and the interactive dimension into a moral and a social aspect. For each aspect we formulated three items, giving us ﬁfteen items in all. Experiential aspect of rituals The experiential aspect of rituals pertains to what the participants in a ritual experience. It is a symbolised experience of entering another temporal and spatial realm. Examples are experiences of security, healing and inner change. How highly do spiritual caregivers rate this aspect of rituals? Here is an example from the three items in which the experiential aspect of rituals was operationalised (respondents have to indicate how frequently each theme is raised): e. Penetrating to the existential layer within oneself.

Expressive aspect of rituals The expressive aspect of rituals lies in symbolic expression, for instance via words, music and the use of natural elements. The ritual symbolically expresses the emotions of a worldview and seeks to make them ‘palpable’ to participants. How highly do spiritual caregivers rate this aspect of rituals? Here is an example from the three items in which the expressive aspect of rituals was operationalised: j. Expression of deep emotions, images.

Cognitive aspect of rituals Beliefs are focal in worldviews as symbolised models of reality. Worldview-related notions and ideas are expressed symbolically. How highly do spiritual caregivers rate this

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cognitive aspect? Here is an example from the three items in which this aspect was operationalised: h. Confessing one’s belief.

Moral aspect of rituals The performance of rituals has a moral aspect in that it refers to values and norms to be realised according to the particular worldview. The ritual couches the relation to the moral beliefs implicit in the ritual in performative language, which addresses an appeal to personal and social behaviour. The symbolised reality is a model for reality. How highly do spiritual caregivers rate this aspect of rituals? Here is an example from the three items in which this aspect was operationalised: b. Stimulating moral consciousness.

Social aspect of rituals The social aspect of rituals is that they establish and reinforce a bond between participants. They aﬃrm and strengthen a sense of community by deﬁning life in communal terms. In addition rites of passage assist people in making the transition from one phase of life to the next. How highly do spiritual caregivers rate this aspect of rituals? Here is an example from the three items in which this aspect was operationalised: a. Expressing communion with others.

Spiritual caregivers’ responses to these items were subjected to factor analysis. This yielded four factors, on the basis of which we constructed Figure 6.5 Aspects of rituals Aspects of rituals

individual

experiential-expressive items: e, i, j mean: 4.0 religious: 4.0 humanist: 3.9

interactive

cognitive items: f, h, l mean: 3.6 religious: 3.6 humanist: 3.6

moral items: b, g, n mean: 2.8 religious: 2.8 humanist: 3.2

social items: a, d, o mean: 4.0 religious: 4.0 humanist: 4.0

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four scales (ﬁgure 6.5; cf. appendix 2, instrument 19 and appendix 3, table 34 and 35). The empirical data conﬁrm the classiﬁcation into an individual and an interactive dimension, as well as the subdivision of the interactive dimension into a moral and a social aspect. Within the individual dimension factor analysis combined the experiential and expressive aspects. On the basis of the factor loadings of the items we labelled this combination the experiential-expressive aspect. We broke up the results into those for spiritual caregivers from religious traditions and their colleagues from the humanistic tradition. Figure 6.5 shows that spiritual caregivers from religious traditions subscribe mainly to the experiential-expressive and social aspects of rituals and less strongly to the cognitive aspect, although they endorse it fully. They are negatively ambivalent about the moral aspect. Figure 6.5 shows that spiritual caregivers from the humanistic tradition also agree with the social and experiential-expressive aspects of rituals and to a lesser extent with the cognitive aspect, even though they endorse it fully. They are positively ambivalent about the moral aspect. Finally we give the social location of the scales in terms of the ﬁve personal characteristics and the institutional characteristic described in 1.3: gender, training, denomination, ministerial approval, professional association and care institution. We ﬁrst present the ﬁndings for spiritual caregivers from religious traditions and then those for spiritual caregivers from the humanistic tradition. ‘Religious’ respondents who do not belong to a professional association are less positive about the experiential-expressive aspect of rituals (mean: 3.8). ‘Religious’ spiritual caregivers in psychiatric institutions attach less importance to the cognitive aspect of rituals (mean: 3.3), as do their colleagues in institutions for handicapped people (mean: 3.3). Theologians account for most of the negative ambivalence about the moral aspect of rituals (mean: 2.8 versus 3.0 for non-theologians). In the case of the social aspect of rituals spiritual caregivers in general hospitals are slightly less positive than the other ‘religious’respondents (mean: 3.9). Humanistic spiritual caregivers in nursing homes attach more importance to the cognitive aspect of rituals (mean: 3.9). Humanistic spiritual caregivers in an academic hospital are more positive about the social aspect of rituals (mean: 4.3).

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chapter six Aspects of supra-disciplinary consultation at meso level

In cooperation with other disciplines and in relations with institutional management we identiﬁed two dimensions: a dimension of multidisciplinary consultation and a dimension of managerial consultation at meso level. The dimension of multidisciplinary consultation we subdivided into problems relating to, respectively competition, division and image. We formulated three items for each aspect, giving us twelve items in all. Dimension of multidisciplinary consultation Competition problems Competition implies that the various disciplines are rivals, for instance by laying claim to treatment of problems about the meaning of life. The professions want to strengthen their control over their work and their inﬂuence over others. To what extent do spiritual caregivers aﬃrm such competition with other disciplines? Here is an example from the three items in which this aspect was operationalised: d. There are conﬂicts with fellow caregivers about each one’s competence.

Division problems Division refers to diﬀerences between spiritual caregiver and other health care disciplines, for instance about goals, paradigms, concepts and methods. These diﬀerences are evident in their respective idioms: spiritual care uses performative language as opposed to the diagnostic and therapeutic idiom of medical disciplines. To what extent do spiritual caregivers aﬃrm such division from other disciplines? Here is an example from the three items in which this aspect was operationalised: b. There is a gulf between empirical, medical conversation and conversation with spiritual caregivers.

Image problems From the spiritual caregiver’s perspective image problems mean that other disciplines have a biased or negative image of spiritual care. It may be biased for lack of information and it may be distorted by negative associations. Spiritual caregivers’ own conduct may contribute to such a biased or negative image, for instance if they advocate the isolation of their profession. In how far do spiritual caregivers believe that they have image problems with

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other disciplines? Here is an example from the three items in which this aspect was operationalised: c. Other caregivers underrate spiritual care.

Managerial dimension Managerial support This refers to the support of spiritual care by the institution’s management as manifested in its readiness to integrate spiritual care with the institution’s services and provide suﬃcient staﬃng and ﬁnancial resources. Management’s attitude is determined by the organisational position of spiritual care in the care institution and by its mission statement. If the statement contains a reference to the signiﬁcance of worldviews, the chances of managerial support are better. How do spiritual caregivers assess the degree of support from management? Here is an example from the three items in which this aspect was operationalised: a. The board has an excellent picture of spiritual care.

Spiritual caregivers’ responses to these items were subject to factor analysis. This yielded three factors, on the basis of which we constructed three scales (ﬁgure 6.6; cf. appendix 2, instrument 20 and appendix 3, table 36 and 37). The empirical ﬁndings conﬁrm the theoretical classiﬁcation into two dimensions of supra-disciplinary consultation at meso level: multidisciplinary and managerial consultation. In the ﬁrst dimension, divison and image problems combine into a single factor. As is evident in ﬁgure 6.6, spiritual caregivers do not agree that they are in competition with other disciplines and they are positively ambivalent about division and image problems. They also feel that management oﬀers spiritual care adequate support. Finally we give the social location of the scales in terms of the ﬁve personal characteristics and the institutional characteristic described in 1.3: gender, training, denomination, ministerial approval, professional association and care institution. Graduates of the HOI are negatively ambivalent about possible competition between spiritual caregivers and other caregivers (mean: 2.9). The same applies to spiritual caregivers in academic hospitals (mean: 2.8), whereas their colleagues in nursing homes show less agreement with the idea of

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Figure 6.6 Aspects of supra-disciplinary consultation at meso level Supra-disciplinary consultation at meso level

multidisciplinary consultation

managerial consultation

competition problems

division and image problems division problems

image problems

managerial support

items: d, g, j mean: 2.4

items: b mean:

c, i, k 3.1

items: a, h mean: 3.4

competition with other disciplines (mean: 2.3). Theoretically we surmised that this aspect would feature most prominently in psychiatric work, since many professionals in this ﬁeld are concerned with patients’ inner life, but this assumption is refuted by the empirical ﬁndings (cf. 6.2.1.2). As for division and image problems, spiritual caregivers in nursing homes are negatively ambivalent about the incidence of such problems (mean: 2.9). In the case of managerial support there is no diﬀerentiation that meets our criterion of relevance. 6.3

Résumé

This chapter dealt with two aspects of spiritual care: its goals and the tasks relating to these. The goals of spiritual care are the results that spiritual caregivers hope to achieve through their activities and that could be considered broadly feasible. The general goal of spiritual care is to contribute to the spiritual aspect of human health by promoting communication on worldviews. We see this communication as the immediate goal of spiritual care and the spiritual aspect of health as the ultimate goal. At the microlevel the immediate goal is diﬀerentiated into experiential, aﬀective, cognitive, moral, social and ritual aspects. At meso level the general goal is diﬀerentiated into a worldview-oriented dimension and an orientation to care as a whole. We also identiﬁed ﬁve goal orientations or approaches to goal attainment. According to the participation and comfort orientations spiritual care is directed to patients’ experience and to giving them scope to verbalise that experience so as to oﬀer comfort and encour-

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agement. The challenge orientation aims at evaluating patients’ experience and challenging them to view their situation diﬀerently. The charismatic and kerygmatic orientations are intent on the actual message of spiritual care, with the accent respectively on the spiritual caregiver’s subjective inspiration and on the objective substance of worldview-related beliefs. Empirical measurement revealed the following picture. Spiritual caregivers support all the goals we investigated. They rate experiential-aﬀective communication on worldviews and promotion of the spiritual aspect of health most important and cognitive communication on worldviews least important. Among the various orientations they consider the experiential orientation very important and the challenge orientation important; they are negatively ambivalent about a mission orientation. Table 6.1 summarises these ﬁndings. The tasks profession spiritual care are activities aimed at goal achievement. Our research focused on some aspects of counselling conversations: their functional or non-functional nature, their approach to a demand/supply structure, and the initiation of counselling by spiritual caregivers. We also examined certain aspects of rituals: the experi-

Table 6.1 Goals and orientations of spiritual care

mean

standard deviation

Goals Experiential-aﬀective aspect of communication Cognitive aspect of communication Social-moral aspect of communication

4.3

.43

3.6 3.8

.60 .54

Ritual aspect of communication

relig. 3.7

hum. relig 3.1 .55

Ultimate goal: promotion of spiritual aspect of health

4.3

.54

Focus on worldview-related dimension of care Focus on care at meso level

4.1

.54

4.2

.47

4.5 4.0 2.7

.37 .64 .69

Orientations Experiential orientation Challenge orientation Mission orientation

hum. .64

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ential, expressive, cognitive, moral and social aspects. Finally we looked at dimensions of supra-disciplinary consultation: a multidisciplinary consultation dimension comprising competition problems, division problems and image problems, and a managerial dimension. Empirical measurement revealed the following picture. Spiritual caregivers subscribe to a supply/demand structure and the initiation of counselling by spiritual caregivers, but they disagree with a purely non-functional, human fellowship approach to counselling. They are particularly in favour of the experiential and social aspects of rituals. They do not think that there is any competition with other disciplines and feel that they receive adequate support from management. Table 6.2 summarises these ﬁndings. Table 6.2 Tasks of spiritual care

mean

standard deviation

Counselling – human fellowship – demand/supply structure – initiation

2.3 4.1 4.0

.68 .51 .61

Rituals – experiential-expressive aspect – cognitive aspect – moral aspect – social aspect

relig. 4.0 3.6 2.8 4.0

Supra-disciplinary consultation – competition problems – division and image problems – managerial support

2.4 3.1 3.4

hum. 3.9 3.6 3.2 4.0

relig. .60 .57 .74 .51

hum. .52 .46 .70 .39

.62 .63 .82

Personal characteristics and the institutional character do play a role in spiritual caregivers’ ideas about their profession. Gender does not aﬀect their views. The type of care institution in which the person is employed has the greatest impact. The strongest diﬀerentiating inﬂuence is observable in regard to the ritual goal of worldviewrelated communication with patients and, to a lesser extent, the human fellowship character of the counselling relationship. The ﬁndings regarding social location appear in table 6.3.

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Table 6.3 Spiritual care: social location variables worldview— experiential-aﬀective worldview—cognitive worldview—social-moral worldview—ritual spiritual aspect health worldview-related aspect care care orientation experiential orientation challenge orientation mission orientation. human fellowship demand/supply structure initiation of counselling rituals—experientialexpressive aspect rituals—cognitive aspect rituals—moral aspect rituals—social aspect competition problems division and image problems managerial support

gender training denoapproval professional care mination association institition

*

*

*

*

*

*

*

* *

* *

* * * *

* * *

7 DETERMINANTS OF SPIRITUAL CARE In earlier chapters we described spiritual caregivers’ views on health care, the function of worldviews in health care, their own worldviews, the legitimacy and position of spiritual care as a professional discipline and the goals and tasks of spiritual care. In this chapter we deal with the predictive power of certain characteristics of spiritual caregivers for their ideas about the goals of spiritual care, more particularly the goals at the micro level of interaction with patients. Our reasons for settling for micro level goals are as follows. We opted for goals because they determine the focus of professional activities and provide the framework in which tasks are performed (cf. 6.1.1). Our research ﬁndings show, moreover, that spiritual caregivers attach great importance to micro level goals (cf. 6.1.3). Finally, the cardinal signiﬁcance of these goals is aﬃrmed by the time expended on them. Our study reveals that patient care is the main component of spiritual caregivers’ work: in practice they devote most of their time to it, and would like to devote even more than they actually do.1 We distinguished between two kinds of goals in spiritual caregivers’ interaction with patients: immediate goals and an ultimate goal. The immediate goals we identiﬁed concern the promotion of communication on worldviews, in which we diﬀerentiated between experiential-aﬀective, cognitive, ritual and social-moral aspects. The ultimate aim is to promote the spiritual aspect of mental health. In this chapter we seek to answer the seventh research question: what are the eﬀects of health care, spiritual caregivers’ personal worldviews and the professional discipline of spiritual care on the immediate and ultimate goals of the profession at micro-level, while controlling for the aforementioned population characteristics? We analyse the characteristics of spiritual caregivers that predict their attitude towards these goals in interaction with patients. In the ﬁrst section (7.1) we describe the analysis and its results. In the second section (7.2) we reﬂect on the results.

1

Time actually spent on patient care, and what caregivers would like to devote to it: individual counselling (resp. 36% and 41%), group counselling (resp. 11% and 13%).

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Determinants of Micro Level Goals: Expectations and Outcome

First we describe the conceptual model and our expectations regarding the predictive power of the aforementioned characteristics for the goals of spiritual care (7.1.2). Then we give the results of the regression analyses we performed (7.1.2). 7.1.1

Expected determinants of micro level goals

Our starting point is the following question: in how far are diﬀering ideas about micro level goals predicted by characteristics of the ﬁeld of health care, the function of worldviews in health care, personal worldviews and spiritual care as a professional discipline, all the while controlling for certain relevant background variables? Our choice of these particular characteristics can be motivated as follows. As an institutional context health care inﬂuences the practice of spiritual care, as we explained in chapter 2. Worldviews have a distinctive— intrinsic and extrinsic—function in health care, which we relate to the contingency of life (chapter 3). In spiritual care professionals and their personal worldviews play a major role in their approach to their practice and its goals, as was demonstrated in chapter 4. Views on the legitimacy and position of spiritual care as a professional discipline, which were dealt with in chapter 5, have implications for the goals of the profession. Finally, the background variables are partly general demographic attributes and partly attributes speciﬁc to the profession of spiritual care. The conceptual model in ﬁgure 7.1 lists the dependent variables on the right: the immediate goals and the ultimate aim of interaction with patients. The independent variables appear on the left: personal worldview, the professional discipline—including the function of worldviews—and health care, as well as the background variables. Personal worldview The ﬁrst group of independent variables—those relating to personal worldview—are characteristics pertaining to identity, worldview-related identity, higher reality, theodicy and life after death (cf. 4.1.1 and 4.2.1). Firstly, we expected spiritual caregivers’ identity generally to inﬂuence their preferences regarding the aim of their work. It is commonly accepted that spiritual caregivers’ personal identity has a

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Figure 7.1 Conceptual model of expected predictive relationships

INDEPENDENT VARIABLES

DEPENDENT VARIABLES

Personal worldview Identity: narrativity, uniqueness, attestation, passivity Worldview-related identity: ritual, social aspect, institutional aspect, tradition, multiple worldview, intrinsic and extrinsic worldview Higher reality: Christian belief, immanentism, atheism Theodicy: apathy, retaliation, plan, development, solidarity, vicarious suﬀering, mysticism After death: life after death, reincarnation, immanentism, agnosticism

Immediate goals: – experiential-aﬀective goal

– cognitive goal

Professional discipline Function of worldview: – Worldview: intrinsic and extrinsic function – Medical worldview: medicalisation, mortality in health care Legitimacy: statutory, institutional care approach-related, patient- related, denominational, domain-related Ministry and sanctuary: micro: facilitating communication, personal value meso: exemption from accountability, marginal position macro: reduced meaning, institutional representation Position in the organisation: isolation, integration, territorial approach, multiple worldview cooperation, multiple worldview patient care

– social-moral goal

– ritual goal

Health care Meso: protocolisation, risk of bureaucratisation, worldview and ethical reﬂection, registration Micro: lack of self-determination, compassion, symmetry, demand orientation BACKGROUND VARIABLES Gender, education, denomination, ministerial approval, professional association, health care institution

