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 DOI: 10.1177/0898010111418118

2012 30: 24 originally published online 21 September 2011J Holist NursKaren Scott Barss

T.R.U.S.T.: An Affirming Model for Inclusive Spiritual Care  

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24

Journal of Holistic NursingAmerican Holistic Nurses Association

Volume 30 Number 1March 2012 24-34

© 2012 AHNA10.1177/0898010111418118

http://jhn.sagepub.com

jhn

T.R.U.S.T.

An Affirming Model for Inclusive Spiritual Care

Karen Scott Barss, RPN, BHSc, MA Saskatchewan Institute of Applied Science and Technology

Literature across health care disciplines has come to acknowledge spiritual care as integral to holistic health promotion. However, caregivers often continue to be reluctant to explore the spiritual dimension of health with their clients. In order to help caregivers feel more prepared to offer spiritual care, the author has drawn upon the interdisciplinary literature to develop the T.R.U.S.T. Model for Inclusive Spiritual Care. This article introduces the T.R.U.S.T. Model and its foundational concept of ‘inclusive spiritual care’: relevant, non-intrusive care which tends to the spiritual dimension of health by address-ing universal spiritual needs, honoring unique spiritual worldviews, and helping individuals to explore and mobilize factors that can help them gain/re-gain a sense of trust in order to promote optimum healing. The article also describes the T.R.U.S.T. Model’s origins, underlying assumptions, and its non-prescriptive outline for exploring five topics: ‘Traditions’, ‘Reconciliation’, ‘Understandings’, ‘Searching’, and ‘Teachers’. Guidelines are included for using T.R.U.S.T. to enhance holistic health care, with an emphasis on its use in holistic nursing practice.

Keywords: spiritual care; cultural competence; holistic care; spirituality; holistic nursing; theory-based interventions; nurse-patient relations

Literature across health care disciplines has come to acknowledge spiritual care as integral to holistic health promotion (Benefiel, 2009; Carr, 2010; Hodge, 2006; Koenig, 2007; Lemmer, 2010, 2005). The literature also reflects a growing attentiveness to approaching spiritual care in an inclusive manner, given the diversity of spiritual worldviews increasingly evident in today’s pluralistic, postmodern context (Heelas & Woodhead, 2005; McSherry & Ross, 2010; Pesut, 2009; Young & Koopsen, 2011).However, caregivers often continue to be reluctant to explore the spiritual dimension of health with their clients, even though substantial literature exists about best practices for culturally safe spiritual care (Handzo, 2006; Hodge, 2006; Molzahn & Sheilds, 2008; Pinto, March, & Pravikoff, 2008; Plotnikoff, 2007).

To address the increasing complexity and ongoing reluctance in relation to offering spiritual care, evolution of integrative, interdisciplinary resources is essential (Lemmer, 2010; Willison, 2008). Health care professionals require encouraging, concrete, yet nonprescriptive resources that explicitly reflect and reinforce current best practices and accreditation standards in the fast-paced, often discouraging

health care environment (Benefiel, 2009; Carr, 2010; Sawatzky & Pesut, 2005). The author, a nurse educator and spiritual director, has drawn on the interdisciplinary literature to develop the T.R.U.S.T. Model for Inclusive Spiritual Care: an affirming, evidence-based, nonlinear model for inclusive spiritual assessment and intervention, created to help health care professionals feel more prepared to address the spiritual dimension of health as an integral part of holistic care (Spiritual Directors International, 2011).

A variety of spiritual assessment and care models have been reported in the nursing literature (Jackson, 2011; McSherry & Ross, 2010; Puchalski & Ferrell, 2010). However, the language used in these models does not yet consistently reflect the inclusive nature

Author’s Note: The author gratefully acknowledges support from the following in the preparation of this article: Dr. Susan McClement, Scholar-in-Residence, SIAST Nursing Division; Alexis Watt, Graphic Artist, SIAST; Office of Applied Research and Innovation, SIAST; and faculty and students, SIAST Nursing Division. Please address correspondence to Karen Scott Barss, Saskatchewan Institute of Applied Science and Technology, PO Box 1520, Saskatoon, Saskatchewan, S7K 3R5, Canada; e-mail: karen.barss@siast.sk.ca.

