Spirituality in the Primary Care Setting
Penny Keith and Melanie Rogers
This chapter introduces spirituality in primary care from the perspective oftwo primary care practitioners. It begins with a brief overview of some of the issues facing those working in primary care and the importance of holistic approaches to care. The current evidence concerning spirituality in primary care is then reviewed before focusing on how to operationalise spirituality in this setting. Chapter 4 provided the framework of availability and vulnerability which is particularly salient in primary care and should be reviewed by the reader as a useful framework for operationalising spirituality. A number of verbatim quotes taken from the interview transcripts from a study by Penny of ANP's in primary care have been included to offer insights into the provision of spiritual care in this setting (1).
Introduction
It is estimated that for around 90% of people their first and main point of contact with the NHS for their physical and mental health and well-being is primary care (2). Primary care includes GP practices alongside dentists, opticians and pharmacists. There are more than 8300 practices in the UK providing primary care services (3). The traditional model of primary care centres has focused on General Practice (4).
The 'Five Year Forward View' report recognised that change was needed in the health service to offer a more 'engaged relationship' to promote well-being and prevent ill-health (4). Working in partnership with local communities and a commitment to delivering care locally was seen as a priority, potentially placing primary care back in the driving seat for delivering care. To deliver the Five Year Forward View, NHS and social enterprise organisations and partnerships were invited to apply to become vanguard sites for new models of care (5). These included integrating primary and acute care systems.
Penny is working alongside colleagues in mid-Nottinghamshire on the Better Together vanguard where a new care model is being implemented. The Better Together programme brings together all health and social care organisations across the area with one aim being to focus on treatment of patients in the community (6).
Primary care needs to be responsive and flexible to meet rising demands for health and social care provision. Traditionally, patients' first contact for health needs would be to see the General Practitioner (GP). In the 1990s the role of the Practice Nurse (PN) was developed to support the GP and offer nursing care in the GP practice. With the increasing skills of nurses and the increasing demand from patients the role of the Advanced Nurse Practitioner (ANP) has developed in many areas. The patient will often present first to the GP or ANP with symptoms or concerns that are troubling them with an expectation that these will be addressed and a 'treatment' offered. The patient may then be referred to the PN for health education, chronic disease management, wound assessment, vaccinations and cervical screening, for example. PNs are often supported by Health Care Assistants (HCAs) working in primary care who are able to offer venepuncture, some health checks and new patient assessments. The primary health teams also cannot function without the full administration team, including the receptionists who have daily contact with patients and play an important role for patients. Primary health care teams continue to evolve and develop. With the Five Year Forward View there was a move to offer services which were previously provided in secondary care leading to new initiatives and services for patients provided in the community.
Most health care professionals would hope to define the care that they deliver as holistic. This, put simply, means care of the whole [Greek oXoq] - body, mind and spirit (6). The main role of the practitioner in primary care, whether making a comprehensive assessment of the patient or offering health education and monitoring, involves direct engagement with the patient. This may include assessment of physical, social, psychological and spiritual factors and provision of appropriate support. Interactions focus on building a relationship with patients, interpersonal skills and holistic assessment of the presenting problem (7-10).
GPs, ANPs and PNs are by definition generalists and yet there is often an expectation from patients that they will also have specialist knowledge. Penny's study of ANPs has been used throughout this chapter to illustrate some of the aspects of spirituality:
... they have this perception that because we're nurses, we can actually deal with anything that comes through the door - it doesn't matter whether it's medical or not, but oh, you're a nurse, you can deal with it! (1)
With the emphasis of provision moving from secondary care to primary care, practitioners need to develop a greater range of skills to manage increasingly complex patients (8). Primary care practitioners are expected to work in equal partnership with patients, supporting them to be self-caring where possible. This is in the face of limited resources, time pressures, and limited capacity and relatively few specialist services available at the point of consultation (11).
With the vanguard projects and the implementation of the Five Year Forward View there may be a move to federations of primary care practices and the integration of other care providers such as social care to improve efficiency and continuity.
Historically patients have only been offered 7- to 10-minute consultations with a GP. However, with the increase in health care complexity and poly-pharmacy in addition to social needs, some practices offer longer or repeat appointments for those who need them. Short consultations increase the likelihood of some aspects of care being overlooked - particularly those (like issues of meaning and purpose) requiring more in-depth discussion (11). Holistic care can be impeded by the need to focus on the presenting problem in a ten-minute consultation. This may lead to relative neglect of psychological, social, cultural and spiritual needs (12).
Clinical presentations to GPs and ANPs historically have been approached bio-medically, with further investigations, treatment or a referral often being the outcome. Many primary care presentations are multifaceted with biological, psychological, social and spiritual factors interacting with each other (13). The bio-medical model often only addresses one part of the human condition, and holistic approaches in primary care are necessary to meet patient need (13). We need to recognise the complexity of human needs and adopt a holistic approach, whichever member of the team the patient is consulting (9,10).
This means listening to patients and eliciting their concerns and anxieties in order to understand how their illness impacts on their lives. In primary care the 'ICE' mnemonic reminds practitioners of the need to elicit patients' Ideas, Concerns and Expectations. It supports effective consultation and has evaluated well in studies (14). Listening to patients in this way ensures a patient-centred focus which is enhanced by shared decision-making. Listening and acknowledging patients' concerns and anxieties is also a key aspect of spirituality. One major nursing survey found that spirituality was regarded as fundamental to holistic care (15). Holistic care is partly dependent on a good long-term relationship between patient and practitioner, often involving regular engagement through intensely private and life-changing events. Holistic and compassionate care go hand in hand and help to build an effective partnership between clinician and patient (16). Working holistically needs recognition and integration of a 'body-mind-emotion- spirit' approach (17).