Ultimate goal: contribution to spiritual dimension of health

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major impact on the goals they set themselves (cf. Heitink, 2001; Immink, 2003b, 32; Van der Ven, 1998a). Narrative identity theories attach importance to human experience, a personal quest with its fundamental feelings and problems (cf. 4.1.1). This leads us to expect that a narrative concept of identity will have a predictive relation with the experiential-aﬀective goal. We also anticipate personal uniqueness to have a similar relation with the experiential-aﬀective goal because of patients’ pre-eminently unique worldview-related experience, feelings and questions. We have already deﬁned attestation as an ethical conception in personal relations with other people. We anticipate that it will have at least some predictive power for the social-moral goal of worldview-related communication. Finally we focus on passivity as a feature of personal identity, in the sense of the pathic aspect of a life dominated by suﬀering. We expect it to have some predictive power for the ultimate goal, the spiritual aspect of human health, since this is oriented to passivity and the suﬀering entailed by illness. We also expect worldview-related identity to predict preferences regarding the goals of spiritual care. After all, spiritual caregivers’ personal worldviews play a major role in their communication with patients. Thus we anticipate that their personal perception of the ritual aspect of worldviews will predict the importance attached to ritual worldview-related communication. At the same time we expect the social aspect of worldviews to predict the importance attached to social worldview-related interaction with patients. Since the institutional aspect concerns the norms and values that are prized by worldview associations, we expect caregivers’ notions in this regard to predict the importance they attach to the social-moral goal of worldview-related communication. Because of the traditional character of worldview-related beliefs we expect their perception of their worldview tradition to predict the signiﬁcance they ascribe to the cognitive goal of worldview-related communication. Since worldviews diﬀer in regard to experience, concepts, norms and rituals, we expect that a multiple worldview approach will have predictive power for the various goals of worldview-related communication. Finally, worldviews can fulﬁl an intrinsic or an extrinsic function for spiritual caregivers. We expect their notions in this respect to inﬂuence their conception of the immediate goals and the ultimate aim of spiritual care. The extrinsic function assumes a means-ends relation between worldviews and health, hence we expect it to have predictive power

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for the ultimate goal of spiritual care. Since the intrinsic function is the value of a worldview in its own right, we expect it to predict the goals of worldview-related communication (cf. 3.2.1). A worldview comprises sets of notions about such things as the existence of an ultimate reality, suﬀering and life after death. Spiritual care guides patients in exploring these contingent themes. Hence we expect spiritual caregivers’ personal ideas in this regard to predict their varying emphases on goals in their interaction with patients. To the extent that they personally share the Christian perception of a transcendent reality—God—we expect a heavy accent on the ritual goal of worldview-related communication, since rituals symbolically celebrate that reality. In the case of immanentist and atheistic perceptions of a supreme reality we anticipate a lower, possibly negative, rating of the ritual goal. As for theodicy, we expect the practical theodicy models with their emphasis on alleviation of suﬀering (solidarity, vicarious suﬀering, mysticism and development) to predict the importance attached to the goal of spiritual health. In the case of notions about life after death we anticipate that, depending on the spiritual caregivers’ own beliefs about an afterlife, they will put greater or lesser emphasis on communication about these beliefs and on rituals symbolising the transition to a diﬀerent reality. Professional discipline Caregivers’ views on the professionalism of spiritual care have implications for their assessment of goals. We classify the function of worldviews in health care under professional characteristics, since it concerns professional worldview-related notions. These characteristics may be divided into two groups: the worldview and the medical approach (cf. 3.1.1 and 3.2.1). Firstly, we anticipate that ideas about the intrinsic and extrinsic function of worldviews from the patients’ perspective will predict immediate worldview-related goals and the ultimate goal, the promotion of the spiritual aspect of mental health: after all, these functions have a bearing on the signiﬁcance of worldview-related communication as such and on its usefulness, inter alia with a view to the spiritual aspect of patients’ health. Secondly, with regard to the medical approach, we expect caregivers’ ideas about medicalisation to have predictive value for the importance assigned to the distinctive goals of spiritual care. The more they agree with medicalisation, the lower we expect them to rate

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those goals. Conversely, we expect emphasis on the goals to increase pro rata to the importance attached to the theme of mortality in health care. Another professional attribute that we investigate is views on the legitimacy and position of spiritual care (cf. 5.1.1). We distinguish between ﬁve forms of legitimacy: statutory, institutional care approachrelated, patient-related, denominational and domain-related legitimacy. The more importance respondents attach to the various forms of legitimacy of their discipline, the more we expect them to accentuate its goals in interaction with patients. After all, legitimacy concerns the reasons for the profession’s presence in health care, and these reasons are fundamental to its goals. The goals of a profession reﬂect its particular focus among those of other professions, while legitimacy provides the basis for this particularity. The more spiritual caregivers underscore worldview-related themes from their own domain, the more we expect them to emphasise worldview-related goals. And the higher they rate the patient’s judgment as legitimising their profession, the higher they will rate these goals in interaction with patients. Prediction of the spiritual health goal, we anticipate, will apply mainly to institutional legitimacy. The legitimacy and position of spiritual care from a worldview perspective is expressed by the ministry and its sanctuary status (cf. 5.2.1). In the case of the ministry we investigate the micro and macro levels, in the case of sanctuary we look at the meso level. We approach the ministry and sanctuary from the angle of possible pros and cons advanced for each. We anticipate ministry and sanctuary to have predictive power for both the immediate goals, which also feature in the sphere of worldview associations, and the ultimate goal, which falls in the ambit of health care. After all, the ministry concerns the importance assigned to worldviews in an institutional sense, while micro level goals likewise underscore the importance of worldviews. The more highly the ministry is rated, the more support we expect for worldview-related goals, particularly their ritual aspect. Sanctuary pertains to freedom of religion and worldview and the immediate goals at micro level in fact concern promotion of worldview-related communication. We anticipate ministry and sanctuary to predict ratings of the ultimate goal on account of the extrinsic function of worldviews for patients’ spiritual health that we discussed above. When it comes to the position of spiritual care in a health care organisation the options are an isolated or an integrated position

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(cfr. 5.1.1). From an isolated position one would expect emphasis on immediate worldview-related goals, since this position implies exclusive concentration on the speciﬁc domain of spiritual care, namely communication about worldviews. But a preference for isolation could also predict greater emphasis on the ultimate goal of spiritual care, on the grounds that, compared to other health care approaches, it makes a very special contribution to patients’ health—that of promoting its spiritual aspect. An integrated position presupposes a territorial mode of operation, multiple worldview cooperation with colleagues and multiple worldview patient counselling (cf. chapter 3). The more spiritual caregivers support integration, the more we expect them to emphasise professional goals, both direct and ultimate. After all, integration implies assigning the profession a speciﬁc purpose in health care. We also expect a territorial mode of operation to have predictive value for both the immediate and ultimate goals. In the case of immediate goals, the prediction is based on the belief that worldview-related communication beneﬁts by embedding the discipline ﬁrmly in departmental care delivery. In the case of the ultimate goal of promoting mental health, the prediction is based on the fact that a territorial mode of operation prioritises the structure of health care. As for multiple worldview cooperation with colleagues and multiple worldview patient counselling—a concomitant of the territorial mode of operation—we again expect it to have predictive power for both immediate and ultimate goals. In the ﬁrst place we expect communication on worldviews to beneﬁt by positive mutual inﬂuencing between diﬀerent worldviews. Secondly, in such cooperation and counselling there is less emphasis on diﬀerences between worldviews and more on the contribution of worldview-related communication to the health goal—the spiritual aspect of mental health. Health care Spiritual caregivers operate in health care and the goals of their care are determined by that context. We concentrate on certain quality care characteristics at the meso and micro levels of health care (cf. 2.1.1 and 2.2.1). Procedures and protocols are goal oriented, more speciﬁcally to the goal of providing quality care for patients. Hence the more spiritual caregivers agree with proceduralisation and protocolisation, the

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more we expect them to value both the immediate goals and the ultimate goal in their interaction with patients. After all, the immediate goals have to do with patient care from the angle of worldviews, and the ultimate goal is care in the spiritual dimension of mental health. As for the risk of bureaucratisation, we again anticipate a predictive relation with micro level goals. Since bureaucratisation is often condemned on the grounds that it operates at the patient’s expense, emphasis of that risk could predict the importance of the spiritual dimension of the goal of health care focused on patients’ interests. We expect a predictive relation beween worldview-related and ethical reﬂection on the standardisation of care and worldview-related communication with patients: the more highly such reﬂection is rated, the more importance will be attached to this communication at micro level. In regard to registration, we expect it to have predictive value for the goals at micro level, since its aim is to ensure professionalism. Hence the higher registration is rated, the greater will be the emphasis on goals. We expect the emphasis on micro level goals to be in keeping with spiritual caregivers’ ratings of quality care aspects at micro level. The more spiritual caregivers feel that patients do not experience suﬃcient autonomy, the more we expect them to emphasise the spiritual dimension of health; after all, this goal implies a focus on patients’ needs and demands in the sphere of health. In addition we expect attitudes of compassion and symmetry to predict an accent on the experiential-aﬀective goal in communication on worldviews, that is communication on existential feelings and experience. Finally we expect an accent on a demand orientation in interaction with patients to predict emphasis of the ultimate goal, since patients’ needs and demands are located mainly in the sphere of health. Background variables As background variables we choose certain population characteristics of spiritual caregivers, as well as worldview-related attributes and their work situation in health care. We substantiated our choice of population characteristics in 1.3.2. The question is, do gender, training, denomination, ministerial approval, membership of a professional association and employment context in health care predict spiritual caregivers’ varying emphases of goals in interaction with patients?

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Women constitute a steadily growing proportion of the number of spiritual caregivers. Some authors stress the diﬀerences in the worldviews of men and women, as well as in their approach to sickness and health. Others doubt whether gender has any eﬀect (cf. Dumez, 2004, 313–323; Holstein, 1999, 240; Kits, 2000, 141–142; Sweep, 2002). We expect that the more highly qualiﬁed spiritual caregivers are, the more value they will attach to the goals of interaction with patients. After all, training enhances professionalism, hence reﬂection on the aims of the profession. Training for health care—and other— professions sets great store by cultivating a professional goal orientation, which is used as a criterion to evaluate professionalism. Socio-scientiﬁc research has shown that membership of a denomination is a major cultural factor in explaining preferences and interests (De Graaf, 2002, 7–8). Ministerial approval from a worldview association we take to be a further indicator of the spiritual caregiver’s position in that association. We expect it to have a predictive relation at least with the ritual goal, since such approval often pertains directly to the performance of rituals. We consider membership of a professional association to indicate the caregiver’s professionalism and hence an emphasis on goals in interaction with patients. In health care institutions where patients remain for long periods (psychiatric centres, nursing and old age homes and institutions for handicapped people) they have prolonged dealings with spiritual care on account of the long-term patient’s needs and the greater availability of the spiritual caregiver. We expect respondents employed in such institutions to put more emphasis on the immediate goals and the ultimate goal, since the greater opportunity for contact permits a stronger focus on achievement of communicative goals and the mental health goal. 7.1.2

Determinants of micro level goals: research ﬁndings

We explored the relations between the independent, background and dependent variables listed in the conceptual model (ﬁgure 7.1) by means of ﬁve regression analyses, one for each of the ﬁve dependent variables. The ﬁrst round of analyses showed that a number of variables have no signiﬁcant predictive value for micro level goals. Those variables were eliminated. In the case of identity the variables

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are uniqueness, attestation and passivity. In the case of worldviewrelated identity they concern the social aspect, institutional aspect, tradition, multiple worldview and extrinsic function of worldviews. When it comes to a higher reality there are two variables—Christian belief and atheism. All attitudes towards life after death were eliminated, as were views on some of the theodicy models: plan, development, solidarity and mystical. Among professional discipline attributes we eliminated two variables relating to the function of worldviews in health care (medicalisation and mortality); one legitimacy variable (institutional legitimation); three variables pertaining to the ministry and sanctuary (personal value, exemption from accountability and institutional representation); and two variables pertaining to location in health care (isolation and multiple worldview patient care). Among health care characteristics we eliminated three variables at meso level (risk of bureaucratisation, worldview and ethical reﬂection, and registration) and two micro level variables (autonomy and demand orientation). We subjected the remaining signiﬁcant variables to a second round of ﬁve regression analyses. The results appear in table 7.1. In describing the results we examine the predictive relations between the independent and dependent variables. Let us consider these with reference to the four immediate goals and the ultimate goal. Experiential-aﬀective goal of worldview-related communication By the experiential-aﬀective goal we mean that spiritual care in interaction with patients focuses on experiences, questions and existential feelings in regard to worldviews. It appears that this goal is predicted by characteristics pertaining to personal worldview and professional discipline, whereas health care characteristics have no predictive role. As for personal worldview, this goal is predicted by a narrative concept of identity, high rating of the intrinsic function of worldviews, and—negatively—the retaliation theodicy model. The more respondents see their identity reﬂected in the stories that they tell about themselves and that others tell about them, the more importance they attach to experiential-aﬀective communication with patients. By the same token respondents who regard their worldview as valuable in its own right attach greater importance to communicating with patients about worldview-related experience. Finally, those who reject the idea that suﬀering is divine punishment rate experientialaﬀective communication on worldviews more highly.

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Regarding spiritual care as a professional discipline, this goal is positively predicted by ratings of the extrinsic function of worldviews from the patient’s perspective, legitimation of spiritual care in terms of patients’ needs and domain-related legitimacy, as well as a preference for integration and a territorial mode of operation. The extrinsic function of worldviews concerns the value assigned to worldviews’ contribution to patients’ mental health. The more this extrinsic function is emphasised, the more important experiential-aﬀective worldview-related communication is considered to be. In addition such communication is rated more highly when the patient is seen as the key premise of spiritual care at the interaction level. Scores on this goal are also predicted by the degree of signiﬁcance attached to domain-related legitimation; that is to say, the importance attached to patients’ communication about their experience is predicted by the spiritual caregiver’s rating of the importance of explicating worldview-related themes. As for the profession’s position in the institution, preference for integrated spiritual care and territorial (i.e. departmental) operation has predictive power. The more respondents see spiritual care as an integrated discipline in health care, the more they feel that it should be directed to patients’ worldview-related experience and questions. The territorial mode of operation assumes that counselling does not require spiritual caregiver and patient to belong to the same worldview tradition. Respondents’ endorsement of this view predicts their rating of experiential-aﬀective communication. As for the background variables, the regression analyses reveal a negative predictive relation with gender and a positive relation with training and ministerial approval. The negative predictive relation with gender implies that female spiritual caregivers score higher on the experiential-aﬀective goal than their male colleagues.2 In addition this goal is rated more highly by respondents with advanced training. Academic training predicts the importance attached to experiential-aﬀective communication about worldviews.3 Ministerial approval likewise predicts emphasis on this aspect of worldview-related communication.4

2

Response category 1 = female; 2 = male. Response category 1 = HBO; 2 = WO. 4 Response category 1= no ministerial approval; 2 = ministerial approval (spiritual caregivers can have approval from any worldview association). 3

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Table 7.1 Determinants of immediate goals and ultimate goal of spiritual care (betas): outcome Variables

Immediate

goals

Ultimate goal

experiential- cognitive social-moral ritual health aﬀective Personal worldview Identity: narrativity Worldview-related identity: – ritualism – intrinsic worldview Higher reality: immanentism Theodicy: – apathy – retaliation – vicarious suﬀering Professional discipline Functions: – worldview intrinsic function – worldview extrinsic function Legitimacy: – statutory – patient-related – denominational – domain-related Ministry and sanctuary: Micro: facilitating communication Meso: marginal position Macro: reduced meaning Position in the organisation: – integration – territorial – multiple worldview cooperation

.13

.11 .19

.10 .11 –.11 –.13 .13

.14

.16

.12 .16

.10 .11

.19

.09

.12

.18

.11 .14

.09 .13

–.12

–.10

Explained variance R2

.17 .10

–.10

.11 .13 .14 .11

.12

.15

.11 .10

Health care Micro: – symmetry – compassion Meso: protocolisation Background variables gender education denomination ministerial approval professional association health care institution

.13

.08 .15 .13 –.13 .10

.13 .16

.09

.12

.12 –.14 .26

.24

–.16 .13 .11

.30

.16

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chapter seven Cognitive goal of worldview-related communication

By the cognitive goal we mean that spiritual care in interaction with patients focuses on an exchange of worldview-related beliefs. This goal is predicted by characteristics pertaining to personal worldview and the professional discipline, whereas health care characteristics have no predictive role. In the case of personal worldview this goal is predicted by a narrative concept of identity and the vicarious suﬀering theodicy model. Spiritual caregivers who perceive their identity from a narrative perspective subscribe more strongly to communicating with patients on worldview-related ideas. A view of suﬀering as something to be endured in solidarity with others also predicts the importance attached to the cognitive goal. As for professional discipline, we look at prediction of the following characteristics: intrinsic and extrinsic function of worldviews from the patient’s perspective, legitimacy from the patient’s point of view and domain related legitimacy, the notion that an oﬃcial ministry facilitates communication with patients (a negative correlation), marginal position of spiritual care in the institution and a preference for integration. Depending on the extent to which spiritual caregivers see worldviews as valuable in their own right and as conducive to patients’ health, they consider worldview-related communication with patients important. Likewise, the higher spiritual caregivers rate their discipline’s legitimacy in terms of patient demand and themes from the domain of worldviews, the higher their rating of the cognitive goal. A remarkable ﬁnding is that spiritual caregivers’ rating of ministerial approval by a worldview association as facilitating communication with patients is a negative predictor of their rating of communication on worldview-related beliefs and ideas. On the other hand, this goal is endorsed by those who feel that at meso level their discipline is marginalised by operating from a sanctuary position. Finally, support of spiritual care as an integrated discipline predicts agreement with cognitive worldview-related communication. In the case of background variables there is a predictive relation with training and denomination and a negative relation with membership of a professional association. As in the case of the experiential-aﬀective goal, we ﬁnd that advanced training results in greater emphasis of the cognitive goal. A positive relation with denomination applies more especially to humanistic spiritual caregivers: membership of the Humanistisch Verbond predicts a stronger focus on the

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exchange of worldview-related ideas.5 Spiritual caregivers who do not belong to the VGVZ also accentuate this goal.6 Membership of a professional association predicts less emphasis on communication about worldview-related beliefs. Social-moral goal of worldview-related communication By the social-moral goal we mean that spiritual care in interaction with patients focuses on the moral aspect of social relations. This goal is predicted by characteristics pertaining to personal worldview, professional discipline and health care. In the case of personal worldview the only predictor of this goal is the immanentist approach, which claims that the meaning of life is to be found exclusively in this world. In other words, the greater the emphasis on the immanence of ultimate reality, the more importance spiritual caregivers attach to talking to patients about moral themes in interpersonal relations. We explore the following predictions in regard to professional discipline: the legitimacy of spiritual care on the basis of worldview association, evaluation of these themes in terms of the caregivers’ own worldview-related domain and—negatively—the notion that the ministry enhances communication with patients. Assigning importance to a denominational legitimation of the discipline predicts an accent on social-moral communication on worldviews, as does a high rating of legitimation derived from the spiritual caregiver’s own worldview-related ideas. Finally, the less spiritual caregivers feel that an oﬃcial ministry facilitates communication with patients, the more highly they rate the social-moral goal. As for health care, social-moral worldview-related communication is predicted by the caregiver’s compassion with the patient and the importance attached to protocolisation. The more important caregivers consider it to focus on the patient’s suﬀering, the more they emphasise social-moral themes in their interaction. Positive evaluation of protocolisation in health care likewise predicts an emphasis on discussing moral issues in social relations with patients.

