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June 2014 Article of the Month
This month's article selection is by Chaplain John Ehman,
University of Pennsylvania Medical Center-Penn Presbyterian, Philadelphia PA.


Puchalski, C. M., Vitillo, R., Hull, S. K. and Reller, N. "Improving the spiritual dimension of whole person care: reaching national and international consensus." Journal of Palliative Medicine 17, no. 6 (June 2014): 642-656.

[Note: This article is available from the Health Sciences Research Commons of the George Washington University's Himmelfarb Health Sciences Library.]


SUMMARY and COMMENT: This month's featured article is the much-anticipated report of the January 2013 international conference, On Improving the Spiritual Dimension of Whole Person Care: The Transformational Role of Compassion, Love, and Forgiveness in Health Care (Geneva, Switzerland), also containing information about the November 2012 National Consensus Conference on Creating Compassionate Systems of Care (Washington, DC). While not a report of research, this is a significant article in the field of Spirituality & Health for its conceptualization and definition of spirituality and its practical support of research and other key agendas in the development of consensus-driven standards for spiritual care.

The authors give at the outset a good background to events leading up to the 2013 conference, highlighting the seminal work of a 2009 consensus conference, Improving the Quality of Spiritual Care as a Dimension of Palliative Care [Pasadena, CA], which "resulted in unprecedented international impact that reached far beyond the field of palliative care," with its "model and recommendations…[being]…well received in the United States…" [p. 643, and see Items of Related Interest, §I (below)]. The 2009 conference formed the foundation for the 2012 meeting, and the latter furthered the conceptualization of spirituality in health care along the lines of "relationship-centered compassionate care" [p. 643].

At the opening of the [2012 Washington] conference, participants reviewed and discussed models in which compassion is recognized as an aspect of spirituality. More specifically, a clinician’s capacity to be compassionate is connected to his or her own inner spirituality or vocation. Compassion is an attitude, a way of approaching the needs of others and of helping others in their suffering. But more importantly, compassion is a spiritual practice, a way of being, a way of service to others, and an act of love. Thus, spirituality is intrinsically linked to compassion…. [p. 643]
This Model of Spirituality and Compassion (given graphically in a figure on p. 644) "depict[s] how spiritual care is entirely relationship based…" [p. 643].

The 2013 Geneva conference brought forward the work of the earlier meetings, "as well as…the importance of understanding and empathy" --"focus[ing] on the importance of understanding and empathizing with the diverse but often subtle cultural mores that influence spiritual beliefs and practices throughout the world" [p. 645]. In light of this, "[c]onference participants were charged with (1) identifying a multiculturally appropriate definition of spirituality within a health care context and (2) proposing consensus-driven standards of care to create whole person, compassionate health care systems through the integration of spirituality and health" [p. 645].

Regarding the task of definition, the authors write: "After a robust and dynamic discussion with several rounds of voting, agreement was reached on the following definition of spirituality:"

Spirituality is a dynamic and intrinsic aspect of humanity through which persons seek ultimate meaning, purpose, and transcendence, and experience relationship to self, family, others, community, society, nature, and the significant or sacred. Spirituality is expressed through beliefs, values, traditions, and practices.
An innovation in this definition from ones developed at the previous conferences is the addition of "a sentence on how spirituality might be expressed" [p. 645]. Moreover, the definition is intentionally broad, "so that as health care providers address spiritual issues with patients, they can remain alert to and hear whatever gives deep meaning to the patient, whether existential, religious, personal, or secular" [p. 646]. The article goes on to describe briefly some of the thinking behind the definition [--see esp. pp. 645 and 648], including the complex connotations and associations of specific words debated by conferees.

Regarding the second major goal of pressing for standards of care, recommendations were drafted around six themes: research, clinical care, education, policy/advocacy, communication, and community involvement. Each is treated individually in the text [pp. 646-648], but the section on research deserves particular attention here:

To generate a scientifically robust evidence base, a research network should be established and linked to key researchers and existing networks. It should house a research database and provide a platform for exchange of evidence-based information, both online and face to face. A major goal of the network should be to establish a research agenda based on the priorities of clinicians, researchers, and patients. The agenda should recognize the importance of establishing the therapeutic effectiveness and cost effectiveness of spiritual care interventions. Several overarching frameworks were discussed, including a learning organization framework with the aim of evidence-based formation of clinicians and health systems/settings to promote health and reduce suffering. [p. 646]
Among specific recommendations are: conducting multicenter research within a three-year period ("e.g., use the research network and small grants to fund small collaborative projects on which to build" [p. 646]), linking research to policy initiatives like the Affordable Care Act, and exploring "plausible outcome measures for clinical research, such as staff retention, staff satisfaction, patient and family satisfaction, readmission, and resource utilization" [p. 646]. Twelve Recommended Standards for Spiritual Care are given in an appendix, including standard #4: "Development of spiritual care is supported by evidence-based research" [p. 656]. A focus of discussions is said to have been "ways to increase the scientific rigor related to spirituality and spiritual care research and practice so that evidence is consistent across different settings and methods of implementation" [p. 645].

