Abstract
Background
Spiritual care (SC) is an important component of whole person care, a goal that many pharmacists embrace. Knowledge about barriers to incorporating SC in pharmacy practice may allow understanding of how to increase its provision.
Objectives
The objective of the study was to investigate pharmacy students' perceived personal and professional barriers to incorporating SC in pharmacy practice.
Methods
Second-year pharmacy students (n = 62) who attended a required class lecture on SC in healthcare responded to three open-ended questions that explored beliefs about SC in pharmacy practice. Students' responses were thematically analyzed using NVivo.
Results
Most (68%) of the students were female; 34% were Asian American. Students identified the following barriers to incorporating SC: limited or lack of time for SC, lack of supervisor and company support for SC, discordant pharmacist-patient spiritual beliefs, discomfort with talking about spirituality, lack of knowledge about spirituality and SC, personal factors, patient refusal of SC, fear of offending patients by discussing spirituality, and pharmacy environment.
Conclusion
Major barriers to SC include lack of time for SC, lack of supervisor and company support for SC, and discordant pharmacist-patient spiritual beliefs. Future studies should be conducted to investigate these and other barriers to SC in pharmacy practice.
Keywords: Pharmacy students, Barriers, Spirituality, Spiritual care, Pharmacy practice, Pharmacy education
Highlights
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Little is known about the barriers to spiritual care (SC) in pharmacy practice.
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This study was conducted to investigate pharmacy students' perceived barriers to incorporating SC in pharmacy practice.
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This study is the first to comprehensively describe the barriers for incorporating SC in pharmacy practice.
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SC was impeded by limited time, lack of supervisor and company support for SC and lack of knowledge about SC among others.
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These challenges need to be addressed and overcome in order to increase the provision of SC in pharmacy practice.
1. Introduction
Most Americans are religious and/or spiritual.1,2 Spirituality plays an important role in the life and health of most people. The 2021 national Gallup poll found that 76% of Americans identify with a religious faith (i.e., mostly Christianity, but also Islam, Judaism, Buddhism, and other faith traditions).3 There is increasing recognition that patients' spirituality and/or religiosity—as it pertains to their health should be considered in patient care.4,5 For example, the Joint Commission mandates healthcare systems to accommodate patients' rights to religious and spiritual services as part of their care.6 Health care professionals (HCPs) address patients' spiritual needs and concerns related to their health, illness, suffering, and treatment when they provide spiritual care (SC).7,8
SC is an important component of whole person care.7,9 Holistic care occurs when patients' physical, social, psychological, spiritual and other factors are considered during patient care. SC is defined as, “Interventions, individual or communal, that facilitate the ability to express the integration of the body, mind, and spirit to achieve wholeness, health, and a sense of connection to self, others, and[/or] a higher power.”10 Although it is limited, there is some evidence indicating that patients who receive SC have health outcomes such as lowered depression and anxiety, and improved blood pressure and increased hope.7,8 Provision of SC is associated with improved patient outcomes, patient satisfaction, and higher quality of life near death.11, 12, 13, 14, 15
Pharmacists often endorse the provision of SC in pharmacy practice.2,7, 8, 9 For example, 73% of 215 pharmacists who responded to a California state-wide survey noted that pharmacists should practice in a spiritually sensitive manner. Furthermore, 63% also agreed that pharmacists should know about patients' spiritual issues and concerns related to their health, and 53% agreed that addressing patients' spiritual needs improves their satisfaction with pharmaceutical care.8 These findings suggest that pharmacists (at least half of them) appreciate that patient spirituality is a domain of interest with relevance for pharmaceutical care.
A previous study found that pharmacists provide SC through praying for and with patients who request it, discussing a spiritual and/or religious topic that influences health with patients, referring patients to trained SC experts and adapting medications to suit patients' spiritual and/or religious beliefs/needs.8 Pharmacists can determine possible reasons patients may not adhere to their medications by assessing patients' religious or spiritual background.