5 Response category 1 = Roman Catholic; 2 = Protestant; 3 = humanist; 4 = other (reference category). Here .16 is the beta for the entire compound variable and the b-value for humanists is the only signiﬁcant deviation from the value for the reference category. 6 Response category 1 = non-member of VGVZ; 2 = member of VGVZ.

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chapter seven Ritual goal of worldview-related communication

By the ritual goal we mean that spiritual care in interaction with patients focuses on expression of their worldview by way of rituals, either ecclesiastic or other. This goal is predicted by characteristics pertaining to personal worldview, professional discipline and health care. In the case of personal worldview this goal is predicted by the importance assigned to the ritual aspect of worldviews and by a theodicy model of vicarious suﬀering. To the extent that spiritual caregivers consider rituals to be a key component of their own worldview they assign ritual worldview-related communication greater importance. And the greater their agreement with the idea of enduring suﬀering in solidarity with others, the more highly they rate the ritual goal. As for professional discipline, we look at the predictive power of the following characteristics: rating of the intrinsic and extrinsic function of worldviews from the patient’s perspective, legitimacy of spiritual care from the patient’s and the denomination’s point of view, and preference for integration; the view that ministerial approval facilitates communication with patients is a negative predictor. The greater spiritual caregivers’ emphasis on worldviews as valuable in themselves and in promoting patients’ health, the higher they rate ritual communication. Endorsement of the ritual goal is also predicted by the belief that the profession is legitimised by the importance attached to it by patients and worldview associations. The less spiritual caregivers feel that an oﬃcial ministry facilitates communication with patients from the same worldview association, the higher their rating of the ritual goal. Finally, the more spiritual caregivers subscribe to integration of their profession in the care institution, the more they support the ritual goal. In the case of health care this goal is predicted by a symmetrical helping relationship. An attitude that stresses reciprocity between caregiver and patient predicts the importance of the ritual goal. When it comes to background variables there is a predictive relation with denomination, membership of a professional association (negative) and the type of care institution where the person is employed. In the case of denomination the relation applies mainly to Catholic respondents, who score higher on this goal.7 As for membership of 7 Response category 1 = Roman Catholic; 2 = Protestant; 3 = humanist; 4 = other (reference category). Here .12 is the beta for the entire compound variable

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a professional association, non-members of the VGVZ rate the ritual goal in interaction higher than members.8 And in the case of type of care institution, the ritual goal is endorsed mainly by spiritual caregivers employed in institutions with long-term patients.9 Caregivers in psychiatric centres, nursing and old age homes and institutions for the handicapped have more prolonged contact with patients; these caregivers attach greater importance to ritual communication on worldview-related experiences, feelings and insights. Ultimate goal: contribution to the spiritual aspect of mental health In their interaction with patients spiritual caregivers seek to promote mental health, in which we identify a spiritual aspect. This goal is predicted mainly by characteristics pertaining to the professional discipline and, to a limited extent, attributes associated with personal worldview and health care. In the case of personal worldview the apathy theodicy model is a negative predictor. The less respondents subscribe to the notion that God is indiﬀerent to human suﬀering, the more emphasis they put on the spiritual aspect of mental health. In other words, the more they believe that God is aﬀected by suﬀering, the stronger their focus on the ultimate goal of their profession—the promotion of spiritual health. Professional discipline has a predictive relation with the following characteristics: recognition of the extrinsic function of worldview from the patient’s perspective, statutory and patient-related legitimacy, belief that the ministry has lost its importance, preference for integration and openness to multiple worldview cooperation. The more spiritual caregivers consider worldviews to have value for patients’ health, the more importance they attach to promoting the spiritual aspect of mental health as the goal of their profession. An accent on this goal is also predicted by the belief that the profession is legit-

and the b-value for Catholics is the only signiﬁcant deviation from the reference category. 8 Response category 1 = non-member of VGVZ; 2 = member of VGVZ. Nonmembers of VGVZ who rate the ritual goal highly include many 2nd grade HBO theologians, church workers in Protestant churches and, to a lesser extent, spiritual caregivers employed in an institution for handicapped people. 9 Category 1 = general and academic hospitals, rehabilitation centres; 2 = psychiatric centres, nursing and old age homes, institutions for handicapped people.

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imised by statutory rules for spiritual care and the importance that patients attach to it. The stronger spiritual caregivers’ conviction that the ministry is losing its social signiﬁcance, the more they underscore promotion of the spiritual aspect of mental health as the goal of their profession. The same applies to the view that spiritual care is an integrated discipline in health care. And the view that spiritual caregivers can oﬀer guidance to patients with a diﬀerent worldview from their own likewise predicts stronger emphasis of the spiritual health goal. In the case of health care this goal is predicted by a compassionate helping attitude. The more weight spiritual caregivers assign such an approach to patients’ suﬀering, the higher they rate promotion of the spiritual aspect of mental health as a goal. Our ﬁnal conclusion is that prediction of the three groups of characteristics relating to personal worldview, professional discipline and health care, as well as those in the category of background variables, is strongest in the case of three worldview-related goals (experiential-aﬀective, cognitive and ritual). It is weakest in the case of the social-moral goal. Prediction of the spiritual health goal is also fairly limited. 7.2 A Profession at Risk In this section we consider the relevance of the results of the regression analyses. To this end we have to interpret certain trends emerging from these results. Here we examine the individual variables with the greatest predictive power, as well as the predictive power of groups of variables. First we consider certain characteristics individually (7.2.1). Then we turn to the three groups of characteristics: personal worldview, professional discipline and health care (7.2.2). 7.2.1

Principal determinants of micro level goals

Five variables have predictive value for at least three goals (both immediate and ultimate) in interaction with patients: 1. the extrinsic function of worldviews from the patient’s perspective; 2. legitimacy of spiritual care from the patient’s perspective; 3. legitimacy derived from themes in the spiritual caregiver’s own worldview domain;

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4. the notion that the ministry facilitates communication with patients (negative relation); and 5. preference for integrated spiritual care. On closer scrutiny the ﬁndings reveal three problems confronting spiritual care: possible functionalisation of worldviews in spiritual care, possible individualisation of the legitimacy of spiritual care, and possible de-legalisation of spiritual care, coupled with loss of statutory support for the legitimacy and position of the profession. Functionalisation of worldviews in spiritual care We start with the ﬁrst and ﬁfth variables with signiﬁcant predictive power. The ﬁrst is the extrinsic function of worldviews from the patient’s perspective. This function concerns the value spiritual caregivers ascribe to worldviews for patients’ handling of their situation. High ratings of the extrinsic function of worldviews from the patient’s perspective predict the importance attached to the experientialaﬀective, cognitive and ritual goals in worldview-related communication and the spiritual aspect of mental health. This ﬁnding suggests a possible functionalisation of worldviews, that is to say, reduction of worldviews to their extrinsic function. This would imply a primary focus on the means-end relation between worldviews and health: it would mean that worldview-related communication is no longer a goal in itself, with its own intrinsic value. Such a utilitarian approach entails two dangers. Firstly, the intrinsic signiﬁcance of worldviews may be obliterated altogether. Secondly, and concomitant with the ﬁrst danger, the extrinsic function may likewise disappear, for if the worldview is no longer valued in its own right it will eventually be of no use whatever. Functionalisation of worldviews tends to erode both kinds of value. Let us brieﬂy consider the two dangers. In the ﬁrst place a worldview claims to have value in its own right, irrespective of its usefulness for some goal or other. Worldviews are primarily concerned with receptiveness to a symbolically perceived ultimate reality. These worldview-related symbolisations have gratuitous value for human beings: they are grateful for them and treasure their worldviews. People are moved by these symbolisations; certain images are important to them, including ritual expressions. Following Geertz, we argued that the symbolised world acquires an aura of decisive factuality (cf. 4.2.1): in a sense it is the real world.

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That is very diﬀerent from assigning symbolic reality a purely functional value for coping with boundary experiences in everyday reality. When worldviews are regarded mainly from the angle of their usefulness for human health, their intrinsic meaning recedes into the background. When their value is reduced to utility, their very usefulness eventually disappears as the aﬃnity with their contents becomes more and more attenuated. The ﬁfth variable with signiﬁcant predictive power is the preference for integration of spiritual care in the care institution as a whole. Such integration occupies a position midway on a continuum ranging from isolation to assimilation. Opting for integrated spiritual care predicts the importance attached to the experiential-aﬀective, cognitive and ritual goals of worldview-related communication and the goal of spiritual health. The two main arguments adduced by proponents of integration are that it allows for the pivotal function of the primary care process and contributes to the goals of the care institution (cf. 5.1.1). Our research ﬁndings indicate that spiritual caregivers would like to coordinate their professional activities with the care provided by other disciplines to enhance human health. Hence they want to link their speciﬁc worldview-related goals with care for patients’ health. On closer scrutiny this ﬁnding about integration is in line with the ﬁndings on possible functionalisation of worldviews. There is a danger that in striving for integration the distinctive nature of spiritual care will recede into the background as spiritual caregivers seek to make their contribution just as ‘functional’ as that of other disciplines. After all, we have seen that in their interaction with patients spiritual caregivers focus on the extrinsic function of worldviews. In other words, this goal orientation in dealing with patients is associated with high ratings for both integration and the usefulness of worldviews for patients’ health. Individualisation of the legitimacy of spiritual care We now turn to the second and third variables with signiﬁcant predictive power. These pertain to the legitimacy of spiritual care. Spiritual caregivers consider all ﬁve forms of legitimation of their profession that we examined important, but only two of the ﬁve have signiﬁcant predictive power. Emphasis of the legitimacy of spiritual care based on patient demand predicts the importance attached to

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the experiential-aﬀective, cognitive and ritual goals of worldviewrelated communication and the goal regarding the spiritual aspect of mental health. Emphasis of themes from the distinctive worldview-related domain of spiritual care predicts the importance ascribed to the experiential-aﬀective, cognitive and social-moral goals. Although spiritual caregivers are positive about the other three forms of legitimation (statutory, institutional and denominational), they have little or no predictive power. In their work with patients they consider these structural forms of legitimation less important, at any rate where the goals of spiritual care are concerned. That brings us to the next problem. Inasmuch as legitimacy predicts the goals of spiritual care, these are mainly at an individual level. From the angle of goals, the only important factors are patients’ demands and needs and the spiritual caregiver’s domain-related themes. The fact that spiritual caregivers base the legitimacy of their profession almost exclusively on these two forms could lead to increasing individualisation of legitimation. Let us brieﬂy examine the emphasis on the two forms. Firstly, the strong focus on patients’ demands and needs is problematic for two reasons. One is that spiritual caregivers themselves are ambivalent about care oriented to patients’ demands and needs; that is evident in their attitude towards quality care at micro level (cf. 2.2.2). A principle that the practitioners themselves are unsure of is not a sound basis for the legitimacy of a profession. Secondly, patients’ demands and needs in the area of worldviews are less circumscribed than they were in the past. De-traditionalisation and deinstitutionalisation have the eﬀect that these demands and needs are less ﬁrmly linked to a particular institutional tradition and display far greater individual variation. A strong focus on the patient’s individual worldview-related demands and needs is also a shaky foundation for legitimacy. As for legitimising spiritual care on the basis of worldview-related themes from its own domain, this amounts—to put it bluntly—to spiritual caregivers legitimising their own profession. In practice it means that spiritual caregivers base the signiﬁcance and relevance of their discipline on their own powers of persuading others (patients, colleagues, managers) of the plausibility of themes from their domain. A profession whose claim to existence depends to some extent on arguments from their own domain, which individual practitioners have to trot out anew each time without adequate statutory and

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managerial support, makes heavy demands on those in the profession. In short: as soon as patients no longer ﬁnd spiritual care as a worldview-related activity meaningful, or if spiritual caregivers themselves fail to legitimise their profession in terms of worldview-related themes, not only their job satisfaction and job security but the very position of spiritual care are in jeopardy. For individual spiritual caregivers pressure on their personal powers of persuasion also incurs a risk of burnout. A major cause of burnout is an imbalance between giving and receiving. In this case it is an imbalance between a continual need to legitimise their profession personally and the ability to invoke structural forms of legitimation. A typical feature of burnout is that suﬀerers largely blame themselves for their disorder and regard it as a personal failure. Often spiritual caregivers regard it as a personal failing when they are unable to demonstrate the legitimacy of their profession to themselves and others. Hence over-emphasis of legitimacy based on the domain of spiritual care jeopardises not only the professional but the profession as such (cf. Abel, 1995; Evers & Tomic, 2003; Golden et al., 2004; Loonstra & Tomic, 2005; Rodgerson et al., 1998; Tomic et al., 2004; Weaver et al., 2002). De-legalisation of spiritual care Finally we consider the fourth variable with signiﬁcant predictive power. It entails the following. The more spiritual caregivers believe that their ministry helps to enhance communication with patients, the less importance they attach to the cognitive, social-moral and ritual goals of spiritual care; conversely, when they ﬁnd that the ministry impedes communication with patients, they rate these goals more highly. This research ﬁnding contradicts the argument of proponents of the ministry to the eﬀect that it facilitates worldviewrelated communication. What our ﬁnding points to is not just a disjunction of ministry and spiritual care, but a negative conjunction. This contrasts sharply with the commonly held notion that, particularly in the area of sickbed rituals, the ministry plays a major communicative role. This argument is particularly favoured by worldview associations. By granting ministerial approval they want to keep an eye on the performance of rituals on the assumption that the ministry provides a clear framework and a stimulus for performing rituals. Spiritual caregivers rate the performance of rituals as important

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to very important.10 But a relation between positive evaluation of rituals and the ministry is by no means self-evident. On the contrary, in the view of our respondents they are mutually contradictory. Our regression analyses show that agreement with the social-moral and ritual goals is also predicted by legitimation based on worldview associations. This ﬁnding does not contradict the previous one regarding the ministry as a framework for communication: one can value the ‘voice’ of worldview associations in a general sense without considering a direct link via the ministry necessary for good communication with patients and the performance of rituals. The negative relation between the ministry and the goals of spiritual care means that if spiritual caregivers value these goals because of their own concept of their profession, they remove the managerial and legal basis of the relation between health care and worldview associations. After all, the ministry—in the sense of denominational approval of the spiritual caregiver’s appointment—shapes and structures this managerial and legal relation between health care and the particular denomination according to the latter’s recognised pattern. The ﬁnding that statutory legitimacy of spiritual care has very little predictive value for the goals of spiritual care corroborates the trend towards de-legalisation of the profession. To sum up: there are three trends that endanger the future of spiritual care. Functionalisation of worldviews, individualisation of professional legitimacy and de-legalisation of spiritual care entail a risk of one-sided development. Together the three trends lead to a highly dyadic basis for spiritual care: its legitimacy and goals depend strongly on the interaction between spiritual caregiver and patient and their joint input in the interaction, without any proper support base outside this dyad. 7.2.2

Professional discipline, personal worldview and health care

The data in table 7.1 tell us that professional discipline is the principal predictor of micro level goals. Personal worldview is second, and health care has least predictive power. 10 This emerges from responses to item 14 in the questionnaire. Actual time spent on rituals, and what spiritual caregivers would like to spend on them: individual rituals (resp. 6% and 6%), group rituals (resp. 7% and 7%) and collective rituals (resp. 14% and 13%).

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None of the other characteristics has as much predictive value for interaction goals as professional discipline. It has considerable predictive power for the experiential-aﬀective, cognitive and ritual worldview-related goals and for the spiritual aspect of mental health as the ultimate goal. Spiritual caregivers’ worldview-related communication is determined by their professionalism more than by their personal worldviews. The disparity is greatest in the case of the ultimate goal, the spiritual aspect of mental health, whose importance depends far more on professional attributes than on personal worldview. Personal worldview has most predictive power for the experiential-aﬀective, cognitive and ritual goals, hence it is a major predictor of worldview-related communication in spiritual care. In this sense the spiritual caregiver’s profession is similar to that of pastors, ministers and humanistic counsellors in a parish, congregational or associational setting: in both types of professions the way the practitioners conceive of their work, its aims and contents, is largely determined by who they are, more particularly by their worldview-related personal identity. But this conclusion does not apply to the ultimate goal of spiritual care: when it comes to promotion of the spiritual aspect of mental health the role of the spiritual caregiver’s personal worldview is barely signiﬁcant. Health care has even less predictive power, though it does have some in the case of the social-moral goal. On the premise that personal worldview, professional discipline and health care all determine the orientation of spiritual care, albeit not to the same extent, we conclude from our analysis that there is no balance between these characteristics, even though that is commonly averred in many publications on the subject. The institutional aspect, health care, plays a particularly small role. In their goal orientation spiritual caregivers pay least attention to it. Health care, more speciﬁcally quality care in the context of a care institution, does not feature signiﬁcantly in the goals they set themselves for their work with patients. They do not really relate their service to patients with the policy arrangements and systems aimed at quality assurance for both patients and caregivers. To spiritual caregivers proper use of human and other resources and accountability for work performed, as envisaged by quality care at meso level, are more or less distinct from their focus on the patient. As for the background variables that we studied, we saw that they have limited predictive power. None of the six characteristics pre-

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dict more than two of the goals for interaction with patients. They do not predict the social-moral goal and the ultimate goal (spiritual aspect of mental health) at all: background variables do not diﬀerentiate in the case of these dependent variables. The distinction between institutions with long- and short-term patients is relevant only in the case of the ritual goal. In psychiatric centres, nursing and old age homes and institutions for the handicapped spiritual caregivers have more prolonged contact with patients, and they attach greater importance to ritual communication of worldview-related experiences, feelings and insights. Conclusion This section dealt with three dangers for the future of spiritual care: functionalisation of worldviews, individualisation of legitimacy and de-legalisation of spiritual care. They entail a risk of one-sided development: that of insuﬃcient attention to the full scope of worldviews, to legitimacy based on diﬀerent perspectives and to the managerial and legal basis of the relation between health care and worldview associations that has hitherto provided a structural framework for spiritual care. On the strength of our ﬁndings we described the professional attitude of spiritual caregivers as dyadic, that is, their professional approach is almost exclusively based on interaction between spiritual caregiver and patient. We concluded, moreover, that there is no balance between the characteristics of personal worldview, professional discipline and health care when it comes to their importance for the goals of spiritual care. Worldview-related communication and a focus on the spiritual aspect of mental health depend more on the professionalism of spiritual caregivers than on their personal worldviews. Quality assurance at the meso level of health care likewise has little eﬀect on orientation to the goals of spiritual care in interaction with patients. In our review of the ﬁndings the limited predictive power for social-moral worldview-related interaction featured regularly. Among all the goals of interaction with patients, personal worldview, professional discipline and health care have least predictive power for this goal. This applies particularly to personal worldview; professional discipline has most predictive power, but even so it exercises least inﬂuence on the social-moral goal. As noted before, spiritual caregivers attach little importance to the social-moral aspect of worldviews.