It should also be noted that a section on Additional Recommendations and Themes [p. 648] contains a paragraph about the role and importance of chaplains, and the authors remark elsewhere that conferees "strongly emphasized the need for spiritual care professionals, such as trained chaplains, as part of the interprofessional team" [p. 646].

Just as the 2009 report of the Washington meeting has been widely cited (to date, in over 130 articles, in addition to many news stories), so too this current report of the Geneva conference may be expected to influencece the integration of spirituality in healthcare, through the literature and by such means as the newly created Global Network in Spirituality and Health [--see p. 649, and also Related Items of Interest, §II (below)]. Chaplains may come at this material from a quite different perspective than physicians, and the definition of spirituality proposed at the Geneva conference may seem overly broad to some (though chaplains participated in its construction [--see the list of conference participants in the appendices]), but this article is an important basis for, as the title states, "Improving the Spiritual Dimension of Whole Person Care" and potentially understanding how research and clinical chaplains may play a part in the achievement of that as an international goal.


Suggestions for the Use of the Article for Discussion in CPE: 

This article would naturally appeal to students who have a special interest in the international movement to integrate spirituality into healthcare and those who are curious about the dynamics and implications of the conceptualization of spirituality. For the former, the article could lead into a discussion of whether and how students have personally experienced the topic of spirituality coming up in healthcare and how they see it manifest at their CPE center. What do students make of the recommendations for Clinical Care [pp. 646-647], including the use of spiritual screening and assessment tools and the strategy of making a "business case for development and implementation of standards and tools" [p. 647]. The section of the article on chaplains [--see p. 648] may figure in here. Are students able to see their own work in relation to any of the conference's international-level recommendations? For those interested in the conceptualization of spirituality, discussion could revolve around a detailed analysis of the proposed definition [--see p. 646], especially in light of the authors' brief comments about some of the thinking behind the wording that was finally agreed upon [--see pp. 645 and 648]. (Writing the definition out on a board word-for-word may be useful here.) Do students believe that such a definition of spirituality supports a goal of hearing patients' expressions of spirituality most broadly and subtly? If students aren't sure about the proposed definition, would they like to try to create one? That exercise itself could be quite enlightening as a CPE group process.


Related Items of Interest:

I. Fore more on the February 17-18, 2009 conference held in Pasadena, CA, see: Puchalski, C., Ferrell, B., Virani, R., Otis-Green, S., Baird, P., Bull, J., Chochinov, H., Handzo, G., Nelson-Becker, H., Prince-Paul, M., Pugliese, K. and Sulmasy, D. "Improving the quality of spiritual care as a dimension of palliative care: the report of the Consensus Conference." Journal of Palliative Medicine 12, no. 10 (October 2009): 885-904. [This seeks to build upon the National Consensus Project for Quality Palliative Care: Clinical Practice Guidelines for Quality Palliative Care (available via Hospice and Palliative Nurses' Association) and another similar project, A National Framework and Preferred Practices for Palliative and Hospice Care (available from the Robert Word Johnson Foundation). A larger version of the report has been published as a book: Puchalski, M. and Ferrell, B., Making Health Care Whole: Integrating Spirituality into Patient Care, Templeton Press, 2010.


II. The Global Network for Spirituality & Health (GNSAH) is an initiative to sustain the efforts that were expressed through the Geneva conference. It will be coordinated by the George Washington Institute for Spirituality and Health (GWish) and Caritas Internationalis, and "led by the chairs of the conference working groups in research, education, clinical care, policy, and community engagement" [p. 649 of our featured article]. The GNSAH website is hosted through the GWish site at "In addition, the Spirituality Online & Education and Clinical Resource Center (SOERCE) will develop an online learning community and share resources from the network" [p. 649]. The SOERCE site is also hosted through GWish at, and is a long-standing online resource for general materials. It is a free but requires registration.