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of current best practices literature as suitable within a pluralistic, postmodern context. Nor have existing models been able to address nurses’ ongoing lack of consistent engagement in spiritual care. The T.R.U.S.T. Model for Inclusive Spiritual Care was created to address these limitations. The purpose of this article is to provide an overview of the T.R.U.S.T. Model’s origins and grounding assumptions, introduce the T.R.U.S.T. Model itself, and offer guidelines for using T.R.U.S.T. to enhance holistic health care, with an emphasis on its use in nursing practice.

Overview of the T.R.U.S.T. Model for Inclusive Spiritual Care

The T.R.U.S.T. Model is an affirmation of inclusive spiritual care for those both providing and receiving health care (see Figure 1). Such attention to both partners in the therapeutic relationship is a cornerstone of holistic health promotion, particularly with regard to spirituality and healing, which are deeply relational in nature (Dossey & Keegan, 2009; McSherry, 2006;

Rakel & Weil, 2007). As such, the T.R.U.S.T. Model’s inclusive nature directs support not only toward the process of offering spiritual care to promote clients' healing; the resource is also intended to support caregivers in their own spiritual reflection and holistic health promotion, which are key factors in gaining comfort and skill to facilitate clients’ spiritual exploration (Carr, 2010; McEewen, 2005; Ross, 2006).

The author has drawn on the interdisciplinary literature to define inclusive spiritual care as relevant, nonintrusive care, which tends to the spiritual dimension of health by addressing universal spiritual needs, honoring unique spiritual worldviews, and helping individuals explore and mobilize factors that can help them gain/regain a sense of trust to promote optimum healing (Caspi, 2007; Lemmer, 2010; Puchalski & Ferrell, 2010). As an affirmation, the model is intended to be a comforting reminder to trust in each individual’s unique abilities and worldview to promote well-being for self and others (Dossey & Keegan, 2009). Pesut (2003) defines worldviews as “the mental maps we use to explain the world around us,” maps that contain a set of core beliefs and meanings that ultimately drive our behavior (p. 291). The T.R.U.S.T. Model is intended to facilitate nonintrusive, relevant exploration of the spiritual dimension of health in ways that both value and transcend diverse worldviews to promote holistic health. The spiritual dimension of health is defined as the dimension of health associated with “matters of the spirit,” as ultimately defined by each individual (Buck, 2006; Lemmer, 2010). The spiritual dimension may or may not involve a sense of connection to a divine presence or to religious structures or traditions and is associated with universal spiritual needs such as trust, hope, meaning, purpose, interconnection, reconciliation, inspiration, and creativity (Lemmer, 2005; Mauk & Schmidt, 2004; McEwen, 2005; McSherry & Ross, 2010).

The T.R.U.S.T. Model is also enriched and informed by world wisdom traditions, the spiritual teachings of various religious and cultural traditions that are increasingly available, given the postmodern rise of “interspirituality” (Secrest & Fageol, 2008; Teasdale, 1999; Vest, 2003). Interspirituality refers to the sharing of ultimate experiences across traditions, while honoring their rich diversity and individuality (Teasdale, 1999). It also recognizes that many people tend to their spiritual needs

Figure 1. T.R.U.S.T.: An Affirmation of Inclusive Spiritual Care

Note: In keeping with the intentions of inclusive spiritual care, users are encouraged to draw on/invite personally meaningful imagery as an alternative or complement to imagery offered in T.R.U.S.T.

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26 Journal of Holistic Nursing / Vol. 30, No. 1, March 2012

outside of a specific tradition (Heelas & Woodhead, 2005; Teasdale, 1999). As such, this movement can offer insight and support to the cause of providing truly inclusive spiritual care.

The acronym T.R.U.S.T. and the imagery emerged from the author’s reflective writings on her personal experience of reconnecting to a sense of trust in the wake of a life-threatening illness. As the author considered a relevant and affirming acronym for an inclusive spiritual care resource, she revisited these writings and noted how frequently the word “trust” appeared (Scott Barss, 1999, 2005). She was also reminded of how central nonintrusive, relevant spiritual care had been to her ability to reconnect to that sense of trust that profoundly influenced her healing process. Drawing on her personal experience and the professional literature, the author defines trust as a state of confidence in and receptivity to optimum healing (Caspi, 2007; Rakel & Jonas, 2007; Scott Barss, 1999).