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From our earlier ﬁndings and the regression analyses we surmise that they experience the social-moral aspect as dissociated from the domain of worldviews. They do not see the theme of social relations and moral themes as typical of worldview-related communication.

8 SYNOPSIS AND RECOMMENDATIONS At the end of this study we look back on the ground we have covered. The topics we explored were health care, worldviews and spiritual care. We described spiritual caregivers’ views on these topics. The previous chapter dealt with the eﬀects of their views on the goals of spiritual care in interaction with patients. We have now reached the point where we must answer the research questions posed in the introduction (8.1). The study concludes with policy considerations and recommendations for advanced training and further research (8.2). 8.1

Synopsis

In the introduction we outlined six research questions about institutional, worldview-related and professional factors pertaining to spiritual care and their eﬀects on the goals of spiritual care (cf. scheme 8.1). Scheme 8.1 Research questions 1. How do spiritual caregivers view quality assurance in health care? 2. How do spiritual caregivers view the function of worldviews in health care? 3. What are the personal worldviews of spiritual caregivers? 4. How do spiritual caregivers view the legitimacy and position of spiritual care as a professional discipline in health care? 5. How do spiritual caregivers see the goals and tasks of their profession? 6. What are the eﬀects of health care, the spiritual caregivers’ personal worldviews and the professional discipline of spiritual care on the goals of the profession, while controlling for relevant back ground variables? Let us answer these questions, with reference to conceptual and empirical material from earlier chapters.

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chapter eight How do spiritual caregivers view quality assurance in health care?

One of the principal developments in health care is quality of care. We conﬁne ourselves to quality assurance at the meso level of care institutions and at the micro level of interaction with care consumers. In our scrutiny of quality care at meso level we focus on the phenomena of proceduralisation, protocolisation and registration. We deﬁne procedures as legitimised, routinely monitored standard events in an organisation, and protocols as comprehensive documents spelling out the goals, plan of approach and agreements on evaluation and management. In quality assurance there is a risk of excessive bureaucratisation, manifested in such things as goal modiﬁcation and undermining solidarity with care consumers. Care procedures and protocols also have implications from a worldview and ethical perspective. Spiritual caregivers are critical of proceduralisation and protocolisation and are keenly aware of the danger of bureaucratisation. They consider reﬂection on worldviews and ethics important. By registration we mean creating and maintaining a register of professionals, who have to meet certain requirements in regard to training, refresher courses and professional practice to qualify for registration. This is a way of regulating, promoting and safeguarding the quality of their work. Spiritual caregivers are moderately positive about professional registration. As for quality care at the level of interaction with care consumers, there are three conditions such care should meet in recognition of the self-determination to which patients are entitled by virtue of their intrinsic human dignity. From the patients’ point of view it is a matter of safeguarding their rights, inter alia by means of the right to selfdetermination. On the part of caregivers it involves two attitudes: compassion in the sense of empathy with others because of the suﬀering they have to endure, and symmetry in the sense of equality and reciprocity in relations between caregiver and patient based on the fellowship of the weak. Their interaction entails demand-driven care at micro level, that is methodical action in which caregiver and patient jointly solve problems. Spiritual caregivers maintain that patients’ selfdetermination is given only limited recognition. They attach particular value to the attitudes of compassion and symmetry as the way to patient-oriented care. They are ambivalent about a patient-oriented, demand-driven approach in their interaction with patients.

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Conclusion: spiritual caregivers favour quality assurance mainly at micro level, and to a much lesser extent at meso level. Their notion of quality care centres chieﬂy on their own attitude of compassion and symmetry in their relations with patients and takes little account of organisational aspects and preconditions at the meso level of the institution. How do spiritual caregivers view the function of worldviews in health care? We break up the question about the function of worldviews in health care into two sub-questions: how does a worldview approach relate to the medical approach, and what functions do worldviews fulﬁl in health care? In response to the ﬁrst question we consider the medicalisation of health care. This is manifested partly in somatisation, which puts the accent mainly on the physical aspect of health, and partly in medical compliance in the sense of a strong orientation to the medical profession as the bringer of ‘salvation and healing’. Spiritual caregivers are ambivalent about the idea that medicalisation imposes any restriction on the scope for worldviews. Worldviews have their own place in health care: the assimilation and endurance of illness, suﬀering and death in a perspective of contingency. The experience of the transience of life—in relation to mortality—is crucial to patients; this establishes a link with worldviews where that experience, and responses to it, are likewise focal. Spiritual caregivers are doubtful whether contingency (i.e. transience and mortality) are in fact so crucial; they clearly do not rate it very highly. Regarding the functions of worldviews, our answer is as follows. Worldviews have two functions, one intrinsic, the other extrinsic. These may be viewed from the perspectives of both spiritual caregiver and patient. The intrinsic function concerns the experience that a worldview is valuable in itself. The extrinsic function is the ‘usefulness’ of worldviews for patients’ health, more particularly for the processes of healing and assimilation. Spiritual caregivers agree unanimously that communication about worldviews contributes to the spiritual aspect of health, hence they put the accent on the extrinsic function. They ﬁnd the intrinsic function, which relates to questions about the meaning of life, less important.

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chapter eight What are the personal worldviews of spiritual caregivers?

The question of how spiritual caregivers see themselves in terms of their own worldviews is answered as follows. The spiritual caregiver’s personal identity is seen as a narrative identity. By that we mean that the integrated nature of human life corresponds with that of a narrative, and that people’s identity takes shape through the stories they tell about themselves or that others tell about them. Following Ricoeur, we diﬀerentiate between three aspects of identity: historicity, sociality and praxis. At a historical level the focus is the uniqueness of the human person, that is the way humans are constantly refashioning the relation between continuity and discontinuity. Under sociality the focus is attestation in the sense of a vulnerable commitment and a promise to the other. At the level of praxis we concentrate on its passive side, which in a health care context chieﬂy concerns suﬀering and the tragedy of life. Spiritual caregivers take a narrative view of their personal identity and emphasise both its uniqueness and its pathic nature. They attach less value to the attestatory aspect of personal identity. As for spiritual caregivers’ worldviews, we follow Geertz’s distinction between three dimensions of worldviews: culture, meaning and ritualism. Culturally it is a matter of the worldview prevailing in the person’s environment. The dimension of meaning concerns the way an individual’s worldview symbolises the ultimate order of existence, suﬀering and death. The ritual dimension of worldviews lies in establishing a connection between the everyday world and a symbolic order. In the ﬁrst—cultural—dimension of worldviews we distinguish between four terms: collective worldview, worldview associations, tradition and multiple worldviews. By collective worldview we mean that people assign meaning to the world in terms of supra-individual symbolic systems. As for worldview associations, their power is declining at present as they undergo a process of de-institutionalisation. Nonetheless worldview traditions continue to form a major cultural substratum. Finally, a multiple worldview refers to openness to dialogue with other worldview traditions. Spiritual caregivers are negatively ambivalent about the signiﬁcance of a collective worldview, implying that they set greater store by individualised worldviews. They value their own worldview tradition positively and are open to dialogue with other worldview traditions, but are fairly negative about their own worldview institution or association. We conclude that in a sense

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spiritual caregivers accept the individualisation and de-institutionalisation of worldviews. The same cannot be said of tradition: they attach great importance to worldview traditions and are perfectly open to engaging other traditions in dialogue on worldviews. In the second dimension of worldviews—that of ascribing meaning—we distinguish between three terms: ultimate reality, suﬀering and death. The ﬁrst term is diﬀerentiated into religious and nonreligious meaning. Under religious meaning we distinguish between panentheistic and deistic interpretations. The former regards God as both transcendent and immanent, as a close presence, even closer to us than we are to ourselves (Augustine). The latter regards God as absolutely transcendent, neither close to people nor caring about them. Under nonreligious meanings we diﬀerentiate between immanentist and atheistic interpretations. The former claims that the meaning of life must be sought exclusively in this world, the latter that there is no such thing as a religious, universal order of existence. Spiritual caregivers from religious traditions believe in the existence of a transcendent reality and reject the immanentist and atheistic views. Spiritual caregivers from the humanistic tradition reject belief in a transcendent reality. They agree with the immanentist view and are ambivalent about atheism. In the case of suﬀering we focus on the theodicy problem: how does one reconcile the experience of suﬀering with belief in an all powerful, benevolent God? Van der Ven identiﬁes seven theodicy models. Three of them are oriented to transcendence: the apathy model, based on the assumption that God keeps aloof from suﬀering; the retribution model, which assumes that suﬀering is divine retribution for human sinfulness; and the plan model, which posits that suﬀering has a place in God’s hidden plan for human history. Three of these models are immanently oriented: the solidarity model, which assumes that God has compassion with suﬀering humans and comforts them with his closeness; the vicarious suﬀering model, which assumes that God has solidarity with suﬀering humans and presents self-sacriﬁce for the good of others as a way to salvation; and the mystical model, which maintains that suﬀering establishes an intimate relationship between God and human beings. Midway on the continuum between transcendence and immanence is the developmental model, according to which God sees suﬀering as a means of puriﬁcation. Spiritual caregivers from religious traditions subscribe to only one theodicy model—that of solidarity. The others they either

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reject or view with negative ambivalence; the transcendently oriented models in particular are rejected. Spiritual caregivers with a humanistic worldview reject all the theodicy models. They are particularly negative about the retribution and plan models, and object least to the solidarity and apathy models. As for views on death, we distinguish between belief in life after death, reincarnation, immanentism and agnosticism. In the ﬁrst case the belief is that death does not put a brutal end to life, but that it continues in a transformed state. Reincarnation holds that after death life on earth continues in a diﬀerent guise. Immanentism is conﬁned to what people can know and experience of death here and now without breaking their heads about what happens afterwards. The agnostic view is that human beings do not know whether there is any continuation of life after death. Spiritual caregivers from religious traditions subscribe to the traditional Christian conception of life after death, more particularly to the immanentist view. They are ambivalent about the agnostic attitude to death and reject reincarnation outright. Spiritual caregivers from the humanistic tradition concur with the agnostic and—very strongly—with the immanentist conceptions of life after death. They reject reincarnation and the Christian approach to life after death. The third dimension of worldviews is ritualism. According to Geertz the performance of rituals gives the ultimate, symbolised reality of worldviews an aura of factuality. This means that rituals occupy a focal place in worldviews, and are in fact called ‘religion’s ﬁnal answer’ to the contingency of life. Rites of passage, which mark the transition to a new social role or phase of life, have a distinctive function in health care as well. Spiritual caregivers from a religious tradition more or less agree with the signiﬁcance of the ritual dimension generally and are positively ambivalent about the speciﬁc meaning of rites of passage. Those from the humanistic tradition are ambivalent about the signiﬁcance of the ritual dimension generally and negative about the speciﬁc meaning of rites of passage. How do spiritual caregivers view the legitimacy and position of spiritual care as a professional discipline in health care? We distinguish between two aspects of spiritual care as a professional discipline: its legitimacy and its position in health care. Legitimacy concerns the various justiﬁcations of its claims as a health care

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discipline. These justiﬁcations may be couched in terms of health care, in terms of worldview and in terms of its own domain. The legitimacy of spiritual care in terms of health care derives from statutes and policy. Its statutory legitimacy hinges on the enabling Quality Care Institutions Act of 1996. Its legitimacy in policy depends on the approach to care outlined in the institution’s policy and on its legitimacy from the patients’ point of view—the value patients attach to worldview-related experience as such and their perception of its usefulness in treating health problems. Legitimacy in terms of worldviews stems from worldview associations’ notions of care and the contribution of worldviews to patients’ health. Finally spiritual caregivers can base their case for the legitimacy and necessity of spiritual care on themes speciﬁc to their profession, such as transience, mortality, suﬀering and death. Spiritual caregivers ﬁnd all the forms of legitimacy that we investigated important. They put most emphasis on the existence of a need for spiritual care among patients. We explore two possible positions of spiritual care in health care: isolation and integration. The ﬁrst position is when spiritual care sees itself as distinct from other disciplines and claims a separate position in the organisation of the institution. Integration is when it neither isolates itself from other disciplines, nor adapts to them completely. In the case of integration the focus is process integration, where spiritual care is closely linked with the care process. Process integration presupposes integration at both the organisational level and that of policy making. Spiritual caregivers are in favour of integration and reject an isolated position in care institutions. The legitimacy and position of spiritual care can also be approached in a worldview perspective, which is when an oﬃcial ministry and a privileged position enter into it. Here we focus on arguments for and against such legitimacy at the micro level of relations with patients, the meso level of the care institution and the macro level of health care and society. At micro level the argument for spiritual care as an oﬃcial ministry is that it facilitates dialogue with patients in that caregivers communicate better with patients from the same worldview tradition; the counter argument is that the signiﬁcance of spiritual care remains conﬁned to its ritual task. At macro level the argument for this form of legitimacy is based on the importance of representing a worldview association, and the counter argument on the dwindling social signiﬁcance of these associations as a result of de-institutionalisation and de-traditionalisation. Spiritual caregivers

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disagree with the idea of the limited signiﬁcance of the oﬃcial ministry—both in society and in their tasks in interaction with patients. They endorse the notion of representing a worldview association via the ministry, but doubt whether adherence to the same worldview tradition as the patient facilitates dialogue. Finally, when it comes to spiritual caregivers’ rating of the ministry in terms of their personal worldview, we ﬁnd that they assign it positive value. In the case of the privileged position of spiritual care we turn to the meso level: exemption from accountability to other disciplines (argument for) versus the risk of marginalisation in the institution (counter argument). Spiritual caregivers concur with the value of a privileged position in the sense of freeing them from accountability; they disagree with the notion that such a position results in a marginal position in the institution. Spiritual caregivers handle the plurality of worldviews in various ways. It aﬀects both their relations with other spiritual caregivers and their relations with patients. An option for counselling patients belonging to the same worldview association means that spiritual care will be denominational or categorical: counsellees are selected on a denominational basis. Non-denominational or territorial spiritual care operates departmentally. Spiritual caregivers prefer a territorial mode of operation. By multiple worldview patient counselling we mean that no distinction is made between patients with diﬀerent worldviews. Spiritual caregivers are positive about this kind of counselling. Multiple worldview cooperation means openness to, and cooperation with, caregivers who hold other worldviews. Spiritual caregivers are solidly in favour or such cooperation in spiritual care. How do spiritual caregivers see the goals and tasks of their profession? The professional activities of spiritual care relate to two aspects: goals and tasks. The goals of spiritual care are the results that spiritual caregivers hope to achieve with their activities and that may be regarded as generally feasible. Here we make a distinction between immediate goals and the ultimate goal at micro level, and the goal at meso level. The immediate goal of spiritual care at micro level is to promote communication on worldviews in interaction with patients. This communication has four aspects. First, it is experiential and aﬀective: spiritual care focuses on worldview-related experience, questions and existential feelings. The second aspect is cognitive,

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in that spiritual care is aimed at exchanging worldview-related beliefs. The third aspect is social and moral, in that spiritual care concerns the moral aspect of social relations. Fourthly, there is a ritual aspect: spiritual care promotes patients’ ritual expression of their worldview. The ultimate goal of spiritual care at micro level is to contribute to the spiritual aspect of mental health: assigning life ultimate meaning as a contribution to health. At meso level the goal, which creates the conditions for goal achievement at micro level, is that spiritual caregivers, in interaction with other caregivers and institutional policy, should focus on the worldview dimension of care. Spiritual caregivers endorse all these goals. They attach most importance to the experiential-aﬀective goal and the ultimate goal of promoting the spiritual aspect of mental health. The cognitive goal is rated least important. Three broad orientations to the goals of spiritual care are examined. Spiritual care may concentrate primarily on patients’ experience by assisting their self-discovery and oﬀering comfort and encouragement. The second approach is challenge-oriented: patients are helped to evaluate their experience and are challenged to observe it detachedly with a view to future change. Finally spiritual care may be aimed at its own mission or message, with the accent either on the subjective inspiration of the spiritual caregiver (testimony) or the objective substance of the message (creed). Spiritual caregivers attach great importance to an experiential orientation; they consider the challenge orientation important but are negatively ambivalent about a mission orientation. The tasks of spiritual care are the activities undertaken in pursuit of its goals. We explore various activities: aspects of counselling conversations, rituals, and supra-disciplinary interaction with fellow caregivers and policy makers. We investigated the following aspects of counselling conversations: their human fellowship character, in the sense that patient and spiritual caregiver engage in the relationship as fellow human beings; a demand/supply structure, in which the spiritual care supplied corresponds with patients’ demands and needs; and initiation of communication by spiritual caregivers. Spiritual caregivers are in favour of a demand/supply structure and taking the initiative in establishing relations with patients; they reject a purely human fellowship approach. Rituals have an individual and a collective dimension. The individual dimension has an experiential-expressive and a cognitive aspect,

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while the collective dimension has a moral and a social aspect. The experiential-expressive aspect pertains to the way participants experience a ritual and to symbolic expression as the key component of rituals. The cognitive aspect concerns the worldview-related beliefs that the ritual conveys. The moral aspect refers to the link the ritual establishes with the norms and values embedded in the worldview, and the social aspect to the bond between the individuals enacting the ritual. Spiritual caregivers attach most value to the experiential-expressive and social aspects of rituals; they consider the cognitive aspect less important. They are negatively ambivalent about the moral aspect of rituals. Supra-disciplinary consultation has a communicative and a managerial dimension. The communicative dimension is characterised by competition, division and image problems. Competition occurs when spiritual care and other disciplines regard each other as rivals; division refers to the disparity between spiritual care and other disciplines as regards goals, concepts and methods; image problems arise to the extent that other disciplines may have a narrow or negative image of spiritual care. The managerial dimension refers to support for spiritual care, or the lack of it, on the part of institutional management. Spiritual caregivers deny that there is any competition with other disciplines, are ambivalent about image problems and division, and claim to receive suﬃcient managerial support. What are the eﬀects of health care, the spiritual caregivers’ personal worldviews and the professional discipline of spiritual care on the goals of the profession, while controlling for relevant background variables? The last research question concerns the determinants of the goal orientation of spiritual care. To investigate the goal orientation we focus on the goals, both immediate and ultimate, of interaction with patients. The immediate goal, we have said, is to promote communication on worldviews, which we diﬀerentiate into four aspects: experientialaﬀective, cognitive, social-moral and ritual. The ultimate goal is to promote the spiritual aspect of health. Our aim is to ﬁnd out how these goals are aﬀected by three sets of variables: health care, personal worldview and the professional discipline. In the process we control for a number of background characteristics: gender, training and membership of a professional association; two worldview-related

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characteristics (denomination and ministerial approval); and the spiritual caregiver’s workplace, classiﬁed into institutions where patients are admitted for a short period only and institutions where admission is long-term. Health care, personal worldview and professional discipline have the greatest predictive power in regard to three of the worldviewrelated goals: the experiential-aﬀective, cognitive and ritual goals. It has least impact on the social-moral goal, and its impact on the ultimate goal, the spiritual aspect of health, is also limited. To some extent the predictive power of health care applies to the social-moral and ritual goals, and to a lesser extent to the ultimate goal (spiritual aspect of health). Personal worldview has most predictive value for the experiential-aﬀective, cognitive and ritual goals, but the spiritual caregiver’s personal worldview plays hardly any predictive role in regard to the spiritual aspect of health. Professional discipline has most predictive power for interaction goals, more particularly the experiential-aﬀective, cognitive and ritual goals and the spiritual aspect of health. When it comes to the eﬀects of professionalism, personal worldview and health care as an institution on the goals of spiritual care, professionalism has most impact, personal worldview comes second and health care as an institution has least. An overview of the ﬁndings highlights three potential dangers for spiritual care. The ﬁrst is that worldviews may be functionalised in the sense of being reduced to their extrinsic function. The second is that the legitimacy of spiritual care may become overly individualised. Spiritual caregivers tend to locate the legitimacy of their profession from the perspective of its goals mainly at the individual level of patients’ demands and needs and themes pertaining to spiritual caregivers’ own domain. They attach little or no importance to statutory and managerial legitimacy or to legitimisation by their worldview association. The third danger is that of ‘de-legalising’ spiritual care in the sense that it is losing its signiﬁcance as an oﬃcial ministry. At the level of interaction with patients there are signs of a negative association between ministry and professionalism. These three trends give spiritual care a pronounced dyadic character: its legitimacy and goals depend largely on the interaction between spiritual caregiver and patient and their input into that interaction; spiritual caregivers do not perceive much support for their work from outside agencies.