III. Our featured article makes several references to the World Health Organization and notes that one of the topics at the Geneva conference was the "WHO’s definition of health and its relationship to spirituality" [p. 645]. By way of background: during 1996-1997, a special group of the WHO's Executive Board reviewed the constitution of the organization, including its definition of health, and recommended that the definition originally adopted in 1946 be changed from "Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity" to "Health is a dynamic state of complete physical, mental, spiritual and social well-being and not merely the absence of disease or infirmity." The Executive Board then adopted that recommendation during its 101st session and on January 22, 1998 requested that the Director-General propose this as an amendment to the constitution to be considered at the 52nd World Health Assembly in May 1999. Ultimately, the change in the definition was never brought before the Assembly because of reservations in a pre-meeting subcommittee regarding any deliberation of changes to the constitution. For more on this course of events, see the following:

Bok, S. "WHO definition of health, rethinking the" [a.k.a., "Rethinking the WHO definition of health"]. In Heggenhoughen, K. and Quah, S., eds., International Encyclopedia of Public Health, vol. 6, pp. 590-597. San Diego, California: Academic Press, 2008. [This was originally published in 2004 as part of the Harvard Center for Population and Development working papers series. The author addresses the historical context for the WHO's definition of health and notes (p. 595) the attempt to change the definition in 1999 to include spirituality.]

Khayat, M. H. "Spirituality in the definition of health: the World Health Organization´s point of view." [1999]. Published online by the Swiss Academy of Medicine and Ethics, co-sponsored by the World Health Organization. Available at [This 1999 article, by the Deputy Regional Director of the WHO's Office for the Eastern Mediterranean gives insight into the background discussion of the proposal to add spirituality to the WHO's definition of health.]

Nagase, M. "Does a multi-dimensional concept of health include spirituality? Analysis of Japan Health Science Council’s discussions on WHO's 'Definition of Health' (1998)." International Journal of Applied Sociology 2, no. 6 (2012): 71-77. [This consideration from a Japanese perspective highlights the cultural diversity dynamics of any definition of spirituality, and it notes some of the concerns of one member of the subcommittee of the 52nd World Health Assembly that prevented deliberations on the constitution during the full Assembly.]

WHO: "Amendments to the constitution: report by the Secretariat [to the fifty-second World Health Assembly]," April 7, 1999. Available online from the WHO archives at [See p. 4.]

WHO: "Review of the constitution and regional arrangements of the World Health Organization: report of the special group" (EB101/7), November 14, 1997. Available online from the WHO archives at [See p. 2.]

WHO: "Review of the constitution of the World Health Organization: report of the Executive Board Special Group" (EB101.R2), January 22, 1998. Available online from the WHO archives at [See p. 1.]

While spirituality may not have become part of the WHO's definition of health, it is a subject of some consideration within the organization, as a basic search of the WHO website ( reveals. In recent years, spirituality has especially received attention in WHO materials regarding palliative care. See, for instance, the WHO's "Definition of Palliative Care" at

[Though ancillary to the present topic, it may be worth noting here with regard to the WHO and spirituality, the occasional confusion about classifications of pastoral care interventions attributed to the WHO but actually originating from an Australian version of the WHO's International Statistical Classification of Diseases. For more on this, see our January 2007 Article-of-the-Month.]


IV. There have been many articles in recent years that have addressed the conceptualization of spirituality in one form or another, but one of the more thought-provoking resources may be found in a somewhat older work: Unruh, A. M., Versnel, J. and Kerr, N., "Spirituality unplugged: a review of commonalities and contentions, and a resolution," Canadian Journal of Occupational Therapy - Revue Canadienne d'Ergotherapie 69, no. 1 (February 2002): 5-19. Though the focus of this article is an internal debate within the Canadian Association of Occupational Therapists concerning the centrality of the concept of spirituality, the authors present over a hundred definitions of spirituality in an extensive appendix [pp. 16-19] and group them by some common qualities. The seven thematic categories [explained on pp. 8-9] are: 1) relationship to God, spiritual being, higher power, a reality greater than the self; 2) not of the self; 3) transcendence or connectedness unrelated to a belief in a higher power; 4) existential, not of the material world; 5) meaning and purpose in life; 6) life force of the person, integrating aspect of the person; and 7) summative (i.e., efforts to combine multiple features of spirituality). This work was featured as our Network's first Article-of-the-Month in September 2002, and that page offers suggestions for further reading as well.



If you have suggestions about the form and/or content of the site, e-mail Chaplain John Ehman (Network Convener) at .
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