In reviewing the interdisciplinary literature, the author has defined healing as the process of moving toward wholeness in all dimensions of health, encompassing the mental, emotional, physical, relational, cultural, and spiritual; as such, it may or may not be associated with “curing” (Dossey & Keegan, 2009; Puchalski & Ferrell, 2010; Rakel & Jonas, 2007). The author’s personal experience with the interrelationship between trust and healing mirrors current integrative health care literature. This literature, which integrates evidence-based care from all healing systems (i.e., biomedical and “complementary”) recognizes healing can be significantly enhanced (up to 30%) when individuals experience a sense of trust in their healing process and relationships (Caspi, 2007; Rakel & Weil, 2007). Such enhanced outcomes are mediated

through activation of “the healing response,” a phenomenon increasingly validated by the field of psychoneuroimmunology wherein fulfilled spiritual needs affiliated with trust (such as hope, meaning, mastery, and calm) are observed to promote enhanced overall physiological functioning and openness to mental, emotional, spiritual, and relational transformation (Caspi, 2007; P. Clarke, Watson, & Brewer, 2009; Fortney & Bonus, 2007; Wright & Bell, 2010).

It is, then, this sense of trust that most clearly links spirituality and health, making spiritual care not only highly relevant but also essential to patient safety (Pinto et al., 2008). Since our spirituality is intricately connected to our sense of trust, nurturing a health-promoting spirituality is pivotal to fostering the trust needed to optimize holistic well-being (Wright & Bell, 2010). To neglect spirituality or to approach it in an intrusive manner is to place individuals at risk of experiencing a thwarted healing process. At best, such neglect or disrespect results in missed or squandered opportunities for trans-formation and greater wholeness that can emerge from crises (P. Clarke et al., 2009). At worst, absent or inappropriate spiritual care results in aborted healing, which can significantly compromise well-being in relation to every dimension of health (Pinto et al., 2008; Wright & Bell, 2010).

The T.R.U.S.T. Model assumes nurses’ competence to create and sustain therapeutic relationships and to assist clients to identify and pursue their health goals in an empowering manner (Balzer-Riley, 2008; Egan & Schroeder, 2008; Rollnick, Miller, & Butler, 2008). It also assumes that nurse educators have the interpersonal skills necessary to promote trusting collegial relationships with those they mentor, a pivotal factor in learning how to provide safe and

Table 1. T.R.U.S.T.: Grounding Assumptions

•  Evidence-based, inclusive spiritual care is integral to holistic health promotion.•  Caregivers need concise, affirming resources to consistently offer spiritual care.•  The spiritual needs of those both offering and receiving care must be addressed.•  Spiritual care is relational, thus rooted in trust between and within those involved.•  Trust, as a precursor to healing, is an essential link between spirituality and health.•  Evidence-based, inclusive spiritual care is a patient safety issue.•  Caregiver interpersonal competence is pivotal to inclusive spiritual care.•  Explicit examples of nonintrusive, inclusive language enhance caregiver comfort and skill.•  The T.R.U.S.T. Model’s imagery invites exploration of imagery meaningful to users.•  Spiritual care involves a natural progression between assessment and intervention.•  Caregivers have an ethical responsibility to ensure appropriate follow-up and referral.

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meaningful spiritual care (Hood, Olson, & Allen, 2007). The model aims to help caregivers reinforce and mobilize these foundational interpersonal skills to deepen their comfort and consistency in offering spiritual care. The T.R.U.S.T. Model’s grounding assumptions are summarized in Table 1.

The T.R.U.S.T. Model’s Five Topics for Exploration

Rooted in its evidence-based grounding assump-tions, the T.R.U.S.T. Model offers a concise, but nonprescriptive outline for exploring five topics: Traditions, Reconciliation, Understandings, Searching, and Teachers. These topics reflect recommended best practices in the nursing literature and cue assessment of all areas required in the frequently cited standards put forth by the Joint Commission on Accreditation of Healthcare Organizations (Hodge, 2006; Pinto et al., 2008).

Inclusive, nonintrusive language is used to help caregivers explicitly honor diverse worldviews and emphasize relevance to health care. In addition, caregivers are reminded to regularly invite clients’ definitions, interpretations, and adaptations of this language to ensure that each client’s worldview remains central to the exploration (Pesut, 2009; Plotnikoff, 2007).

Even when the client’s language and worldview guide the exploration, it can be very difficult to clearly convey the relevance of spiritual care in ways that are nonintrusive and client centered (Pesut,

2008, 2009). The T.R.U.S.T. Model’s nonlinear nature and imagery endeavor to address this challenge by emphasizing that spiritual exploration can begin on any one of its interconnected five “stems,” as determined through deep listening for the client’s uppermost concerns and questions. However, for the purpose of introducing the model, these topics will be introduced in order from left to right (see Figure 2).