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Policy Considerations and Recommendations

The research aim was to glean scientiﬁc knowledge about the actual proﬁle of spiritual care in care institutions (cf. 1.2.2). The ﬁndings prompt certain policy considerations and recommendations for the advanced training of spiritual caregivers and future research. These considerations and recommendations incorporate input from the committee supervising the research, which comprised, as mentioned already, both scientiﬁc advisors and spiritual caregivers. Policy considerations: expanding the legitimacy of spiritual care In regard to goals spiritual caregivers locate the legitimacy of their profession mainly at an individual level: patients’ demands and needs and their own domain-related themes. Thus they overlook the potential of legitimation on other grounds. At policy level, for example, the legitimacy of spiritual care may be reinforced both by the deﬁnition of care in policy documents and its statutory basis. Possible means to this end would be involvement in quality assurance and public law registration. Such involvement could have implications for the initiation of spiritual counselling by caregivers in the future. Firstly, spiritual care can become more involved in quality assurance, especially at the meso level of the institution (cfr. Van Houten, 1997, 112–118; VandeCreek, 2000, 7–17). This option cannot be taken for granted, since our research shows that spiritual caregivers are not really proponents of quality assurance at meso level. If they themselves have a hand in shaping care procedures and protocols and devise modiﬁed protocols for their own activities, it would enhance their legitimacy from the angle of the institution’s perception of care. Early attempts at drawing up protocols for spiritual care (e.g. those developed in the NIAZ) could be applied more broadly. Thus spiritual care could evolve into a discipline that makes a proportional, expertise-based or evidence-based contribution to the professional team eﬀort. Our study also reveals that spiritual caregivers attach some importance to worldview-related and ethical reﬂection on the standardisation of care. If they want to make a useful contribution in this regard, they should concentrate on aspects of care where worldviews are pertinent: what are these aspects, and how can reﬂection on worldviews and ethics be translated into care policy and protocols? Among the worldview-related and ethically relevant

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aspects of health care we would include the institution’s mission statement, medical-ethical policy generally and policy regarding research on human beings. In spiritual care such reﬂection is still in its infancy (Bouwer, 1998, 42–43; Liégois, 1997; Schepens, 1997, 88–91). To analyse the worldview-related aspects of health care one could consider establishing multidisciplinary committees for spiritual care in institutions, analogous to committees in areas like hygiene, calamities and drugs. This would be another way of entrenching the legitimacy of spiritual care in the institutional deﬁnition of care. If it should be decided to extend the legitimacy of spiritual care beyond the individual level, it is bound to have implications for the future initiation of contact with patients by spiritual caregivers. Spiritual caregivers are positive about their right to initiate contact with patients. However, there is little future for such initiation of contact by spiritual caregivers without consultation with other caregivers and without a referral policy on their part. It would give spiritual care a ‘separate’ status and contribute to undesirable isolation—something that spiritual caregivers themselves condemn. There is a further consideration in this regard. Spiritual caregivers favour a demand/supply structure for spiritual care. In view of this, care procedures and protocols could incorporate agreements on contexts and ways in which spiritual caregivers introduce themselves to patients. By gearing the substance of spiritual counselling to patients’ demands and needs, and by integrating the supply with the rest of the care process, spiritual caregivers’ heavy emphasis on their professional legitimacy based on distinctive themes and patients’ needs can be linked to the legitimacy they are assigned in the institution’s care policy. A major tool for the statutory legitimation of spiritual care is professional registration. Our study indicates that spiritual caregivers are cautiously positive about this. Meanwhile the preparations for private law registration in the VGVZ professional association is well advanced. In the long term registration as stipulated in the BIG act, and within that framework the most exhaustive form of registration paralelling that of doctors, has one major advantage. It would give spiritual care private law recognition, in that the professional association could establish a central college that submits an arrangement to the minister. After obtaining the minister’s approval a registration committee could be charged with the administration of such registration and re-registration. However, inclusion in the BIG act would require government to clarify its stance on the position of spiritual

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care in health care, also in relation to the responsibility of worldview associations. Within that framework the professional association will have to draw up a general plan, in which the substance of spiritual care is spelled out. Training in spiritual care would also have to be reviewed and an arrangement worked out for the funding of specialised training in care institutions. In addition spiritual care will have to be included in the activities of the steering committee for the modernisation of health care training and professions. Recommendation for the training continuum: balancing the intrinsic and extrinsic functions of worldviews In our overall approach to spiritual care we put the accent on its goals, especially goals of interaction with patients. Here we established the importance of spiritual caregivers’ personal worldviews and their professionalism. Their personal worldview, and especially their professionalism, have a major impact on their worldview-related communication with patients. In addition professionalism is vitally important for achieving the ultimate goal: promotion of the spiritual aspect of patients’ health. We have noted, however, that this important eﬀect of the professional discipline of spiritual care on the goals of communication on worldviews entails a risk: the extrinsic function of worldviews may overshadow their intrinsic function, thus marginalising and ultimately perhaps eclipsing it altogether. Paradoxically, in the long run this could cause the demise of the extrinsic function as well, for a purely extrinsic function that is not grounded in an intrinsic function cannot survive on its own. The aforementioned ‘general plan’ for training and advanced training could devote the necessary attention to the intrinsic function of worldviews, from both a cultural and an individual point of view. Following Geertz, we have indicated that personal worldview-related meaning is rooted in a worldview-related culture. Culturally the intrinsic function is to activate the symbols, beliefs and ideas inhering in the worldview as values in their own right. Training and advanced training could explore the cultural network of meanings in worldviews, thus aﬀording broader and deeper insight and showing how to deal with them. In practical terms this would entail a study of people’s worldview-related symbols, beliefs and ideas regarding such things as the meaning of life, suﬀering and death as reﬂected in texts, art and folk religion through the ages. In the process diﬀerent

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worldview traditions can interrelate, for instance by exchanging and coordinating their perspectives (Van der Ven, 2004, 169–176). This would help to develop a personal worldview in a multiple worldview perspective. In deﬁning the identity of a spiritual care service or in arranging a meditation centre or prayer chamber such knowledge and insight could be applied. From an individual point of view the intrinsic function pertains to worldviews as valuable in their own right in every situation in life, especially boundary experiences. Training should aim at teaching trainees how to stimulate patients to evolve a personal worldview (cf. Schilderman, 2002, 228–229). In practical terms this means learning how to discuss patients’ answers to existential problems with them with the aid of methods like worldview-related anamneses or spiritual biographies (Bouwman & Bras, 2001; Glas, 2001). Two other elements can help spiritual caregivers to invoke the full scope of worldviews in their communication with patients: the socialmoral and ritual aspects of worldviews. In 7.2 we noted that the social-moral aspect of worldviews is experienced as dissociated from spiritual caregivers’ personal worldview. This causes a blind spot when it comes to moral themes in social relations. Training and advanced training in this area can make spiritual caregivers more aware of the social-moral aspect in the sense of greater insight and a more positive attitude towards it. Firstly, it requires a focus on relations and participation in worldview-related groups and communities. Secondly, it requires a focus on moral themes in social relations: ideals, values, moral norms and moral choices in real-life situations. This can take the form of training and advanced training in the ﬁeld of people’s moral and social development (e.g. Kohlberg’s theory) and spiritual care methods speciﬁcally geared to this angle (e.g. contextual pastoral work and systems theory). Thus spiritual caregivers can learn to talk to patients about values and norms both in their personal lives and in a health care context. Rituals form an important part of worldviews. We established that spiritual caregivers from religious traditions hesitantly endorse the signiﬁcance of the ritual dimension generally and are ambivalent about the speciﬁc meaning of rites of passage, and that spiritual caregivers from the humanistic tradition are ambivalent about the signiﬁcance of the ritual dimension generally and negative about the speciﬁc meaning of rites of passage. These attitudes among spiritual caregivers seem to suggest that they do not properly appreciate the

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potential of this facet of their work. The ability to use rituals, including rites of passage, in boundary situations is peculiar to spiritual care as a health care discipline. Greater emphasis on rituals can assume various forms. Firstly, the meaning of rituals can be acknowledged more fully, thus underscoring the socio-cultural nature of worldviews. Rituals are arousing renewed interest in our culture at present. Spiritual caregivers can join in this ‘ritual invention’ on the basis of their own expertise (Driver, 1998; Hughes-Freeland & Crain, 1998). Secondly, the meaning of rituals to people can be integrated with their life stories. The introduction of a ritual dimension will put more emphasis on the relational nature of narrative identity, apart from its historical character (Grimes, 1990, 159–173). Recommendations for further research Both quality assurance and public law registration of the profession demand a thorough, systematic deﬁnition of the competencies of spiritual care in terms of knowledge, insight, skills and attitudes, based on reﬂection on the goals and tasks of the profession in health care. Measuring instruments need to be constructed to assess the various competencies in terms of the knowledge, insight, skills and attitudes required. These can be used for objective measurement of the competencies of spiritual caregivers, which would form the basis for advanced training in the framework of registration and re-registration. Possibly the measuring instrument could also be used to establish patients’ evaluation of spiritual caregivers’ competencies. Hence the research we are recommending should be long-term and international. Spiritual care would appreciate international cooperation and consensus on the proﬁle of the profession. Our research revealed that spiritual caregivers doubt whether the contingency of life, which signiﬁes the ﬁnitude of existence, really plays such a prominent role in health care, hence in their work as well, considering the focal place of these experiences and responses to them in worldviews. The importance attached to contingency is associated with the realisation that passivity is an essential part of personal identity. The low rating of contingency raises the question of what themes actually predominate in spiritual caregivers communication on worldviews with patients. Some information is provided by spiritual caregivers’ responses to an item (not discussed elsewhere in this book) on the themes of their interviews with patients. These

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reveal the main themes as illness, experiences of bereavement in relationships and radical events from the past, followed by themes pertaining to loneliness, suﬀering, relations with their immediate environment and the meaning and value of life.1 These responses by spiritual caregivers contrast with their responses regarding the focal place of contingency, more especially transience and mortality, in health care. Further research is needed to clarify the issue. For instance, are spiritual caregivers averse to narrowing down contingency to transience and mortality? Should training for spiritual care devote more attention to theories on so-called life events, and are these mainly developmental crises, which are integral to life itself, or traumatic crises? (Caplan, 1974.) Also, how does the theme of contingency relate to that of existential recognition? The ﬁrst theme concerns the boundaries of life, the second has to do with the importance of being recognised, of ‘being allowed to exist’, which is worked out in certain psychological and theological theories (BoszormenyiNagy, 2000; Erikson, 1997; Laing, 1969; Tillich, 1977, 89–113). Finally, our study reveals that spiritual caregivers’ conception of quality care centres mainly on their own attitude of compassion and symmetry towards patients and is not much concerned with organisational aspects and preconditions at the meso level of the institution. Present-day health care is characterised, not only by growing proceduralisation and protocolisation coupled with statutory protection of patients’ right to self-determination, but also by enormous advances in medical science. We found that spiritual caregivers are doubtful about medicalisation in health care encroaching on the territory of worldviews. In other words, they do not believe that there is any medical compliance in the sense that patients look to the medical profession as the bringer of ‘salvation and healing’. But what is their general attitude towards advances in medical sciences and the repercussions of these for their profession? The question calls for further research, for instance to determine in how far spiritual caregivers’ attitudes towards medicine are prompted by the present 1

41% of the respondents indicate that illness features commonly in interviews; 33% cite the theme of bereavement in relationships, 30% the theme of radical events from the past, 27% the theme of being alone/loneliness, 26% cite suﬀering, and 23% relations with friends, a partner, parents, family and the meaning and value of life. In the case of death, 20% indicate that it is a frequent theme in interviews.

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situation in medical science, by a particular image of medicine in the past, or by concern about future developments in this ﬁeld. Some light is shed on the question by a questionnaire item (not discussed elsewhere in this book) about developments in health care. In their responses 63% of the spiritual caregivers indicate that developments in medical science have both a negative and a positive inﬂuence on spiritual care; 27% indicate that the inﬂuence is positive; and 9% feel that they will make spiritual care more or less redundant. Further research can help to diﬀerentiate these ﬁndings and clarify the relation to medical science, which is crucial to the future of spiritual care. After all, good cooperation between medicine and spiritual care is essential (Goudswaard, 1998; Rebel, 1998).

APPENDIX 1 RESEARCH POPULATION Personal characteristics Gender

Frequency

Percent

Female Man

218 326

40.1 59.9

Total

545

100%

Age: year of birth

Frequency

Percent

Geboren vóór 1940 1940–1944 1945–1949 1950–1954 1955–1959 1960 en daarna

63 112 132 103 84 50

11.6 20.6 24.2 18.9 15.4 9.2

Total

544

100

Educational qualiﬁcation College level (HBO) – Humanistic Training Institute (HOI) – HBO Theology 2nd grade1 – HBO Theology 1st grade – Another college qualiﬁcation

Frequency

Percent of responses

22

3.4

53 48 67

8.1 7.3 10.2

University level (WO) – Humanistic studies (UvH) – Theology – Religious studies – Another WO qualiﬁcation

9 397 12 46

1.4 60.7 1.8 7.0

Total

654

100

1 Training at college level (Hoger Beroeps Onderwijs, HBO) is divided into two levels: bachelor’s (2nd grade) and master’s (1st grade).

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Professional association No Association of Spiritual Caregivers (VGVZ) Association of Pastoral Workers (VPW) Union of Dutch Clergy (BNP) Albert Camus Association of Spiritual Workers (VGW) Association of Spiritual Caregivers tot the Aged (VGVO) Another professional association, namely

Frequency

Percent of responses

82 396

11.5 55.6

115

16.2

67 11

9.4 1.5

20

2.8

21

2.9

712

100

Frequency

Percent

Roman Catholic Dutch Reformed Reformed Other Christian denomination Humanistic association Judaic Islamic Hindu Other association, namely No world view association

233 122 119 26 30 2 1 0 9 9

42.3 22.1 21.6 4.7 5.4 0.4 0.2 0 1.6 1.6

Total

551

100

Frequency

Percent

Total

World view association

Oﬃce in a world view association No Humanistic counsellor Church worker for a Protestant denomination Pastor of a Protestant church Pastoral worker in the Roman Catholic Church Priest in the Roman Catholic Church Another oﬃce, namely (rabbi, pundit, imam . . .)

83 27 26

15.4 5.0 4.8

186 131

34.5 24.3

65 21

12.1 3.9

Total

539

100

research population Ministerial approval

231

Frequency

Percent

No Yes

134 406

24.8 75.2

Total

540

100

Institutional characteristics Health care institution

Frequency

Percent of responses

General hospital Academic hospital Psychiatric hospital Rehabilitation centre Nursing home House for the elderly Facility for mentally handicapped people

168 27 65 13 220 49 44

28.7 4.6 11.1 2.2 37.5 8.4 7.5

Total

586

100

APPENDIX 2 MEASURING INSTRUMENTS Range of all scales: 1–5. Possible answers: 1 = totally inapplicable, 2 = inapplicable, 3 = half applicable, half not, 4= applicable, 5= highly applicable. Or: 1 = totally disagree, 2 = disagree, 3 = partly agree, partly disagree, 4 = agree, 5 = totally agree. Or: 1 = totally unimportant, 2 = unimportant, 3= neither important nor unimportant, 4 = important, 5 = very important. Measuring instruments of chapter 2 Instrument 1. Attitudes towards quality assurance at meso level We would like to have your opinion on the following statements about care, health and health care. a. The fact that ‘spiritual caregiver’ has not yet been included in the BIG act will impact negatively on the future of the profession. b. Forming opinions on worldviews is essential for working with care protocols. c. Increased regulation is essential for good care. d. I consider it regrettable that my profession has not yet been included in the Individual Health Care Professionals Act. e. Eﬀorts should be made to have the spiritual caregiver profession included in the Individual Health Care Professionals Act. f. In institutions procedures are so focal that care is jeopardised. g. Unless procedures are based on a worldview they do not guarantee proper patient care. h. The provision of care is impeded by the bureaucratic organisation of care institutions. i. If one works according to care protocols discussion of themes relating to worldview are redundant. Instrument 2. Attitudes towards quality assurance at micro level We would like to have your opinion on the following statements about care, health and health care. a. Care should be wholly oriented to the patient’s wishes. b. Patients lose their autonomy in complex care organisations.

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c. I am a strong proponent of what is known as demand driven care. d. Patients’ autonomy is often underrated. e. Patients should be treated as ‘customers’ according to principles of supply and demand. f. Caregivers overtax patients with demands to make autonomous decisions. (–)*2 g. Confrontation with evil aﬀects me profoundly. h. Caregivers can learn a lot from their patients’ experience of life. i. Confrontation with aﬄiction in a care institution evokes fundamental compassion. j. The deepest response to other people’s suﬀering is empathy. k. Patients can give the caregiver a great deal through their personal assimilation of aﬄiction. l. There is no way of compensating for the inequality in vital capacity between caregiver and patient. (–)* Measuring instruments of chapter 3 Instrument 3. Attitudes towards medicalisation and contingency We would like to have your opinion on the following statements about care, health and health care. a. Patients ascribe superhuman qualities to the medical profession. b. Patients are totally preoccupied with their own bodies. c. The fact that our existence culminates in death is essential in our concern for our fellow beings. d. As a rule patients attach most value to physical well-being. e. People ﬁx their hopes mainly on doctors. f. Death as the ultimate future of life is the basis of ‘showing concern for’. g. To patients health is everything. h. When it comes to the ﬁnitude of life patients rely entirely on medical intervention.* i. Our care for others relates to our mortality.