Likewise, pharmacy students also appreciate the importance of spirituality in pharmacy practice.16,17 To illustrate, most incoming student pharmacists at a private university in the southeastern United States indicated that they anticipated that spirituality would play a role in their academic course work (58%) and professional practice (74%); they also believed that a general understanding of the role of spirituality in society was useful to be prepared for pharmacy practice.17 In 2019, Purnell and colleagues reported that final-year pharmacy students at four private universities believed that patients' spirituality or religious beliefs can affect their overall health (88%) and medication adherence (76%).16 Most of these pharmacy students (57%) also reported that they would pray with patients if requested of them.16
Despite evidence indicating that spirituality contributes to patient health outcomes and decision making,12,18 and the favorable opinions about SC held by pharmacists in pharmacy practice,8,9 few pharmacists address patients' spiritual needs in practice.8 For example, 25% of Californian pharmacists surveyed indicated that they talked to their patients about a spiritual and/or religious topic.8 The limited provision of SC by pharmacists could be explained by the existence of many challenges or barriers. Several challenges to providing SC have been reported, albeit mostly in the nursing and medical literature.17,19,20 These challenges include lack of education on SC topics, provider unwillingness and discomfort with providing SC, time pressures, fear of rejection, lack of congruence between patient and clinician beliefs, and ethical considerations.17,19 Lack of SC education and training also challenges pharmacists.20 In a survey of pharmacy schools and colleges in the United States and Canada published in 2003, only 21% reported including some aspect of SC training in their curricula.21
The evidence about SC in pharmacy care is scant; however, what exists supports its inclusion to some degree. Although pharmacists and pharmacy students may endorse SC provision within pharmacy care, it is rarely provided. Barriers presumably exist. Understanding pharmacy student perspectives about SC can provide insights about what future pharmacists believe in this regard. Therefore, the aim of this study is to investigate pharmacy students' perceived personal and professional barriers to incorporating SC in pharmacy practice.
2. Methods
This cross-sectional descriptive inductive exploratory study used qualitative methods. Participants were second-year pharmacy students taking a required 3-credit course on Social and Behavioral Aspects of Pharmacy in Spring, 2021 at an accredited private faith-based School of Pharmacy located in an urban area in Southern California. These students had not had any prior formal education about SC. All students had completed three Introductory Pharmacy Practice Experience (IPPE) rotations that provided them ample clinical experience working with pharmacists in a pharmacy setting. Students had undertaken an IPPE Community I rotation (once a week for 14 weeks), IPPE Institutional I rotation (once a week for 7 weeks), and IPPE Community II rotation on the pharmacist patient care process (two weeks).22
3. Study procedure
Data were collected as part of a required assignment associated with this course that provided content on various social and behavioral aspects of pharmacy topics (e.g., health disparities, cultural competence, and theories of health behavior). One of the course topics was on the role of religion and spirituality in health and healthcare. Learning activities for this session included a 90-min guest lecture that introduced spiritual care; this lecture with PowerPoint slides was delivered via Zoom due to pandemic restrictions. The guest lecturer was a professor from the university's School of Nursing who is internationally renowned for her expertise in SC. The purpose of the lecture was to introduce students to SC and covered the importance and benefits of SC, empirical evidence supporting the use of SC, the link between spirituality and tragedy, making meaning of difficult situations, aspects of spiritual healing, how to provide SC, and concepts of person-centered supportive communication. The lecture also went over how to screen for patients with spiritual struggles and the need for providing ethical SC that respects patients' needs and beliefs.
Immediately after the lecture, an assignment was made available to all students via learning management system. The assignment required students to respond in writing to 3 open-ended questions (which would account for 1% of the overall course grade). These questions included the prompt that generated the data for this study: What are the personal and professional barriers you see to implementing spiritual care in pharmacy practice? (Identify at least 3 barriers). The other assigned questions included, What questions does this lecture prompt within you? (Identify at least 2 questions) and How might these barriers be addressed—if indeed you believe they should be addressed? Students were given 24 h to respond.
4. Ethical approval
After the course ended, we downloaded the data to an Excel worksheet. We also added students' gender and ethnicity from information gathered from the office of admissions to this data. We submitted a study protocol to the Loma Linda University Health Institutional Review Board (IRB) to retrospectively analyze the students' responses. The IRB determined the protocol to be exempt. We adhered to the criteria established by the Standards for Reporting Qualitative Research.23
5. Data analysis
Frequencies were computed for gender and ethnicity. Data were transferred from Microsoft Excel® 2010 worksheet to NVivo statistical software (QSR International 2021) for qualitative analysis. The participants' responses to the question were linked to their gender and ethnicity in NVivo using case classification. Nodes were manually extracted using node classification and we came up with themes based on each participant's response to the question. Consistent with most qualitative approaches,24 no prior hypotheses were generated. Two study authors (PG and BR) independently conducted the analyses and compared the themes that were generated. We computed and reported the number of times the participants reported the identified code (frequencies). Agreement between the authors' coding that was discrepant, however, was achieved through discussion.