Traditions?

The first “T” refers to “traditions,” wherein the focus is on exploring the impact of clients’ past and present spiritual/religious/cultural/healing traditions and practices on their well-being (Pinto et al., 2008; Plotnikoff, 2007). Since not all traditions and practices may nurture or enhance one’s well-being, it is important to avoid the common trap of assuming that identified tradition(s) have relevance to or positive influence on clients' health (Plotnikoff, 2007).

Any number of examples exist as to how one’s identified tradition(s) may not meet one’s spiritual needs, ranging from a doctrine that conflicts with personal beliefs to personal and/or communal interpretations of that doctrine that are experienced as blocks to personal well-being (Plotnikoff, 2007; Puchalski & Ferrell, 2010). If individuals experience all or part of an identified tradition as irrelevant or counterproductive to their health and healing, it is important to help them identify that reality and to explore how they wish to address it.

Conversely, traditions and practices that individuals experience as life giving and health promoting can be essential catalysts for coping, healing, and transformation (Mehl-Madrona, 2003; Puchalski & Ferrell, 2010). Spiritual practices are defined as practices that nurture the spirit (Plante, 2010; Puchalski & Ferrell, 2010; Teasdale, 1999). “All spiritual practices are transformative, be they contemplative forms of prayer, meditation, and sacred reading; a restful, active participation and presence in liturgy and ritual; music and chanting; yoga and certain martial arts; hiking and even walking” (Teasdale, 1999, p. 129). In addition, integrative health care literature increasingly documents the physical benefits associated with such practices, including functional enhancement of the immune, cardiovascular, musculoskeletal, and nervous systems (Fortney & Bonus, 2007; Mehl-Madrona, 2003). Central to inclusive spiritual care is assisting individuals

Figure 2. T.R.U.S.T. Model for Spiritual Assessment and Care

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to explore and mobilize the spiritual practices they find most healing (particularly those that foster a sense of trust in the healing process), remembering that individuals’ choices may be influenced by more than one tradition (Heelas & Woodhead, 2005; Lemmer, 2010; Plante, 2010; Vest, 2003).

Reconciliation?

The “R” stands for “reconciliation,” offering reminder to explore any unresolved issues and how they might be reconciled. Often, reconciliation is needed in terms of acceptance of the immediate crisis or circumstances at hand, so one can eventually move into a health-promoting state of peacefulness and trust (Caspi, 2007). Reconciliation might also involve a self-identified need for healing or forgiveness within a relationship or oneself (Rindfleisch, 2007). “There is strong evidence that forgiveness can improve health in individuals with a variety of physical and psychological conditions” (Rindfleisch, 2007, p. 1046).

Since the need for reconciliation is often associated with past or present trauma, it is critical that the individual’s interpretations, personal boundaries, and pacing be respected throughout the exploration—and that sufficient personal and professional support is consistently available. Any sense of judgment or rushing of the process has the potential not only to block healing but also to further traumatize the individual (Rindfleisch, 2007).

Conversely, given enough time and support, reconciliation can assist individuals to make meaning of their suffering and move through tragedy and pain toward greater wholeness (Rindfleisch, 2007; Wright & Bell, 2010). To this end, it is particularly important that this area of exploration includes identification of the client’s personal meaning of terms such as reconciliation and forgiveness, keeping in mind that commonly associated words from the predominant “Western” worldview such as sin and grace may be irrelevant or even harmful for someone who makes meaning from a different worldview (Secrest & Fageol, 2008; Vest, 2003). For example, someone who identifies strongly with an “Indigenous” worldview will likely resonate more with an intent to return to a natural state of “balance” or “harmony” than with “forgiveness of sin” (V. Clarke & Holtslander, 2010; Hunter, Logan, Goulet, & Barton, 2006). Similarly, an individual who identifies with an “Eastern” worldview may resonate most with

language such as “nonattachment” or “letting go” of suffering (Rinpoche, 2002). Only through ongoing reflective dialogue will individuals be able to find voice for personal language that can help them make meaning of and reconcile their painful experiences (Wright & Bell, 2010).

Understandings?