2 Items marked with a * have been eliminated because of statistical reasons, mentioned in 1.3.2.

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Instrument 4. Attitudes towards intrinsic and extrinsic functions of worldviews In my view health care should allow for the patiënt’s worldview because even in the context of illness, suﬀering and death . . . a. The experience of a Supreme Reality (e.g. God) is a major goal. b. Reﬂection in terms of a worldview (e.g. prayer) is helpful or comforting. c. Life should respond to what a Supreme Reality requires of people (e.g. the will of God). d. People’s worldview gives them support and peace of mind. e. Belief based on a worldview provides support and gives direction to life. f. It is important to live in accordance with one’s worldview.* g. People are in distress and that is when a worldview is particularly important. The following questions pertain to your personal notions about worldview: h. The experience of a Supreme Reality (e.g. God) is a major goal in my life. i. I feel that my life must comply with what a Supreme Reality (e.g. the will of God) demands of me. j. The main purpose of reﬂection in terms of worldview (e.g. prayer) is to obtain help or comfort. k. My worldview, more than anything else, gives me support and direction in life.* l. Worldview is particularly important to me when I am worried or in trouble. m. I consider it important to live in accordance with my worldview. n. The main thing about my worldview is that I derive support and peace of mind from it. Measuring instruments of chapter 4 Instrument 5. Attitudes towards personal identity We would like to have your opinion on the following statements relating to your perception of humankind. a. Personal judgments are always tentative. b. Whatever challenges I face become clear when I describe my life to others. c. There is something unique about me that is not reducible to other people’s lives.

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d. I have to undergo many things in life. e. Statements about myself are always assailable, I must be able to reconsider them. f. Suﬀering is an essential part of my life. g. People diﬀer in respect of a few general features, but there is no such things as genuine individuality. (–) h. Talking about the course of my life clariﬁes my essential self. i. My identity, that which sets me apart from others, is constantly evolving.* j. My existence also has a passive, pathic side.* k. Unfolding my life in conversation with others helps greatly to make me aware of my identity. l. I might say, ‘that’s the kind of person I am’, but such statements are always fragile. Instrument 6. Attitudes towards worldview-related culture The following questions pertain to your personal notions about worldview. a. In the end you, as a spiritual caregiver, have to fall back on the tradition of your own worldview. b. I learn a lot from other worldviews and religions. c. When it comes to worldview you are completely thrown back on yourself. (–)* d. Dealing with other worldviews gives me more insight into my own tradition. e. I recognise elements of my own worldview in other traditions. f. Only by discussing my beliefs with others can I discover their meaning. g. The leadership of my worldview association are perfectly equal to their task. h. Drawing strength from one’s own tradition is of fundamental signiﬁcance. i. The way I relate to religious and other themes depends greatly on what others tell me about them.* j. It is extremely important to be grounded in a worldview of one’s own. k. Only in conversations with other people do I discover what the tradition based on my worldview entails. l. When it comes to my worldview, I am greatly supported by my worldview association.

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Instrument 7. Attitudes towards the existence of an ultimate reality According to my belief or thinking . . . a. The divine is nothing but the valuable in humankind. b. There is something like a supreme being who controls life c. It is purely accidental that human life developed on earth. d. Life is merely an evolutionary process. e. There is a God, who wants to be our God. f. The deity is not above us, he only exists in our hearts g. There is a God who concerns himself with every individual personally. h. Our lives are determined only by the laws of nature. i. There is a supreme being. j. There is no God.* Instrument 8. Attitudes towards God and suﬀering What is your opinion about the following statements? (Humanistic spiritual caregivers may want to skip this question.) a. God comforts those who suﬀer.* b. God calls suﬀerers to learn from their suﬀering. c. God inspires people to learn from suﬀering. d. Through suﬀering one draws close to God. e. Suﬀering happens according to God’s purpose for human beings. f. God is unmoved by suﬀering. g. God gives us strength to become better people through suﬀering.* h. Through suﬀering God stimulates us to serve others. i. God permits suﬀering as a punishment for evil. j. God is full of compassion for suﬀerers. k. Suﬀering puts humans in direct contact with God. l. Suﬀering is part of God’s plan. m. In suﬀering we become one with God. n. Suﬀering is a punishment from God. o. God suﬀers with those who suﬀer. p. God gives us strength to help others through our suﬀering. q. God calls us to make our suﬀering a sacriﬁce for others. r. God is impervious to suﬀering. s. Suﬀering is God’s retaliation for evil. t. When suﬀering happens God is not aﬀected by it. u. Suﬀering has a place in God’s purpose.

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Instrument 9. Attitudes towards the meaning of death In how far do you agree with the following statements about the meaning of death in terms of religion/worldview? a. Death is part of life, there is nothing problematical about that. b. Death has no meaning without life.* c. It is impossible to say what happens after death. d. Death is the passage to another life. e. Death is part of the natural order. f. In death God holds on to me. g. All creatures return to earth after death. h. One can say nothing about death. i. After death one return to earth in a diﬀerent form. j. God abandons human beings in death. (–)* k. Death cannot possibly be ﬁnal. l. In death one meets God face to face. m. I believe that people are reincarnated. n. Death is a passage to another existence, whatever that may be. o. Nobody really understands the meaning of death. Instrument 10. Attitudes towards rituals and worldviews The following questions again pertain to your personal notions about worldview. a. Rituals are the most vital element of a religion. b. Extreme unction (or some other ritual) can reconcile a person with the inevitable.* c. Rituals are of secondary importance for the essence of a religion. (–) d. When there is nothing more to be done about aﬄiction, one can still resort to ritual communication. e. A religion manifests itself most clearly in rituals.* f. When death is unavoidable extreme unction (or some other ritual) is a last response. Measuring instruments of chapter 5 Instrument 11. Attitudes towards legitimacy of spiritual care In the legitimation of spiritual care (in my care institution) I rate . . . a. My persuasive powers regarding the importance of worldview in the care institution. b. Patient demand for spiritual care in care institutions.

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c. Involvement at a national level of worldview associations in the provision of spiritual care. d. My theoretical basis for patients’ need for spiritual care. e. Statutory guarantee by a future Spiritual Care Act. f. Institutional boards speaking out in favour of spiritual care. g. Heeding patients’ requests for guidance in worldview-related problems. h. The full recognition that spiritual care is accorded in institutional policy documents. i. Statutory guarantee in terms of the Dutch Quality Institutions Act, which stipulates that if a person is admitted to a care institution for longer than 24 hours, spiritual care must be provided. j. Eﬀorts by worldview associations in my region to promote spiritual care. k. Legal guarantee of spiritual care in terms of section 6 of the Constitution, which proclaims freedom of religion and worldview. l. Advocacy of spiritual care by boards of care institutions in discussions with other disciplines. m. My focus on worldview-related themes when providing care. n. The attention devoted to spiritual care by worldview associations in their policy documents. o. The spiritual needs of patients in care institutions Instrument 12. Attitudes towards position of spiritual care Please indicate to what extent the following statements apply to your cooperation with other disciplines in the care institution. We are thinking mainly of such disciplines as social work, psychology, remedial education, nursing . . . a. In the interest of optimal patient care spiritual caregivers should cooperate closely with other caregivers. b. Spiritual caregivers should position themselves quite separately from social workers, psychologists and remedial educationists. c. Spiritual care should make a distinctive contribution to interdisciplinary consultation. d. Spiritual care should maintain total exclusiveness in relation to nursing. e. Spiritual care has its own distinctive goal, to such an extent that there can be no cooperation whatsoever with other disciplines. f. In discussions about the care of patients receiving spiritual care, the latter form of care should be closely implicated.

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Instrument 13. Attitudes towards ministry and sanctuary of spiritual care Notions about the spiritual caregiver’s ministry vary. In this context the term ‘ministry’ means a relationship with a worldview association which, partly on grounds of training, confers a mission to provide spiritual care (hence not to be confused with, e.g., the ministry of elders and deacons in the Protestant tradition). Please indicate in how far you agree with the following statements. a. From my own experience in the ﬁeld of worldview I assign the ministry a positive meaning. b. The fact that the person exercising the ministry represents a speciﬁc organisation is a positive factor in dealing with patients with the same worldview aﬃliation. c. Spiritual caregivers’ position as minister isolates them from other workers in the care institution. d. The sanctuary associated with the ministry oﬀers more advantages than disadvantages for the provision of spiritual care. e. The ministry gives the spiritual caregiver a symbolic function, in that it refers to a particular worldview association. f. Despite ‘de-pillarisation’ the oﬃcial connection with a particular worldview association remains highly meaningful. g. For most of the spiritual caregiver’s tasks ministerial approval is redundant. h. By virtue of their ministry spiritual caregivers do not function in a purely personal capacity.* i. Their sanctuary optimally distances spiritual caregivers from institutional policy. j. At present the ministry has great personal value for me. k. As a result of pluralism and individualisation in the ﬁeld of worldviews the ministry of spiritual care has lost its importance. l. Talking about worldview is easier when patient and minister come from the same worldview tradition. m. A sanctuary is inalienably part of spiritual care. n. Their ministry enables spiritual caregivers to fall back on their own organisation.* o. When the spiritual caregiver has the same aﬃliation as the patient it facilitates discussion of worldview-related themes. p. The ministry is only important when it comes to the performance of ritual tasks. q. The ministry makes me feel committed to my tradition. r. In a secularised society the ministry of spiritual caregivers in care institutions has hardly any meaning any more.

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s. Ministerial approval creates clarity in conversations with patients. (–) t. An oﬃcial connection with a worldview association reduces the inﬂuence of spiritual care on institutional policy. u. Emphasis on the ministry entails the risk that spiritual care will end up in a marginal position in the care institution. Instrument 14. Attitudes towards categorical and territorial spiritual care The following statements pertain to your views on ecumenical and inter-worldview cooperation between spiritual caregivers. a. Diﬀerences in background between non-Christian and Christian spiritual caregivers make dialogue impossible. (–)* b. I am a proponent of organising spiritual care categorically, that is classifying and allocating patients according to worldview. c. Categorical organisation complicates the integration of spiritual care with multidisciplinary care in a section. (–) d. A Christian spiritual caregiver can guide patients from a nonChristian background. e. Spiritual caregivers can guide patients holding diverse religious and nonreligious worldviews. f. Diﬀerences in background between Christian spiritual caregivers and patients with other beliefs are a major impediment to dialogue. (–) g. Organising spiritual care territorially, that is dividing departments between spiritual caregivers, promotes integration of spiritual care in that just one spiritual caregiver is associated with each hospital department. h. I am a proponent of territorial organisation of spiritual care. i. Categorical organisation of spiritual care, that is classiﬁcation according to worldview, facilitates dialogue on topics relating to worldview because spiritual caregiver and patient come from the same background. j. Cooperation between non-Christian and Christian spiritual caregivers is essential. k. Territorial organisation of spiritual care complicates conversation on topics relating to worldview, because the spiritual caregiver is confronted with opinions from diﬀerent worldviews. (–)* l. What is needed is openness between non-Christian and Christian spiritual caregivers.

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Measuring instruments of chapter 6 Instrument 15. Attitudes towards goals of spiritual care at micro level How important do you consider the following goals of spiritual care in your dealings with patients (dialogue, ritual . . .)? The point is not so much whether the goals are attained in your praxis as what you consider to be ‘ideal’. In my dealings with patients I consider the goal of . . . a. Ritual expression of their worldview (e.g. prayer). b. Exploring what their key relationships (partner, children, parents . . .) mean to them. c. Examining possible conﬂicts with others about their outlook on life. d. Reviewing their past at a moral level (e.g. guilt problems). e. Exploring possible answers to their questions about meaning. f. Stimulating discussion with those around them on issues relating to worldview. g. Mobilising their spiritual resources. h. Discussing their feelings of happiness and unhappiness.* i. Inviting them to join in rituals in the care institution. j. Oﬀering support with their health problems (e.g. dealing with aging, being handicapped, being sick).* k. Discussing moral topics (e.g. limits of treatment).* l. Dealing with existential feelings. m. Reinforcing their commitment to their religion/worldview. n. Coping with their existential experience by way of rituals. o. Discussing themes relating to worldview (e.g. suﬀering and death, transcendence).* p. Guidance regarding experiences in the sphere of meaning. q. Exploring their emotions about themselves and others.* r. Focusing on their opinions in regard to worldview. s. Promoting their psychological and/or spiritual well-being. t. Exploring their personal values.* u. Contributing to their mental health. Instrument 16. Attitudes towards goals at meso level of spiritual care How important do you rate the following goals of spiritual care in your cooperation within the institution? The point is not so much whether the goals are attained in your praxis as what you consider to be ‘ideal’. In my institutional cooperation I rate the importance of the goals as follows:

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a. Stimulating reﬂection on worldview at the level of institutional policy. b. Harmonising guidance to patients with the various care disciplines.* c. Discussing the importance of worldviews in multidisciplinary cooperation. d. Deliberating with others on the care objectives of the institution. e. Bringing ethical dilemmas to the attention of fellow helpers. f. Contributing to quality of care. Instrument 17. Attitudes towards goal orientations of spiritual care How essential do you ﬁnd the following orientations of action in spiritual care? The point is not whether you actually manage to realise a particular orientation but how important you consider that orientation to be for good spiritual care. a. Demonstrating the strength of my own worldview in my dealings with patients. b. Referring patients to the tradition of my own worldview. c. Challenging patients to take charge of their own lives. d. Witnessing to my own belief in my behaviour as a spiritual caregiver. e. Searching with patients for possible sources of comfort. f. Allowing scope for patients’ inner experience. g. Introducing patients to the worthwhile things in my worldview. h. Homing in on patients’ accounts of their worldviews. i. Showing what inspires me in life when I interact with patients. j. Examining with patients what they can fall back on when they encounter problems. k. Calling on patients’ to take personal responsibility. l. Oﬀering patients support in their troubles. m. Listening to patients’ concerns. n. Confronting patients with things that they may ﬁnd discomﬁting.* o. Presenting my own norms and values. Instrument 18. Attitudes towards aspects of counselling We would like to know your opinion about the following dealings with patients. a. I must try and understand what patients tell me worldview. b. My primary task is to focus on the question: patient expect from me and what can I oﬀer?’ c. I should also take the initiative in approaching

statements on your in terms of their ‘What does the patients.

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d. I consider it important to determine what help the patient is asking for. e. In listening to the patient’s story I must suspend my own humanistic or theological frame of reference. f. I should regard my relationship with the patient as a type of friendship. g. I ought to wait until the patient appeals to me. (–) h. I should interpret what the patient tells me in terms of my knowledge of trends in the sphere of worldview.* i. It is very important for spiritual caregivers to visit patients on their own initiative. Instrument 19. Attitudes towards aspects of rituals How important a part of your ritual task do you consider the following aspects of rituals to be? Each statement refers to what happens to patients during/as a result of the ritual. a. Expressing communion with others. b. Stimulating moral consciousness. c. Embodying personal experience of the meaning of life.* d. Experience of being incorporated into a larger social whole. e. Penetrating to the existential layer within oneself. f. Reﬂecting on personal religious and existential belief. g. Fostering sense of good and evil. h. Confessing one’s belief. i. Experience of union with the ground of existence (the transcendent, nature). j. Expression of deep emotions, images. k. Being addressed by words, music, symbols.* l. Dwelling on religious or philosophical ideas. m. Expressing a personal worldview.* n. Developing values. o. Fostering solidarity with fellow human beings. Instrument 20. Attitudes towards aspects of supra-disciplinary consultation at meso level To what extent do you agree with the following statements about your contact with other caregivers? a. The board has an excellent picture of spiritual care. b. There is a gulf between empirical, medical communication and communication of spiritual caregivers.

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c. Other caregivers underrate spiritual care. d. There are conﬂicts with fellow caregivers about each one’s competence. e. Management is very critical of spiritual care. (–)* f. There is no diﬀerence between the way spiritual caregivers and other caregivers talk about their work. (–)* g. There are discussions with other caregivers about the demarcation of their respective areas of operation. h. Institutional policy oﬀers little support for spiritual care. (–) i. Fellow caregivers have a biased view of spiritual care. j. There are hardly any clashes about work with other disciplines. (–) k. There is a great deal of ignorance about spiritual care among other disciplines. l. Other disciplines are always talking about technical activities, achievements and results, whereas spiritual care cannot be understood in these terms.*

APPENDIX 3 TABLES Tables of chapter 2 Table 1 Aspects of quality assurance at meso level: factor analysis Items d e a f h b g c i

communality

factor 1

factor 2

factor 3

factor 4

.81 .73 .71 .47 .44 .51 .32 .30 .22

.87 .84 .82 .10 .09 .11 .09 .10 .07

.12 .06 .04 .61 .59 .02 .20 –.19 –.03

.08 .11 .09 .09 .18 .69 .52 .14 –.10

.12 .09 .03 –.10 –.11 –.07 .03 .45 .45

rotation varimax total r2 = 44.4%

registration

a .903

danger of bureaucratisation

reﬂection on proceduracare stanlisation & dardisation protocolisation

r .464

r .36

r .25

Table 2 Aspects of quality assurance at micro level: factor analysis Items k h c e a d b i g j

communality .63 .34 .46 .24 .18 .55 .37 .39 .25 .16

3 4

factor 1 .83 .45 .01 .01 –.01 –.01 –.01 .11 –.07 .11

factor 2

factor 3

factor 4

.02 .00 .67 .49 .41 .03 –.01 –.03 .03 –.02

.06 –.08 –.01 .04 –.05 –.75 –.61 .00 .03 –.09

–.06 .18 .02 –.05 .04 –.05 .02 .57 .54 .29

a: Crohnbach’s reliability coeﬃcient. r: Pearson’s product-moment correlation coeﬃcient.

appendix three

246 Table 2 (cont.) Items

communality

rotation oblimin total r2 = 36%

factor 1 symmetry

r .43

factor 2 demanddriven approach

factor 3

factor 4

loss of self- compassion determination

a .52

a .49

r .45

Correlation between factors: 2 3 4

1

2

3

.04 –.18 .47

–.18 .04

–.34

Tables of chapter 3 Table 3 Medicalisation and the limits of contingency: factor analysis Items d b g e a i f c

communality

factor 1

factor 2

.44 .43 .37 .33 .16 .63 .44 .34

.66 .65 .61 .57 .39 .04 .10 .07

.03 .04 .03 .09 .09 .79 .66 .57

rotation varimax total r2 = 39%

medicalisation mortality in health care a .72

a .71

Table 4 Medicalisation and the limits of contingency: social location5 Scale

social location category

Medicalisation Medicalisation Mortality in health care

General hospital Psychiatric institution Roman Catholic

mean category

other

sign.

eta

3.26 2.79 3.21

3.00 3.12 2.98

.00 .00 .00

.22 .20 .15

5 We applied two criteria: a signiﬁcance criterion of p ) 0.05 and, in view of the exploratory nature of the study, a rather low relevance criterion of eta * 0.15.