6. Results
All 62 students registered in the course (100% response rate) submitted their responses. A majority of students were female (68%). Students were from diverse racial and ethnic backgrounds comprising Asian American (34%), Latino/ Hispanic (21%), Caucasian (19%), Middle Eastern (15%), and African American (11%).
Nine main themes emerged from the data. (Table 1) The four most cited themes were limited or lack of time for SC (n = 51), lack of supervisor and company support for SC (n = 33), discordant pharmacist-patient spiritual beliefs (n = 24), and discomfort with talking about spirituality (n = 22). (Table 1) These themes are described below.
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A.
Limited or Lack of Time for SC
Table 1.
Main Themes from Students' Responses.
| Theme | Description or example | Number of Responses |
|---|---|---|
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Not having enough time to provide SC or connect with patients. | 51 |
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Lack of support from supervisors, peers, and company to provide SC. | 33 |
|
Different spiritual or religious beliefs between patient and pharmacist. | 24 |
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Feel uncomfortable talking about spirituality or providing SC (e.g., praying with patients). | 22 |
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Lack of knowledge, training, and skills on SC. | 21 |
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Personal fears, biases, lack of confidence, and being shy, and difficulty empathizing etc. | 21 |
|
Patients refuse or deny SC or talking about spirituality. | 13 |
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Fear of offending patients by discussing spirituality or providing SC. | 8 |
|
Lack of private space for counseling in community pharmacies and understaffing. | 8 |
Several students indicated that there was limited time, not enough time or lack of time to converse or interact with patients, to counsel patients, to provide SC, “to build rapport with patients”, “to determine the underlying cause for patients' distress”, “to assess if patients need spiritual care” and “to deeply listen to a patient”. Students noted, “Time is the biggest constraint. Often, we do not have the time to perform spiritual care”, and “We do not have enough time to spend with our patients.”
Some of the reasons provided by the students for the lack or limited time were excessive numbers of patients seen by pharmacists and understaffing in many pharmacies.
Some students indicated that employers restricted the amount of time that they could take to interact with patients as illustrated by the following quotes: “Time constraints in certain practices or chain pharmacies limit your interactions with patients. Often, we are allotted only enough time to review the label and 3 side effects or so before we are dinged in our performance metrics for taking too long at consultation” and “One barrier is time, there are some environments where you can only dedicate a certain amount of time to a patient, and this may be less than what they need.”
Some students indicated that they felt rushed and could not give the needed time with patients or give patients enough time to tell their story or express themselves. Providing SC and building personal relationships with patients was seen by students as being time consuming. Therefore, time was seen as a barrier to SC, especially in the chain pharmacies and community pharmacy setting.
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B.
Lack of Supervisor and Company Support for SC
Some students indicated that their supervisors and co-workers did not provide SC, did not support provision of SC, or were opposed to SC as illustrated by the following quotes: “Often, our superiors don't see the benefit of spiritual care or consider it to be an unprofessional topic of discussion. Having to defend our practice of spiritual care can be taxing on our professional relationships”, “Another professional barrier may be advice from my co-workers or managers on how to engage with patients and what we can and cannot discuss with them at work while getting them their medications in an efficient manner” and “I also think that my manager will be opposed to changing the way things are done, since the way it is now is working for them.”
In addition to management not allowing SC, some students indicated that the provision of SC sometimes conflict with job rules, protocols and company policies on how patients should be treated. The following quotes illustrate: “Some pharmacies frown upon bringing spirituality into their practice. They do not want to be associated with spiritual care.” Those working for federal institutions were impacted by the separation of church and state. There were negative repercussions for talking about spirituality in the workplace: “I may be in trouble if the patient complains about my behavior to the corporates” and “Some companies do not allow you to share your religious beliefs, so the possibility of being fired is one of the barriers”.
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C.
Discordant Pharmacist-Patient Spiritual Beliefs
Many students described having different religious and spiritual beliefs with patients as a barrier. They noted that some patients were not religious and/or spiritual or held religious or spiritual beliefs that were different to those of the pharmacists and pharmacy staff. Students indicated that they were not sure how to provide SC in such situations and that it was difficult to be unbiased and connect with patients of other beliefs. “Patient not following the same religion as me, how will I approach them or pray for them?”, “I feel uncomfortable praying with patients who are not Muslims”, “What if your spiritual beliefs and medical teachings disagree and how do you decide what to tell the patient?” and “My faith in God leads me to feel empowered that He won't give me more than I can handle. My patients may not feel empowered or have that same faith.” Having different spiritual beliefs was reported to make it difficult for pharmacists and pharmacy staff “to connect with patients of other religions.”