The “U” addresses “understandings,” the individual worldview and associated personal beliefs that can significantly influence well-being (Pesut, 2009; Wright & Bell, 2010). Given the significant validation in the scientific literature over the past two decades about the ability of our beliefs to influence health positively or negatively, it is essential for clients and their caregivers to be aware of which beliefs are sustaining, inspiring, and health promoting—and which ones are distressing, disempowering, and health compro-mising (Pinto et al., 2008; Wright & Bell, 2010). Identifying the former creates opportunity to mobilize such affirming beliefs, whereas identifying the latter offers invitation for individuals to challenge unhealthy beliefs and to eventually find related reconciliation (Rakel & Wiel, 2007; Rindfleisch, 2007; Wright & Bell, 2010).

Searching?

The “S” refers to “searching.” Reconciliation and realization of health-promoting spiritual under-standings is, of course, impossible without consid-erable exploration of existential and/or faith questions prompted by current suffering (Plotnikoff, 2007; Rindfleisch, 2007; Wright & Bell, 2010). Frequently, individuals’ previously held beliefs are no longer serving them, creating a strong need for them to challenge old beliefs and seek new ones that help make meaning of their current distress (Wright & Bell, 2010). Depending on individual beliefs, some will seek this meaning in a secular context such as the humanities and social sciences (Heelas & Woodhead, 2005). Others will seek this meaning through exploration of their natal and, increasingly, additional traditions (Secrest & Fageol, 2008; Teasdale, 1999). The interspiritual movement affords the latter, since “every form of religion is an effort to respond faithfully to the mystery of the sacred by whatever name” (Vest, 2003, p. vii). Whatever resources the client deems suitable for his or her search, it is critical that caregivers offer explicit

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validation and active support for individuals to find ways of meeting the universally recognized spiritual need to explore and make meaning around the mystery of suffering (Wright & Bell, 2010).

Teachers?

The final “T” represents “teachers,” encompassing the spiritual, religious, and personal mentors and internal/external resources individuals trust to help sort through the spiritual issues they see as relevant to their healing process. These resources may include any of the clients’ caregivers on the health care team with whom they have developed a strong sense of trust (McSherry & Ross, 2010; Olson & Clark, 2010; Puchalski & Ferrell, 2010; Young & Koopsen, 2011). They may also include trusted spiritual and/or religious leaders and healers, along with affiliated sacred texts and teachings (Vest, 2003). Increasingly, individuals are seeking out spiritual directors or companions, those educated to engage in the process of accompanying people on the spiritual journey (Spiritual Directors Inter-national, 2011). Other “teachers” may include any readings, educational events, retreats, or experiences individuals identify as helpful in meeting their spiritual needs. The caregiver needs nothing more than a sense of humility to help clients explore their potential options. This sense of humility allows the caregiver to be informed by colleagues; by clients and their self-identified, relevant traditional communities; and by the resources themselves (Plotnikoff, 2007; Vest, 2003; Young & Koopsen, 2011). Such humility also allows the caregiver to be deeply observant about internal resources evident within clients themselves and to share these observations with clients to empower, inspire, and promote well-being (Plotnikoff, 2007; Young & Koopsen, 2011).

Guidelines for Use of the T.R.U.S.T. Model

The guidelines offered in this article focus on use of the T.R.U.S.T. Model with clients in the practice setting, keeping in mind that T.R.U.S.T. is also intended to support caregivers to facilitate and deepen their own spiritual exploration. When working with clients, the ongoing necessity of using the model’s language and structure in an exploratory,

nonlinear manner cannot be overemphasized. Closely related is an emphasis on the importance of each caregiver carefully discerning whether to directly share the T.R.U.S.T. Model’s acronym and imagery with clients and, if so, actively inviting conceptualizations and imagery from each client’s worldview in the process. It is possible that these more concrete aspects of the model are not relevant or helpful to the exploration, depending on the caregiver and/or client’s worldviews, learning styles, vocabulary, and the context of their relationship. In this case, the model may be more an internal reference point to support the caregiver in facilitating and focusing their spiritual assessment and care. Regardless of how T.R.U.S.T. is drawn on, specific guidelines are necessary in relation to using it to carry out appropriate initial spiritual assessment and facilitate deeper levels of spiritual assessment and care. These guidelines are now offered.

Recommendations for Initial Spiritual Assessment

Recommendations for initial spiritual assessment represent the minimum standard of spiritual assessment and care now being routinely required by accreditation bodies in a variety of jurisdictions (Pinto et al., 2008). This standard aims to ensure that all who wish to receive spiritual care within the context of their holistic health care are explicitly invited to receive it in ways that uphold their dignity and demonstrate respect for their worldview.