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Table 5 Intrinsic and extrinsic function of worldviews: factor analysis 5a Items

From the spiritual caregiver’s perspective communality

factor 1

factor 2

.59 .44 .38 .42 .31 .12

.78 .66 .61 .02 .06 –.04

–.06 .04 .02 .64 .54 .35

intrinsic

extrinsic

i h m n j l rotation oblimin total r2 = 38%

a .72

a .52

Correlation between factors: .22 5b Items

From the patient’s perspective

communality

d e g b a c

.62 .51 .21 .32 .67 .29

rotation oblimin total r2 = 44%

factor 1

factor 2

.81 .74 .43 .42 –.04 .02

–.09 –.10 .08 .27 .83 .53

extrinsic

intrinsic

a .69

r .44

Correlation between factors: .33 Table 6 Intrinsic and extrinsic function of worldviews: social location Scale Intrinsic Intrinsic Intrinsic Intrinsic Intrinsic

social location category sp. sp. sp. sp. sp.

caregiver caregiver caregiver caregiver caregiver

HOI 6 UvH Humanistisch Verbond Humanistic counsellor No professional association

mean category 2.44 2.59 2.50 2.44 3.77

other sign. eta 3.53 3.50 3.54 3.54 3.43

.00 .00 .00 .00 .00

.30 .16 .34 .34 .17

6 For the meaning of the Dutch terms and abbreviations: see ‘list of abbreviations’ and appendix 1.

appendix three

248 Table 6 (cont.) Scale Intrinsic Intrinsic Intrinsic Intrinsic Intrinsic Intrinsic Intrinsic Intrinsic

sp. caregiver sp. caregiver patients patients patients patients patients patients

social location category

mean other category

sign. eta

VGVZ-member Psychiatric institution Gender HOI UvH Humanistisch Verbond Humanistic counsellor VGVZ-member

3.41 3.15 F: 2.79 2.27 2.11 2.22 2.22 2.92

.00 .00 .00 .00 .00 .00 .00 .00

3.68 3.53 M: 3.14 3.03 3.01 3.05 3.04 3.20

.16 .17 .21 .19 .14 .24 .22 .15

Tables of chapter 4 Table 7 Narrative identity: factor analysis Items h k b a e l g (–) c f d

communality factor 1 .37 .37 .34 .23 .30 .14 .27 .13 .20 .20

rotation oblimin total r2 = 42%

factor 2

.74 .72 .65 –.06 .07 .11 –.09 .15 .06 –.06

.11 –.01 –.11 –.80 –.49 –.36 .01 –.12 .07 .01

factor 3

factor 4

.05 –.03 –.02 –.01 .04 –.10 .53 –.38 –.07 .08

–.04 .01 .01 –.08 .24 .09 .00 .01 .66 .56

narrativity attestation uniqueness passivity a .75

a .59

r .24

Correlation between factors: 2 3 4

1

2

3

.04 –.17 .43

–.11 .39

–.09

r .37

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249

Table 8 Narrative identity: social location Scale

social location category

mean category

Uniqueness Uniqueness

Theology Academic towards college education No denominational oﬃce

3.87 3.60 .00 Ac: 3.86 Col: 3.54 .00

.18 .18

3.55

.16

Uniqueness

other

3.85

sign. eta

.00

Table 9 Worldview-related culture: factor analysis Items

communality factor 1

d b e h a j f k g l

.63 .51 .32 .64 .30 .27 .74 .38 .53 .55

rotation varimax total r2 = 49%

.78 .71 .53 –.02 –.13 .07 .07 .07 –.03 –.06

factor 2 .07 .00 –.12 .79 .52 .49 –.03 .09 .01 .21

factor 3

factor 4

.11 .06 –.00 .09 .10 –.09 .86 .60 –.06 –.03

.03 .01 –.13 .07 .03 .11 –.06 –.03 .73 .71

multiple worldview collective worldview worldview tradition worldview institution a .71

a .61

r .53

r .52

Table 10 Worldview-related culture: social location Scale

social location category

Institution Institution Institution Institution Institution

Roman Catholic Nederlands Hervormd Gereformeerd Protestant minister Pastoral worker in Catholic Church VPW-member No worldview association

Institution Tradition

mean category

other

sign. eta

2.26 2.84 2.84 2.82 2.15

2.83 2.50 2.50 2.45 2.71

.00 .00 .00 .00 .00

.37 .18 .18 .23 .31

2.28 3.00

2.66 3.82

.00 .00

.20 .19

appendix three

250

Table 11 Ultimate reality: factor analysis Items i b e g a f d h c

communality

factor 1

factor 2

factor 3

.62 .48 .68 .53 .63 .46 .71 .44 .53

–.79 –.73 –.70 –.69 .00 –.00 –.09 .09 .22

.06 .05 –.11 –.10 .82 .62 –.01 .04 .07

–.04 .03 –.09 .02 –.05 .08 .91 .57 .52

rotation oblimin total r2 = 57%

religious immanentist atheistic interpretation interpretation interpretation a .84 r .54 a .77

Correlation between factors: 2 3

1

2

.50 .60

.66

Table 12 Ultimate reality: social location Scale

social location category

Religious respondents Immanentism Theology Immanentism Academic towards college education Immanentism Gereformeerd Immanentism Protestant minister Immanentism BNP-member Atheism Nederlands Hervormd Atheism Protestant minister Atheism BNP-member Humanistic respondents Religious UvH towards HOI interpretation

mean category

other

sign eta

2.27 2.58 .00 .16 Ac: 2.29 Col: 2.63 .00 .15 2.10 2.14 2.05 1.73 1.84 1.72

2.49 2.55 2.46 2.11 2.12 2.07

.00 .00 .00 .00 .00 .00

.19 .22 .16 .21 .18 .16

UvH:2.17 HOI:1.53 .03 .40

2 3 4 5 6 7

Correlation between factors:

.51 .42 .60 .62 .46 .33 .74 .72 .61 .71 .64 .59 .64 .40 .49 .40 .34 .45 .93

communality

rotation oblimin total r2 = 55%

p q h t r f n s i o j l e u k m d c b

Items

–.03 –.25 .01 .42 –.45 .50

1

substitution a .70

.63 .54 .42 –.03 –.04 .03 –.02 .00 .01 .05 –.06 .02 .11 –.03 .01 .12 –.01 .05 .08

factor 1

.25 .48 –.02 –.02 .08

2

apathy a .70

.09 –.07 .05 –.86 –.61 –.47 –.02 –.01 .01 –.00 .13 .01 –.03 .02 –.01 –.12 .07 –.01 –.02

factor 2

3

.20 –.44 .07 –.22

retribution a .85

.03 –.10 .01 .00 –.07 .03 –.83 –.83 –.76 .06 –.00 –.10 –.01 .01 –.08 –.01 .07 –.01 –.07

factor 3

solidarity r .66

.08 –.01 –.11 .09 –.10 –.13 .00 .05 –.09 .86 .67 .04 –.04 .04 .08 .02 –.06 .04 .03

factor 4

Table 13 Suﬀering: factor analysis

–.07 –.20 .07

4

plan a .76

–.04 .14 .15 –.06 –.05 .12 .07 .01 –.01 .02 .06 .78 .71 .58 –.04 .05 .13 –.03 .05

factor 5

–.35 .55

5

mystic a .63

–.16 .06 –.11 –.01 –.01 –.03 .00 .00 –.04 .03 –.10 .04 .00 –.08 –.63 –.51 –.51 –.02 .02

factor 6

–.44

6

development r .58

.05 .11 .16 .00 .05 –.02 –.00 –.00 .06 –.02 .11 –.07 .04 .06 –.10 .05 .20 .76 .67

factor 7

tables 251

appendix three

252

Table 14 Suﬀering: social location Scale

social location category

mean category

other

sign. eta

Religious respondents Apathy Roman Catholic Apathy Protestant minister Substitution Gender

1.79 1.47 F: 2.31

1.57 1.77 M: 2.58

.00 .16 .00 .21 .00 .19

Humanistic respondents Solidarity HOI towards UvH

HOI:2.33 UvH:2.50 .00 .15

Table 15 Death: factor analysis Items d l k f n g i m e a o c h rotation varimax total r2 = 51%

communality factor 1 .66 .55 .49 .50 .40 .72 .67 .54 .66 .40 .41 .47 .20

.77 .71 .69 .68 .58 .08 –.01 –.07 .01 –.05 –.12 –.35 –.01

factor 2 .11 –.10 –.02 –.11 .14 .84 .81 .73 –.02 –.04 .01 –.12 .09

factor 3

factor 4

.05 –.17 –.05 –.11 .20 –.04 –.08 .03 .81 .62 .21 .27 –.05

–.23 –.08 –.09 –.08 .05 .05 .02 .03 .12 .07 .59 .52 .44

christian

reincarnation

immanentism

agnosticism

a .81

a .84

r .54

a .54

social location category mean category

other

sign. eta

Theology Roman Catholic Nederlands Hervormd Protestant church workers

3.55 3.91 4.15 4.10

.00 .00 .00 .00

Table 16 Death: social location Scale Religious respondents Christian Immanentism Immanentism Immanentism

Humanistic respondents Christian UvH versus HOI

3.87 4.26 3.76 3.35

.21 .24 .22 .22

Uv H:2.69 HOI:1.97 .01 .48

tables

253

Table 17 Rituals and worldviews: factor analysis Items

communality

factor 1

factor 2

c (–) a d f

.44 .48 .40 .39

–.69 .59 –.06 .14

.06 .16 .66 .54

rituals in general r .44

rites of passage r .38

rotation oblimin total r2 = 43%

Correlation between factors: .53 Table 18 Rituals and worldviews: social location Scale Humanistic respondents Rites of passage

social location category

mean category

other

sign

eta

Humanistic counsellor

2.33

3.18

.00

.25

Tables of chapter 5 Table 19 Legitimacy of spiritual care: factor analysis Items communality e i k g o b m a d f l h n j c rotation oblimin total r2 = 48%

.53 .77 .50 .53 .42 .26 .52 .33 .33 .61 .53 .34 .66 .51 .41

factor 1

factor 2

factor 3

factor 4

factor 5

.84 .57 .49 .00 .00 .00 .00 .00 .11 .00 .00 .21 .00 .00 .00

.00 .00 .00 .69 .62 .51 .19 .00 .00 .00 .00 .00 .00 .00 .00

.00 .00 .00 .00 .00 .00 .65 .58 .54 .00 .00 .00 .14 .00 .00

.00 .20 .00 .00 .00 .00 .00 .00 .00 .75 .52 .41 .00 .00 .10

.00 .00 –.33 .00 .00 .00 .00 .00 .00 .00 .26 .00 –.73 –.67 –.58

statutory patientrelated

a .77

a .62

domainrelated

a .61

institu- denomitional nationcare related approachrelated a .71

a .76

appendix three

254 Correlation between factors:

2 3 4 5

1

2

3

4

.23 .23 .49 –.53

.11 .21 –.23

.33 –.36

–.39

Table 20 Legitimacy of spiritual care: social location Scale

social location category

mean category

other

sign

eta

Statutory Denomination

Gender Psychiatric institution

F: 4.18 3.08

M: 3.93 .00 3.53 .00

.16 .19

Table 21 Position of spiritual care: factor analysis Items

communality

a f c b d e rotation oblimin total r2 = 36%

.55 .35 .33 .49 .19 .24

factor 1

factor 2

.72 .61 .52 –.14 .09 –.13 integration a .65

–.06 .09 –.12 .63 .46 .43 isolation a .53

Correlation between factors: –.37. Table 22 Position of spiritual care: social location Scale

social location category

mean category

other

sign

eta

Integration Integration

Psychiatric institution Nursing home

3.64 4.15

4.08 3.94

.00 .00

.24 .17

.52 .53 .45 .45 .34 .72 .61 .66 .56 .32 .61 .43 .26 .41 .66 .44 .78 .67 .46

2 3 4 5 6

–.15 .35 –.50 .41 .59

1

communality

Correlation between factors:

rotation oblimin total r2 = 52%

g k p r s o l d m i t u c e f b j a q

Items

a .79

limited signiﬁcance

–.71 –.60 –.58 –.56 .41 –.00 .00 –.00 .00 .00 –.15 –.23 .00 –.00 .20 .00 .28 .00 .19

factor 1

.18 –.05 .36 .17

2

r .67

facilitation of dialogue

.00 .00 –.12 .00 .00 .82 .79 –.00 .11 –.00 –.00 –.00 –.00 .00 –.00 .23 .00 .00 .00

factor 2

a .73

–.10 .28 .14

3

exemption from accountability

.00 –.00 –.00 –.00 .00 .00 –.00 .79 .73 .55 –.00 –.00 .00 .00 –.00 .00 .00 .00 .00

factor 3

a .64

marginal position

.00 .00 .00 .00 .00 –.00 .00 –.16 .00 .00 .72 .48 .46 –.00 –.15 –.00 .00 –.16 .00

factor 4

Table 23 Ministry and sanctuary of spiritual care: factor analysis

–.24 –.38

4

a .68

denominational representation

–.00 .00 .00 .00 .17 .00 –.00 .00 –.00 .00 –.00 –.13 .00 .65 .49 .42 –.00 .11 .18

factor 5

.41

5

a .82

personal value of ministry

.00 –.16 –.00 –.00 .00 .00 –.00 .00 .00 –.00 .12 .00 –.16 –.00 .24 .13 .67 .65 .46

factor 6

tables 255

appendix three

256

Table 24 Ministry and sanctuary of spiritual care: social location Scale

social location category

mean category

other

sign

eta

Facilitation of dialogue Denominational representation Denominational representation Denominational representation Denominational representation Denominational representation Denominational representation Denominational representation Denominational representation Personal value of ministry Personal value of ministry

Gereformeerd Theology

2.69 3.71

3.02 3.42

.00 .00

.16 .17

Academic towards college education No denomination

Ac: 3.69

Col: 3.40 .00

.15

2.48

3.66

.00

.20

No oﬃce

3.10

3.73

.00

.31

Ministerial approval VGVZ-member

3.76

3.23

.00

.31

3.72

3.39

.00

.20

VGW-member

2.42

3.66

.00

.24

General hospital

3.80

3.56

.00

.15

Theology Academic towards college education No denomination No oﬃce Protestant minister Priest in Catholic church Ministerial approval VGVZ-member BNP-member VGW-member Theology Academic towards college education No denomination No oﬃce Protestant minister Ministerial approval VGVZ-member VGW-member General hospital No oﬃce

3.75 Ac: 3.71

3.34 .00 Col: 3.30 .00

.20 .18

2.04 2.84 3.89 4.04

3.67 3.79 3.51 3.59

.00 .00 .00 .00

.24 .39 .21 .17

3.83 3.73 4.00 2.12 2.44 Ac: 2.46

3.00 3.38 3.59 3.68 2.74 Col: 2.77

.00 .00 .00 .00 .00 .00

.41 .18 .16 .26 .18 .16

3.84 3.15 2.34 2.36 2.44 3.40 2.35 3.13

2.50 2.41 2.62 3.02 2.74 2.50 2.60 3.51

.00 .00 .00 .00 .00 .00 .00 .00

.24 .37 .18 .39 .18 .17 .16 .17

Theology No denomination No oﬃce Protestant minister Ministerial approval VGW-member

2.35 3.54 2.93 2.23 2.32 3.54

2.67 2.42 2.34 2.54 2.80 2.41

.00 .00 .00 .00 .00 .00

.19 .19 .29 .20 .28 .22

Personal Personal Personal Personal

value value value value

of of of of

ministry ministry ministry ministry

Personal value of ministry Personal value of ministry Personal value of ministry Personal value of ministry Limited signiﬁcance Limited signiﬁcance Limited signiﬁcance Limited signiﬁcance Limited signiﬁcance Limited signiﬁcance Limited signiﬁcance Limited signiﬁcance Limited signiﬁcance Exemption from accountability Marginal position Marginal position Marginal position Marginal position Marginal position Marginal position

tables

257

Table 25 Categorical and territorial spiritual care: factor analysis 25a Items

Categorical spiritual care

communality

b c (–) i principal axis total r2 = 46%

.35 .24 .21

factor 1 .93 –.53 .49 categorical spiritual care a .66

25b

Territorial spiritual care

Items

communality

factor 1

factor 2

factor 3

e d f (–) h g l j

.48 .43 .22 .63 .62 .22 .24

.85 .79 –.44 .01 –.01 –.04 .05

.01 –.08 –.10 .91 .86 –.01 .00

–.02 –.01 –.05 –.02 .01 .72 .62

rotation oblimin total r2 = 58%

multiple worldview counselling a .73

territorial spiritual care

multiple worldview cooperation r .44

r .79

Correlation between factors:

2 3

1

2

.37 .38

.31

Table 26 Categorical and territorial spiritual care: social location Scale

social location category

mean other sign eta category

Categorical mode Categorical mode Territorial mode Territorial mode Territorial mode Territorial mode Territorial mode Territorial mode Multiple worldview patient counselling

Judaic Nursing home Judaic No professional association VGVZ-member General hospital Nursing home Old age home HOI

4.67 2.46 1.87 3.55 4.02 4.13 3.72 3.43 3.17

2.30 2.22 3.93 3.99 3.66 3.82 4.05 3.97 3.96

.00 .00 .00 .00 .00 .00 .00 .00 .00

.20 .16 .16 .20 .20 .18 .21 .20 .24

appendix three

258 Table 26 (cont.) Scale

social location category

Multiple worldview Humanistic association patient counselling Multiple worldview Humanistic counsellor patient counselling

mean other sign eta category 3.42

3.96

.00 .19

3.43

3.96

.00 .18

Tables of chapter 6 Table 27 Goals of spiritual care at micro level: factor analysis Items communality factor 1 l p e g a n i c d b s u r f m rotation oblimin total r2 = 44%