Students noted that the existence of many diverse religions made it difficult to know about all religious beliefs that patients may hold. Therefore, some students indicated that they avoided spirituality and SC because they did not want to go against their own beliefs, offend patients or to push their beliefs onto patients.
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D.
Discomfort with Talking about Spirituality
Several students indicated that they were uncomfortable to talk about spirituality with others or provide SC as illustrated in the following data: “A personal barrier is my own personal comfortability talking about my spirituality as well as spirituality in general with others”, “Many health care professionals are not comfortable with being spiritual with their patients … some are terrified to share their beliefs” and “Sometimes I'm not comfortable at praying in front of other people.” The discomfort could be explained by their perceived limited religiosity or spirituality, and lack of opportunity to provide SC as illustrated by the following quotes: “I am not as strong as I would like to be spiritually so I feel out of place offering help to others”, “Another barrier is that the clinicians themselves may not be spiritual” and “If I were to be in a hospital, I think I'd have a lot more opportunities to practice spiritual care, but it would take some time. I think it would take a while to build enough confidence in my own spiritually to offer spiritual care and prayer to other people.”
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E.
Lack of Knowledge About Spirituality and SC
Several students noted that lack of knowledge of and training on spirituality, SC and other religions among pharmacists and pharmacy staff impeded SC provision as illustrated by the following quotes: “The healthcare professionals including pharmacists, technicians, interns are not well trained to provide spiritual care”, “Not understanding what spiritual care is and how it differs in the pharmacy setting compared to other healthcare settings”, “Pharmacists are not always well educated in all of the different spiritual areas” and “There is a learning curve and experience needed to properly implement spiritual care and become competent.”
Students wrote that they were not aware or informed about spiritual practices that were different to theirs and some did not know how to address the spiritual needs and concerns of patients of religions other than theirs. Furthermore, they reported that there were limited resources and guidance available to those who may be interested in providing SC: “lack of clear guidelines for the pharmacist's role in providing spiritual care” and “lack of guidance about spiritual care.”
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F.
Personal Factors
Students mentioned several personal factors that hampered the provision of SC such as personal fears, having “a habit of imposing positivity on patients”, and personality (i.e., being shy, introvert, or finding it difficult to get closer to people). Some students also mentioned that they lacked emotional awareness as illustrated by the following quote: “Another barrier for me would be emotional awareness, it is sometimes difficult for me to relate to other people's emotions and understand their feelings.”
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G.
Patient Refusal of SC
Students wrote that some patients did not want to share their spirituality with pharmacists, open up to strangers or to receive SC. Students wrote, “It can be difficult to provide spiritual care when patients simply want to take their medications and be on their way”, “Many patients may not want this service”, “Many people just want to pick up their medications quickly and leave”, “Patient resistance is another barrier”, “Most patients are looking to have as little interaction time as necessary” and “Personally, it would be exhausting for me to be on that spiritual care gear because not everyone is accepting of it.”
Students indicated that some patients believe that SC was not part of pharmaceutical care and that they come to the pharmacy for medical but not spiritual advice. Many students indicated that it was difficult to tell who is and who is not open to SC in the pharmacy setting given their insufficient knowledge, training and time to assess patients' need for SC.
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H.
Fear of Offending Patients
Some students indicated that they did not want to offend patients or to make patients feel uncomfortable by discussing spirituality or offering SC as illustrated by the following quotes: “I do not want to offend patients and seem like I am trying to pry into their personal lives” and “saying God bless you to a patient might not sit well with them.” Some feared that SC may be taken the wrong way by patients while others did not want to seem insensitive or intrusive. Other students noted that they feared wasting patients' time.
The fears about offending patients and making patients feel uncomfortable were attributable to some patients holding different religious beliefs than the provider. “I believe sometimes people may not agree with your religious beliefs or are not religious themselves” and “A personal barrier may be not seeing eye-to-eye with a patient's spiritual views and not wanting to go against your own beliefs or offend the patient at the same time.” The fears were also reflective of the providers' own discomfort with SC.
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I.
Pharmacy Environment
The pharmacy environment was also cited as a barrier to SC. Students identified lack of private space for counseling in community pharmacies and understaffing as impediments to SC. One student wrote, “Pressure with workflow will keep me from helping the patients. I will not be able to focus on the conversation with my patients if I keep worrying about other customers that are waiting in line.” Furthermore, students believed that many pharmacies preferred “filling prescriptions over patient counseling” and some pharmacists working in hospital settings were reported to not have sufficient exposure to patients in their day-to-day jobs. Furthermore, incorporating SC was seen by some students as interrupting the pharmacy workflow.