At the same time, it is essential to uphold the principle of human dignity by avoiding assumption that clients wish to receive spiritual care or see it as relevant to their current health care (McSherry, 2006; Pesut, 2009; Pinto et al., 2008; Young & Koopsen, 2011). Before initiating conversation about this very personal aspect of one’s well-being, it is essential for caregivers to clearly communicate the relevance of such inquiry. This relevance can be clarified by sharing information such as the following: “As part of offering holistic care, we would like to be aware of anything you consider to be important in relation to the spiritual aspect of your care.” Caregivers may need to spend time clarifying and inviting the client to self-define the nature of “the spiritual”—or may prefer to use alternate language that speaks more directly to relevant spiritual needs (e.g., “finding hope” or “making meaning” in relation to clients’ current challenges). At the appropriate

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time in the ensuing conversation (in a nonlinear, nonintrusive, client-centered manner), the initial assessment questions need to be addressed (see Figure 3).

Each of the initial assessment questions are closed ended (i.e., answerable with a “yes” or a “no”) to avoid assumption that the individual has or wishes to share related information (Balzer-Riley, 2008). Each such question needs to be followed up with relevant open-ended questions and empathetic responses that facilitate identification of how spiritual care can be integrated into holistic care in an individualized, nonintrusive manner. Specifically,

. . . if the answer is “yes”:“What are these? How can we help to integrate

them into your health care/healing process?”. . . if the answer is “no”:“Sometimes people become aware of and/or feel

more comfortable sharing spiritual concerns as they become better acquainted with the health care team. Please feel free to raise any such concerns that may arise at any time and to ask us to help seek out any resources you might like.”

It is essential to provide follow-up assessment and intervention as desired by the individual. The caregiver doing the initial assessment is not necessarily the most appropriate person to provide this more in-depth spiritual care, but is the person accountable for ensuring that appropriate referral is made, based on the client’s wishes (Hodge, 2006; Plotnikoff, 2007).

Recommendations for Ongoing Spiritual Assessment and Care

The guidelines for ongoing use of the T.R.U.S.T. Model are based on the premise that spiritual assessment and care are intricately intertwined, particularly when spiritual assessment is approached in a collaborative, inspiring manner (McSherry, 2006; Rollnick et al., 2008). As such, spiritual care may already have unfolded naturally out of the initial spiritual assessment, since so much of spiritual care involves simply being fully present and listening deeply to individuals’ spiritual needs and questions (Benefiel, 2009; Hodge, 2006; McSherry, 2006).

However, if clients indicate during the initial assessment that they wish to receive further spiritual care, two key considerations must be consciously integrated in determining how ongoing spiritual care will most appropriately be offered. First, it is important to clarify whom clients wish to provide this care. Further exploration of “Teachers” may assist in this clarification, noting carefully with whom clients voice and demonstrate a sense of trust. This vigilance helps ensure that spiritual care is experienced by clients as relevant, inclusive, and nonintrusive. Second, it is essential for all involved caregivers to carefully discern whether the context of their therapeutic relationship with a given client ethically affords deeper exploration, given the existing level of trust and the anticipated length of that relationship. Each caregiver also needs to honestly self-evaluate their expertise in the spiritual care needed to address individual clients’ specified needs in the context of their particular worldview, issues, and health status (Handzo, 2006; Hodge, 2006; McSherry & Ross, 2010). In this way, those offering and receiving care can co-discern which members of the health care team or community can best meet clients’ identified spiritual needs at a given time. If those needs are beyond the initial caregiver’s scope of practice, referral needs to be made to spiritual caregiver(s) co-identified as being most suitable to offer ongoing spiritual care for as long as the client wishes (Hodge, 2006; McSherry & Ross, 2010).

Throughout the process, it is essential that each care provider ensures clients’ spiritual, psychological, and physical safety by providing appropriate referral and follow-through in relation to concerns shared as a result of engaging in this deeper level of spiritual assessment and care. Such protection includes identification of and intervention with levels of

Figure 3. T.R.U.S.T. Initial Assessment Questions

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Table 2. T.R.U.S.T.: Sample Reflective Questions

Traditions • Are there things about your spiritual, religious, cultural, and/or healing traditions/practices/experiences you would like the

health care team to be aware of? How might these affect how we work together?a

• What practices, activities, or issues are you inspired by/passionate about? How can these be integrated into your healing? What new practices, activities, or issues might you like to explore?