.48 .42 .32 .31 .65 .43 .38 .54 .37 .22 .73 .55 .47 .39 .41

.66 .59 .51 .47 .00 .22 –.19 .00 .15 –.00 .00 .00 .00 .00 .16

factor 2

factor 3

factor 4

factor 5

–.00 .00 –.00 .00 .83 .54 .50 –.00 .00 .14 –.00 .00 –.00 .00 .22

.00 .00 .16 –.14 .00 .00 .00 .72 .51 .40 .00 .00 .14 .26 –.12

–.11 –.11 .00 –.00 .00 –.00 –.00 –.00 .00 –.00 –.85 –.71 –.12 –.00 –.00

.12 .00 –.00 –.19 .11 –.00 –.23 –.00 –.00 .00 –.00 .00 –.59 –.48 –.47

socialhealth

mental

cognitive

a .58

r .62

a .63

4

experiential- ritual aﬀective moral a .67

a .67

Correlation between factors:

2 3 4 5

1

2

3

.17 .19 –.41 –.29

.22 –.24 –.34

–.17 –.32

.30

tables

259

Table 28 Goals of spiritual care at micro level: social location Scale

social location category

mean other sign eta category

Religious respondents Ritual Ritual Ritual Ritual Ritual Ritual Ritual Ritual

HBO theology 2nd grade No denominational oﬃce Protestant minister Denominational approval No professional association VGVZ-member General hospital Nursing home

4.01 3.96 3.59 3.70 3.97 3.67 3.62 3.88

3.73 3.71 3.85 3.90 3.71 3.95 3.82 3.67

.00 .00 .00 .00 .00 .00 .00 .00

.16 .16 .22 .16 .17 .22 .17 .18

Table 29 Goals of spiritual care at meso level: factor analysis Items e f d c a rotation oblimin total r2 = 45%

communality

factor 1

factor 2

.47 .36 .44 .62 .39

.65 .63 .62 –.00 .00 focus on care

–.00 .00 –.00 –.79 –.61 focus on worldviewrelated dimension of care r .49

a .68

Correlation between factors: –.56 Table 30 Goal orientations of spiritual care: factor analysis Items g i d b o a f l m e h j k c rotation oblimin total r2 = 46%

communality

factor 1

factor 2

factor 3

.56 .54 .52 .48 .46 .40 .48 .45 .38 .37 .36 .34 .64 .43

.74 .73 .72 .68 .68 63 –.00 .00 .00 –.00 –.00 .00 .00 .00 mission

.00 .00 .00 –.12 –.00 .00 .68 .65 .63 .60 .58 .41 .00 –.00 experience

.00 –.00 –.00 .00 .00 –.00 .00 .00 –.13 .00 .00 .27 .76 .66 challenge

a .85

a .78

r .52

appendix three

260 Correlation between factors: 2 3

1

2

.09 .13

.36

Table 31 Goal orientations of spiritual care: social location Scale

social location category

mean category

other

sign

eta

Mission Challenge

Protestant minister Church worker in protestant church

2.52 3.48

2.74 4.02

.00 .00

.15 .18

Table 32 Aspects of the counselling: factor analysis Items

communality

c g (–) i d b a f e rotation oblimin total r2 = 36%

.55 .56 .46 .30 .23 .17 .46 .18

factor 1

factor 2

factor 3

.72 –.71 .65 .00 .00 .00 .00 –.17 initiation by spiritual caregiver a .72

.19 .00 .15 .54 .46 .41 .00 .00 ‘demandsupply’ structure a .47

–.00 .24 .00 .00 .12 .00 .67 .39 ‘human fellow’ r .24

Correlation between factors:

2 3

1

2

.16 .11

–.22

Table 33 Aspects of the counselling: social location Scale Human Human Human Human Human

fellowship fellowship fellowship fellowship fellowship

social location category

mean other sign eta category

Ministerial approval No professional association VGVZ-member General hospital Nursing home

2.20 2.60 2.16 2.03 2.44

2.47 2.20 2.55 2.38 2.16

.00 .00 .00 .00 .00

.17 .20 .25 .23 .20

tables

261

Table 34 Aspects of rituals: factor analysis Items b g n e i j d a o l f h

communality factor 1 .63 .68 .58 .46 .46 .35 .47 .39 .38 .45 .40 .24

rotation oblimin total r2 = 44%

factor 2

.81 .76 .72 .00 –.00 –.00 –.00 –.00 .18 .13 .22 .00 moral

–.00 .00 .00 .69 .67 .54 .00 –.00 .00 –.17 .11 .00

factor 3

factor 4

–.00 .00 –.00 .00 –.00 –.00 –.66 –.64 –.55 .00 .00 –.00

–.00 .11 .00 .00 –.00 .00 .00 –.00 –.00 .62 .46 .44

experiential- social expressive

a .83

a .68

a .65

cognitive a .63

Correlation between factors:

2 3 4

1

2

3

.03 –.17 .55

–.41 .29

–.20

Table 35 Aspects of rituals: social location Scale Religious respondents Experientialexpressive Cognitive Cognitive Moral Social

social location category

mean other sign eta category

No professional association 3.79

4.06

.00 .16

Psychiatric institution Facility for mentally handicapped people Theology General hospital

3.27 3.28

3.63 3.62

.00 .20 .00 .17

2.76 3.90

3.07 4.09

.02 .17 .00 .17

3.89 4.33

3.46 3.93

.02 .45 .05 .37

Humanistic respondents Cognitive Nursing home Social Academic hospital

appendix three

262

Table 36 Aspects of supra-disciplinary consultation at meso level: factor analysis Items

communality

factor 1

factor 2

factor 3

.52 .39 .53 .21 .50 .32 .20 .56 .64

.74 .64 .62 .43 .10 .00 .00 .00 .00

–.00 .00 –.00 .00 .66 .56 –.47 .00 .00

.00 .00 –.18 –.00 .00 –.00 .00 .76 –.74

k c i b d g j (–) a h (–) rotation oblimin total r2 = 43%

division and competition image problems a .72

a .58

managerial support r .57

Correlation between factors:

2 3

1

2

.47 –.59

–.29

Table 37 Aspects of supra-disciplinary consultation at meso level: social location Scale

social location category

mean other sign. eta category

Competition Competition Competiton Division and image problems

HOI Academic hospital Nursing home Nursing home

2.92 2.85 2.29 2.93

2.41 2.41 2.52 3.22

.00 .00 .00 .00

.17 .16 .18 .23

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INDEX OF SUBJECTS AND NAMES accountability (exemption from-) 132, 137–138, 143, 195, 218 agnosticism 102, 113–114, 216 Andriessen 165 apathy (-theodicy) 110, 112, 201, 215–216 Aristotle 3, 56, 70, 85 atheism 85, 89–92, 108–109, 118–119, 195, 215 attestation 74–79, 79 n. 3; 116, 170, 172, 189, 195, 214 Baart 8, 124, 165 Bach 123, 132, 166, 171, 173 n. 3 Bell 103–104, 150, 168–171 BIG-act 31–32, 32 n. 3; 34, 223, 232 Bouwer 6, 165, 223 bureaucratisation 23–30, 32–35, 49, 193, 195, 212 Casparie 4, 9, 11, 13, 20, 30 categorical (-spiritual care) 130, 140, 143–144 challenge 1, 2 n. 3; 5, 8, 75, 83, 93, 96, 152–153, 155, 160–162, 183, 219, 234 chance 10, 28, 54, 56–58, 61, 63, 66, 174, 181 charismatic 153–155, 160–162, 183 cognitive goal (of spiritual care) 189, 198, 219 collective worldview 82, 105, 117–119, 214 comfort 95, 110, 152–154, 160–162, 164, 182, 215, 219, 234, 236, 242 compassion 40–44, 47–48, 48 n. 10; 49–50, 95, 107 n. 7; 110, 193, 199, 202, 212–213, 215, 227, 233, 236 competence (of spiritual care) 29, 169 n. 1; 180, 244 competition 171–173, 180–182, 184–185, 220 contingency 10, 28, 43, 51, 54, 57–59, 61, 66, 76–77, 92, 96, 105, 115, 123, 142, 147–148, 165, 187, 213, 216, 226–227, 233 contingency (limit of-) 10, 28, 43, 51, 53–54, 57–59, 61, 66

Dalferth 86–87, 91–92 De Mul 54, 56–57 De Swaan 37, 45, 52–53 de-institutionalisation 82–83, 105, 129, 137, 214–215, 217 deism 85–92, 108, 113 de-legalisation (of spiritual care) 203, 206–207, 209 demand/supply structure 164–165, 175–176, 176 n. 4; 177, 183–184, 219, 223, 233 demand-driven care 36, 44–45, 47, 49–50, 121, 212 denominational (-legitimation) 125–126, 199 denominational representation (ministry) 137–138, 143–144, 207 de-traditionalisation 82–83, 118, 129, 137, 205, 217 development (-theodicy) 93, 110, 195 division 60, 171–173, 180–182, 184, 220 domain-related (-legitimation) 122, 124–125, 142, 191, 196, 198, 205, 222 Doolaard 163 Dunn 98–99 experiential goal (of spiritual care) 158, 164, 189, 193, 195–196, 198, 202–205, 208, 219, 221 extrinsic (function of worldview) 5–6, 60–65, 65 n. 2; 66, 122, 187, 189–191, 195–196, 198, 200–204, 213, 221, 224, 234 Felling 83, 167 Fortmann 150–151, 172 functionalisation (of spiritual care) 203–204, 207, 209 Ganzevoort 153, 170 Geertz 4–6, 18, 51, 61, 69, 80–82, 84–85, 92–93, 96, 103, 107, 114, 116, 145, 148–150, 170, 203, 214, 216, 224 Gribnau 58, 121, 151–152

288

index of subjects and names

Hartshorne 89 health care 1–2, 2 n. 3; 3–7, 9–21, 23–24, 26, 26 n. 2; 27–32, 36–38, 40, 42, 45–46, 49, 51–53, 55–67, 77–78, 115, 120–121, 121 n. 1; 122, 124–129, 132–134, 137, 139, 141–142, 145–147, 149, 151–153, 159, 162, 167, 171, 180, 186–187, 190–196, 198–202, 207–209, 211–214, 216–217, 220–221, 223–228, 232–234 Hekking 4, 163, 169 Hiltner 7, 152 Hosman 45–46 human fellow 164–165, 175–176, 176 n. 4; 177, 184, 219 humanism 81, 89–91, 91 n. 5, 147, 170 n. 2 idem (identity) 72 image problem 171, 173, 180–182, 184, 220 immanence 85, 87–89, 93, 95–96, 108, 110, 199, 215 immanentism 89–90, 102–103, 109, 113, 216 immetiate goal (of spiritual care) 145–146, 150, 155–157, 159, 174, 182, 190, 192, 208, 218–219 individualisation (of spiritual care) 1, 53, 82, 137, 167, 175, 203–205, 207, 209, 215, 239 initiation (of spiritual care) 176, 222–223 integration (of spiritual care) 12, 32, 122–123, 132, 142, 171, 204, 240 intrinsic (function of worldview) 6, 61, 61 n. 1; 62–67, 195, 224 ipse (identity) 71–73 isolation (of spiritual care) 12, 122, 135, 142, 180, 195, 204, 217 Janssen 104 judaism 97–99, 147 Kant 40, 44 kerygmatic 154–155, 160–161, 183 Klessmann 57, 124, 129 Körver 28, 173–174 legitimacy (of spiritual care) 10, 120–121, 121 n. 1, 122, 124, 126, 133, 136, 142–145, 186–187, 191, 198–201, 205, 207, 209, 211, 216–217, 221–223, 237, 253–254

Liégois 27, 123, 223 limited signiﬁcance (ministry) 137–138, 142–144, 218 Lukken 103–105, 149, 170 managerial support 181, 206, 220 marginal position (of spiritual care) 138, 198, 218, 240 medicalisation 51–53, 57–60, 66–67, 81, 129, 137, 190, 195, 213, 227, 233 Menken-Bekius 104–105, 169, 171 ministerial approval 12–13, 16, 18, 35, 40, 60, 66–67, 79, 107, 119, 126, 138–139, 144, 158, 176, 179, 181, 193–194, 196, 196 n. 4, 200, 206, 221, 239–240 ministry 11–12, 32, 120, 124, 127–131, 133–134, 136–139, 142–144, 154, 167–168, 191, 195, 203, 206–207, 217–218, 221, 239–240 Mintzberg 24, 28 mortality 44, 54–56, 58–60, 66–67, 76, 79 n. 4; 96–97, 99, 103, 191, 195, 213, 217, 227, 233 multiple worldview 82–83, 105–107, 107 n. 7; 139, 144, 189, 192, 195, 214, 225, 249, 257–258 multiple worldview cooperation 135, 140–141, 143–144, 192, 201, 218 multiple worldview counselling 133, 140–141, 143 mystical (-theodicy) 93, 96, 110–112, 195, 215 mysticism 93, 111, 190 narrative identity 69–71, 77, 189, 214, 226 narrativity 69, 77–79, 119 panentheism 85, 88, 108–109, 112 pantheism 85, 87–90 participation 82, 146–147, 149, 160, 162, 171, 173, 182, 225 passivity 75–79, 79 n. 4; 116, 189, 195, 226 Pieper 62, 152, 173 Pijnenburg 58, 121, 151–152 plan (-theodicy) 110 position (of spiritual care) 9, 11–13, 15–17, 120, 122, 124, 126–127, 129, 131, 133, 135, 137, 139, 141–145, 168, 173, 181, 186–187, 191, 206, 211, 216–218, 238, 254

index of subjects and names presence 8, 16, 56, 74, 88–89, 92, 95, 135, 152, 154, 165, 191, 215 proceduralisation 22, 25–26, 33, 35, 49, 192, 212, 227 procedure 9, 33, 38, 128 process integration 123, 126–127, 133, 217 process theology 88 professionalisation 13, 23–25, 29–30, 32–35, 45, 49, 53 protocol 26, 28, 33 protocolisation 22, 25–26, 33, 35, 49, 192, 199, 212, 227 quality assurance 3, 3 n. 4; 4, 8–9, 13–17, 20–26, 29, 31–32, 35–36, 47–48, 51, 208–209, 211–213, 222, 226, 232, quality of care 2, 2 n. 3; 3, 3 n. 4; 4, 8–9, 13, 18, 20–21, 21 n. 1; 23–24, 28–31, 36, 44, 47–50, 159, 212, 242 Quality of Care Institutions Act 2–4, 10, 20, 61, 121, 121 n. 1, 122, 217, 238 Rebel 121 n. 1; 123, 128, 172 registration 21, 23, 25, 30–35, 49, 193, 195, 212, 222–223, 226 reincarnation 100–102, 112–114, 117, 216 retribution (-theodicy) 93–94, 110, 112, 215–216 Ricoeur 3, 42–44, 44 n. 9; 55–56, 69–73, 73 n. 2; 74–78, 80, 82, 85, 116, 170, 172, 214 right (of patiënt) 21, 23, 36–38 rites of passage 104–105, 114–118, 178, 216, 225–226 ritual 219–221, 225–226, 237, 239, 241, 243 ritual dimension 103, 105, 115–118, 216, 225–226 ritual goal (of spiritual care) 206, 221 Rooijakkers 123 Roosjen 173, 173 n. 3; 174 sanctuary 11, 11 n. 7; 12, 32, 120, 127–128, 131–133, 136–139, 142, 167–168, 178, 191, 195, 198, 239 Scherer-Rath 54 Schilderman 13–14, 30–31, 99–100 Schillebeeckx 98–100 Self 7–8, 42, 44, 74, 76, 78–79, 116, 148, 235

289

self-determination 22, 35–37, 38 n. 7; 39–41, 44, 47, 49–50, 76, 166, 212, 227 Smeets 2 n. 3; 6, 7, 32 n. 3; 167 social-moral goal (of spiritual care) 206–207 solidarity (-theodicy) 110 Sölle 95–96 spiritual aspect of health 213, 220–221 spiritual care 204–209, 211, 216–218 standardisation 24–25, 28–29, 33–35, 49, 54, 129, 193, 227 statutory (-legitimation) 121, 121 n. 1; 124, 126, 142, 191, 203, 205, 207, 217, 221–223, 227, 238 Stevens 53, 164–165 Stiver 73–74 substitution (-theodicy) 111 suﬀering 5, 40–42, 44, 47, 51, 53–58, 61, 65–66, 75–78, 81, 85–86, 92–97, 102, 105, 107, 109–111, 116–117, 122, 149, 150, 153, 189–190, 195, 212–215, 217, 224, 227, 227 n. 1; 233–236, 241, 198–202 symmetry 40–41, 43–44, 47–50, 107 n. 7; 193, 212–213, 227 Taylor 147, 152, 166 Ter Borg 53, 81 territorial (-spiritual care) 139–140, 218, 240 theism 85–89, 91–92 theodicy 76, 93, 109–112, 117, 137, 108, 187, 190, 195, 200–201, 215–216 time 1, 10, 22, 39, 54–59, 61, 63, 66, 70–73, 75, 81–82, 88–89, 93–94, 96–97, 100 104, 106, 110, 117, 129, 145, 153, 164, 166, 186, 186 n. 1 tradition 7, 38, 40, 55–56, 58, 72, 82–83, 89–91, 93–94, 101, 104–109, 111–118, 130, 134–135, 142, 149, 152, 154, 158–159, 161, 167–169, 179, 189, 195–196, 205, 214–218, 225, 235, 239, 242 tragedy 5, 28, 54, 57, 75–78, 116, 214 transcendence 85–91, 93–94, 96, 108, 110–112, 117, 215, 241 ultimate goal (of spiritual care) 145, 150, 157, 174, 189–190, 192, 208, 219 ultimate reality 4, 62, 81, 85, 90–92, 103, 105, 107, 108–109, 117, 149–150, 168–170, 190, 199, 203, 215, 236

290

index of subjects and names

uniqueness 36, 72 74, 77, 79, 79 n. 3; 86, 116, 189, 195, 214 Van den Berg 6, 171 Van der Krogt 23, 30–31, 172 Van der Slik 63–64, 105 Van der Ven 9, 11–13, 30, 40, 43, 53–54, 69, 73 n. 2; 75, 81, 83, 85, 88, 110, 128, 134, 146–147, 149, 152, 165, 172, 174, 189, 215, 225 Van Uden 62, 152, 173 Veltkamp 153 Vergote 62, 63, 92 Vermeer 94

Weber 23–25, 29, 94, 153–154 Whitehead 88–89 Wildiers 87 worldview 1, 1 n. 1; 2, 4–8, 8 n. 5; 9–11, 11 n. 7; 12–19, 27–29, 32–35, 49, 51–69, 80, 85, 90–91, 93, 96–97, 103–107, 107 n. 7; 112, 114–117, 120–125, 133–144, 146–151, 153, 155–161, 163, 165–175, 177, 181–184, 186–187, 189–196, 198, 227, 230, 234–235, 237–243 Zuidgeest 58, 173, 173 n. 3; 174

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