7. Discussion
This study provides important findings about the barriers perceived by pharmacy students when providing or contemplating SC in pharmacy practice. This is the first known empirical study to document SC barriers faced by pharmacy staff. The delineation of these barriers will hopefully help in future efforts to find solutions aimed at increasing SC knowledge in pharmacy practice and education.
Lack of time was identified by most students as a major barrier to SC provision in the pharmacy setting. Students noted that pharmacists, interns, and technicians did not have enough time to build rapport with patients, spiritually assess patients, listen to patients and to provide SC. Many pharmacies are understaffed and cater for huge patient loads. Pharmacists have also indicated that their provision of SC was impeded by time constraints and the many competing needs on pharmacists' time.8 Lack of time also hampers pharmacists' provision of other professional services.25,26 Limited time to provide SC has also been found to be a major barrier for SC in nursing.27,28 In one nursing study, not having enough time was reported as the most significant barrier to SC.29 Nurses prioritize other care activities such as providing medication over SC when faced with time pressures.30
The students believed that SC was impeded by lack of perceived supervisor, management and company support. Some organizations were reported to have policies that prohibited talking about spirituality with patients at the workplace especially in the retail chain setting. Such policies were reported to have a negative effect on SC provision as some students indicated that they would jeopardize their employment by providing SC. A previous study of pharmacists also found that lack of perceived employer support curtailed their provision of SC.8 Similarly, employed nurses who perceived administration's support for SC were more likely to provide it.31 It is unlikely that SC will be widely provided in pharmacy without management and company support.
Students also identified lack of knowledge on spirituality and SC as a barrier to providing SC. Many students indicated that many pharmacists and pharmacy staff did not know much about SC and how to provide SC in practice. Purnell and Colleagues also found that pharmacy students lacked SC and spirituality training.32 This is understandable given that many schools and colleges of pharmacy do not provide this kind of education to students in the US and beyond.16,21 Most pharmacy schools and colleges do not cover this topic in their curriculum.16,21 Similarly, pharmacists also reported that lack of education and training was a barrier to their provision of SC.8,9 Consequently, many pharmacists and students do not have the knowledge, skills and confidence to provide SC or to address patients' spiritual and religious concerns.1,9 Furthermore, there are no clear professional guidelines pertaining to SC and no known pharmacy professional organization has clearly outlined the role of the pharmacist in meeting or addressing patients' spiritual needs. Spirituality is not explicitly mentioned in the code of professional conduct for pharmacists thus resulting in role ambiguity concerning SC in pharmacy practice. More pharmacists would value and integrate spirituality and SC if they were explicitly included in the pharmacy professional code and had appropriate spirituality and SC education and training. Some pharmacists recommend more education and training on spirituality and SC in pharmacy education to better prepare students to provide holistic patient care.32, 33, 34
Some students indicated that some patients were not comfortable and did not want to talk about spirituality in the pharmacy or to accept SC. Previous studies also reported that some few patients did not welcome or appreciate SC from HCPs.35,36 Similarly, some pharmacists also believed that some patients did not want to talk about spirituality or to receive SC.8,9 Given their limited knowledge, time and guidance to screen patients for spiritual needs, pharmacists and pharmacy staff typically just end up not providing SC to all patients.
8. Limitations of study
Several limitations should be considered when interpreting the findings of this study. First, the sample utilized for this study were students from a single faith-based private institution. These students may not be representative of all the pharmacy students in California and the United States. Second, the data reported here were self-reports from the students who responded to a single open-ended question on an assignment. It is possible that these findings may not capture the full breadth of all the possible barriers actually found in pharmacy practice. We were not able to collect non-verbals because we used written responses from the students. Finally, although two investigators independently analyzed the data, the analysis is subjective and other researchers could have arrived at different interpretations and conclusions.
9. Conclusions
Major barriers to SC include lack of time for SC, lack of supervisor and company support for SC, and discordant pharmacist-patient spiritual beliefs. Future studies should be conducted to investigate these and other barriers to SC in pharmacy practice.
Funding
This study did not receive any specific grant from funding agencies in the public, commercial, or not for profit sectors.
CRediT authorship contribution statement
Paul Gavaza: Conceptualization, Methodology, Formal analysis, Investigation, Writing – original draft, Investigation, Resources. Bhaktidevi M. Rawal: Conceptualization, Validation, Formal analysis, Writing – review & editing. Elizabeth Johnston Taylor: Conceptualization, Methodology, Validation, Writing – review & editing.
Declaration of Competing Interest
The authors declare no relevant conflicts of interest or financial relationships.
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