• Do you have affiliation with particular spiritual, religious, cultural, and/or healing tradition(s) If so, . . . Do you see it/them as a current source of strength? Of distress? How so? Are there aspects of/experiences with your tradition(s) that you feel contribute to your well-being? Compromise your well-being?

• What do/does your tradition(s) say about the nature of suffering? How do you feel about that?• What gives you hope? How can we help you connect to your sources of hope?• How are you creative in your daily life? Your coping? How can this creativity be applied to your current challenges? To your life

in general?Reconciliation• Are there any unresolved issues you would like support in exploring at this time?a

• Are there situations, choices, or actions of others in your life with which you cannot currently make peace? How does this influence your sense of well-being? What do you wish to do with this awareness?

• Do you find yourself focusing on past choices or actions that you regret? How does this focus influence your sense of well-being? What do you wish to do with this awareness?

• What does “reconciliation” mean to you? What would “reconciliation” look/feel like to you? What might be the benefits of reconciliation?

• Do your current spiritual/religious/cultural traditions play a role in finding reconciliation? What do their teachings say about “reconciliation”/“forgiveness”/”non-attachment”/“rebalancing”? Do they assist?/interfere? How so?

• Have you found anything positive arising from your painful experiences (e.g., development of inner strengths you didn’t know you had; closer relationships; deeper trust; lessons learned; deeper appreciation for the good times; a sense of purpose or meaning, more creative coping)? If so, how does/can this enhance your daily life amid the difficulties you face? If not, does it feel okay, for now, to grieve the losses associated with your difficulties?

• What/who can sustain you until you feel more hopeful/peaceful? Do you see yourself being able to feel more hopeful/peaceful?Understandings• Are there particular personal beliefs or practices sustaining you/offering you comfort at this time? How can we help you draw

on these for strength?a

• Are you aware of any beliefs or questions that are distressing/compromising your well-being? If so, how do you wish to address these? Do you see it as possible to eventually transform them into ones that promote wellness?

• Are there particular spiritual, religious, or cultural influences that influence or inform your understandings? How do you feel about these influences?

• What do you believe about the nature of suffering? How do you think these beliefs are influencing your current healing process?

• What gives your life meaning? Is there any meaning that you make in relation to your current difficulties? If so, what? How does this influence the way you navigate your circumstances?

• Has this experience prompted you to ponder your overall life’s purpose(s)? If so, what is your sense about it/them? How does this influence your well-being/your approach to life?/your healing process?

Searching• Are there spiritually oriented questions about your current difficulties that you would like an opportunity to explore?a

• How have your current difficulties influenced your beliefs? Are there any of your previously held beliefs that you are currently questioning? How do you feel about questioning these beliefs? Does this type of questioning feel safe/unsafe? What/who contributes to this sense of safety/risk?

• What answers about life/death/spirituality are you currently seeking? How difficult is this searching?• What/who is a source of disillusionment for you? Have you had an opportunity to grieve associated losses? If not, how might

you do so?• Has the imposition of others’ beliefs added to your distress? If so, how? How can you gain protection from these intrusions?Teachers• Are there people/groups/groups/resources you find helpful in exploring spiritual questions? How can they be involved in your

healing process?a

• Whom do you consider to be your spiritual teachers/mentors/leaders/companions?• What readings and activities do you find personally inspiring or comforting? How might they contribute to your healing? How

can you draw these resources into your regular routine?• What new mentors, readings, activities and events would you like to access?• What resources within yourself can you name and draw on? What new internal resources would you like to develop?

a. Questions identified as suitable for initial assessment/trust building.

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distress that pose any risk to clients or others. It also includes facilitation of referral to appropriate resources and to relevant spiritual care professionals of the individual’s choice when questions/issues arise that are beyond the scope of a health care worker of another discipline (Handzo, 2006; Hodge, 2006).

For the caregiver offering deeper levels of spiritual assessment and intervention, the sample reflective questions in Table 2 may be helpful for the client to explore at the appropriate time of readiness, as determined by the client’s voiced and demonstrated need, openness, and ability (Rollnick et al., 2008). These questions are based on recommended best practices and sample questions evident throughout interdisciplinary spiritual care literature in relation to addressing various universal spiritual needs (Espeland, 1999; Handzo, 2006; Hodge, 2006; Jackson, 2011; Koenig, 2007). The questions also draw on the health-promoting practices of “Motivational Interviewing,” given their focus on being collaborative, evocative, and empowering in their language and usage (Rollnick et al., 2008).

The sample questions provided may simply be internal questions that spiritual care providers use to focus their listening and facilitation. On the other hand, some questions may be specifically asked to help motivate and inspire clients to engage in spiritual exploration and mobilize their spiritual resources (Rollnick et al., 2008). Regardless, the caregiver will need to use a variety of therapeutic communication techniques and helping skills in the exploration process (Balzer-Riley, 2008; Egan & Shroeder, 2008). Deep listening is essential for caregivers to discern which questions are currently most relevant to the client. Such deep listening also assists caregivers to continually take note of the individual’s language and related worldviews and to ask additional clarifying questions that ensure facilitation is not limited by assumptions from caregivers’ own worldview (Secrest & Fageol, 2008). The reflective questions identified are most safely, appropriately, and meaningfully explored when they arise naturally out of listening intently to what is uppermost in individuals’ awareness/experience and are individualized to meet the person where they are (Espeland, 1999; McSherry & Ross, 2010). At their best, such questions are interspersed with sharing information and observations that clarify their relevance and that help individuals apply and mobilize their spirituality to reach their self-identified goals for well-being (Balzer-Riley, 2008; Egan & Schroeder, 2008; Rollnick et al., 2008).

Given its grounding assumption that spiritual assessment and care are intricately intertwined, the

T.R.U.S.T. Model’s emphasis, then, is clearly on implementing conversation that fosters safe, relevant exploration of how clients’ spiritual needs and resources can be addressed and mobilized to promote healing. As such, the model has not included formal ways of conceptualizing and documenting spiritual diagnoses and interventions, particularly since literature from various professional disciplines already offers numerous such frameworks (Hodge, 2006; Koenig, 2007; McSherry & Ross, 2010; Olson & Clark, 2010; Pesut, 2008; Puchalski & Ferrell, 2010; Young & Koopsen, 2011). Rather, the T.R.U.S.T. Model emphasizes explicit language, topics, and questions that may help clarify the relevance of and enhance comfort with exploring spiritual needs and mobilizing spiritual resources in the health care context. As such, caregivers are encouraged to trust in their ability to facilitate creative, individualized dialogue and intervention through listening carefully for and following their client’s lead in order to provide truly client-centered care.

Conclusion

Spiritual care provision in today’s pluralistic, postmodern context involves an unprecedented degree of challenge. However, such care provision also enjoys an unprecedented degree of opportunity. The interdisciplinary literature is now offering evidence-based validation for its centrality to health promotion. For the first time, best practice guidelines and accreditation standards are not only affirming but also requiring the integration of spiritual care in the context of holistic care. Furthermore, this evolution is paralleled by the interspiritual movement that fosters greater dialogue than ever among those with diverse spiritual traditions, practices, and beliefs.

Therefore, it is essential to develop resources that can help caregivers to address the challenges and maximize the opportunities at hand. The T.R.U.S.T. Model for Inclusive Spiritual Care is one such resource. Ongoing interdisciplinary research will determine the T.R.U.S.T. Model’s effectiveness in increasing caregiver comfort and consistency of offering spiritual care in keeping with existing best practice and accreditation guidelines. Such investigation also needs to examine the model’s potential positive impact on patients. Foundational to this ongoing inquiry is the author’s current qualitative study on the experiences of nursing faculty, students, and clinicians in use of the by guest on March 21, 2014jhn.sagepub.comDownloaded from

T.R.U.S.T. Model for Inclusive Spiritual Care / Scott Barss 33

T.R.U.S.T. Model for Inclusive Spiritual Care (Scott Barss, 2010).

In the meantime, it is the author’s hope that centering our spiritual exploration around the affirming symbol of “T.R.U.S.T” serves as a reminder to trust that we, as caregivers, can foster relevant, safe, and inclusive spiritual care; individuals we care for can gain trust in their ability to heal; individuals’ sense of trust will promote optimum healing; and conversations at a spiritual level will unfold as trust deepens within and between those giving and receiving care. May each of us feel richly validated, nurtured, and supported as we continue our explorations of this powerful and transcendent dimension of holistic health.

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Karen Scott Barss, RPN, BHSc, MA, is a faculty member in the Nursing Division of the Saskatchewan Institute of Applied Science & Technology and an Adjunct Professor of the University of Regina, College of Nursing. She is also a spiritual director and writer with a focus on holistic healing.

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